Existence of advanced glycation / lipoxidation end-products in parenteral nutrition solutions and effects of infusion conditions on their levels

Abstract Infusion solutions must be stable from the production stage until the infusion stage. Some infusion fluids contain degradation products, known as advanced glycation end products (AGEs); however, it is unknown whether AGEs exist in parenteral nutrition solutions. We aimed to investigate this question and test the effect of infusion conditions on AGE formation in parenteral nutrition solution. Nine parenteral nutrition solutions were supplied by the pharmacy with which we collaborated. To simulate the infusion conditions, the solutions were held in a patient room with standard lighting and temperature for 24 hours. Samples were taken at the beginning (group A) and the end (24th hour, group B) of the infusion period. The degradation products were 3-deoxyglucosone, pentosidine, N-carboxymethyl lysine, and 4-hydroxynonenal, which we investigated by high-performance liquid chromatography-mass spectrometry (LC-MS) and Q-TOF LC/MS methods. Two of four degradation products, 4-hydroxynonenal and N-carboxymethyl lysine, were detected in all samples, and Group B had higher levels of both compounds compared to Group A, who showed that the quantities of these compounds increased in room conditions over time. The increase was significant for 4-hydroxynonenal (p=0.03), but not for N-carboxymethyl lysine (p=0.23). Moreover, we detected in the parenteral nutrition solutions a compound that could have been 4-hydroxy-2-butynal or furanone

Inquérito Brasileiro Sobre Terapia de Nutrição Domiciliar: panorama atual / Brazilian Survey on Home Nutrition Therapy: current overview / Encuesta brasileña sobre terapia nutricional domiciliaria: panorama actual

Objetivo: descrever como a terapêutica nutricional domiciliar é realizada no Programa Melhor em casa do Ministério da Saúde e na Saúde suplementar. Método: Estudo transversal, com dados secundários, onde foram selecionados os perfis de profissionais atuantes em atenção domiciliaria no Brasil. A coleta de dados ocorreu de março a junho de 2018, depois de submetido e aprovado pelo Comitê de Ética e Pesquisa. Resultados: Dos 289 brasileiros, 74% eram profissionais atuantes na Assistência domiciliaria. O tipo de Terapia Nutricional realizada foi 67% enteral exclusiva seguida de 33% terapia mista. A prescrição realizada de dieta exclusiva artesanal foi de 9% e de dieta enteral mista 55%. A maioria recebe dieta por gravidade intermitente, seguida de administração em "bolus", gravitacional contínua e controle do gotejamento através da bomba de infusão. Conclusão: Os achados nos dão uma visão panorâmica da terapia nutricional enteral domiciliar no Brasil. A aumento da terapia nutricional domiciliaria se faz necessária especialmente pelo aumento da população idosa e consequentemente de maior presença das doenças crônicas que podem levar a incapacidade, dependência, maior tempo de hospitalização e custos para o sistema de saúde. É fundamental a presença da equipe interdisciplinar, de boas práticas e do acompanhamento das famílias nos domicílios.

Objective: To learn how home nutritional therapy is carried out in the Ministry of Health's Better Home Program and in Supplementary Health. Method: Cross-sectional study, with secondary data, in which the profiles of professionals working in home care in Brazil were selected. Data collection took place from March to June 2018, after being submitted and approved by the Ethics and Research Committee. Results: Of the 289 Brazilians, 74% were professionals working in home care. The type of nutritional therapy performed was 67% exclusive enteral followed by 33% mixed therapy. The prescription of an exclusive handmade diet was 9% and a mixed enteral diet 55%. Most receive intermittent gravity diet, followed by bolus administration, continuous gravitational and drip control through the infusion pump. Conclusion: The findings give us a panoramic view of home enteral nutritional therapy in Brazil. The increase in home nutritional therapy is necessary especially because of the increase in the elderly population and, consequently, the greater presence of chronic diseases that can lead to disability, dependence, longer hospitalization and costs for the health system. The presence of an interdisciplinary team, good practices and monitoring of families at home is essential.

Objetivo: Conocer cómo se lleva a cabo la terapia nutricional domiciliaria en el Programa Mejor Hogar del Ministerio de Salud y en Salud Complementaria. Método: Estudio transversal, con datos secundarios, en el que se seleccionaron los perfiles de los profesionales que trabajan en la atención domiciliaria en Brasil. La recolección de datos tuvo lugar de marzo a junio de 2018, luego de ser presentados y aprobados por el Comité de Ética e Investigación. Resultados: De los 289 brasileños, el 74% eran profesionales que trabajaban en la atención domiciliaria. El tipo de terapia nutricional realizada fue 67% enteral exclusiva seguida de 33% terapia mixta. La prescripción de una dieta exclusiva artesanal fue del 9% y una dieta enteral mixta del 55%. La mayoría recibe una dieta de gravedad intermitente, seguida de administración de bolo, control gravitacional continuo y de goteo a través de la bomba de infusión. Conclusión: Los hallazgos nos brindan una visión panorámica de la terapia nutricional enteral domiciliaria en Brasil. El aumento de la terapia nutricional domiciliaria es necesario sobre todo por el aumento de la población anciana y, en consecuencia, la mayor presencia de enfermedades crónicas que pueden derivar en discapacidad, dependencia, mayor internación y costos para el sistema de salud. La presencia de un equipo interdisciplinario, buenas prácticas y seguimiento de las familias en el hogar es fundamental.

Aluminum toxicity to bone: A multisystem effect?

Aluminum (Al) is the third most abundant element in the earth's crust and is omnipresent in our environment, including our food. However, with normal renal function, oral and enteral ingestion of substances contaminated with Al, such as antacids and infant formulae, do not cause problems. The intestine, skin, and respiratory tract are barriers to Al entry into the blood. However, contamination of fluids given parenterally, such as parenteral nutrition solutions, or hemodialysis, peritoneal dialysis or even oral Al-containing substances to patients with impaired renal function could result in accumulation in bone, parathyroids, liver, spleen, and kidney. The toxic effects of Al to the skeleton include fractures accompanying a painful osteomalacia, hypoparathyroidism, microcytic anemia, cholestatic hepatotoxicity, and suppression of the renal enzyme 25-hydroxyvitamin D-1 alpha hydroxylase. The sources of Al include contamination of calcium and phosphate salts, albumin and heparin. Contamination occurs either from inability to remove the naturally accumulating Al or from leeching from glass columns used in compound purification processes. Awareness of this long-standing problem should allow physicians to choose pharmaceutical products with lower quantities of Al listed on the label as long as this practice is mandated by specific national drug regulatory agencies.

O preparo de medicamentos realizado por um time de medicação: estudo descritivo / Drug preparation performed by a medication team: a descriptive study / La preparación de medicamentos realizada por un equipo de medicación: estudio descriptivo

O time de medicação constitui-se como um grupo de trabalho formado por enfermeiros que se dedicam às etapas do sistema de medicação, com uma certa uniformidade na realização das atividades, entretanto, não foi construída qualquer padronização do seu processo de trabalho. OBJETIVO: descrever o preparo de medicamentos enterais e soluções parenterais pelo time de medicação na unidade neonatal. MÉTODO: estudo qualitativo, descritivo, com o método pesquisa-ação. Os sujeitos foram os enfermeiros do time de medicação da unidade neonatal. A coleta de dados foi constituída por: pesquisa de documentos; observação do preparo da medicação; coleta de problemas na reunião do time de medicação. RESULTADOS: atualização do tema e das atribuições da equipe de enfermagem da unidade neonatal; construção de fluxogramas relacionados ao preparo de medicamentos. CONCLUSÃO: o estudo possibilitou implementar intervenções no preparo de medicamentos realizadas pelos sujeitos do estudo, padronizando as etapas e definindo as relações de trabalho da equipe de enfermagem

The medication team is a work group formed by nurses who dedicate themselves to the stages of the medication system, with certain uniformity in the accomplishment of the activities; however, no standardization of their work process was developed. AIM: describe the preparation of enteral medications and parenteral solutions by the medication team in the neonatal unit. METHOD: this is a qualitative, descriptive study that uses the action research method. The subjects were the nurses of the medication team of the neonatal unit. Data collection consisted of: document search; observation of medication preparation; and collection of problems at the medication team meeting. RESULTS: updating of the theme and attributions of the nursing team of the neonatal unit; construction of flowcharts related to the preparation of medicines. CONCLUSION: the study allowed implementing interventions in the preparation of medicines carried out by the study subjects, standardizing the steps and defining the work relationships of the nursing team

El equipo de medicación es un grupo de trabajo formado por enfermeros que se dedican a las etapas del sistema de medicación, realizándolas con una cierta uniformidad, pero sin haber sido construida cualquier estandarización de su proceso de trabajo. OBJETIVO: describir la preparación de medicamentos enterales y soluciones parenterales por el equipo de medicación en la unidad neonatal. MÉTODO: estudio cualitativo, descriptivo, con el método investigación-acción. Los sujetos fueron los enfermeros del equipo de medicación de la unidad neonatal. La recolección de los datos fue constituida por: investigación de documentos; observación de la preparación de la medicación; recopilación de problemas en la reunión del equipo de medicación. RESULTADOS: actualización del tema y de las atribuciones del equipo de enfermería de la unidad neonatal; construcción de organigramas relacionados a la preparación de medicamentos. CONCLUSIÓN: el estudio posibilitó implementar intervenciones en la preparación de medicamentos realizadas por los sujetos del estudio, estandarización de las etapas para definir las relaciones de trabajo del equipo de enfermería.

Registro de la utilización de nutrición parenteral en el Hospital de Pediatría Juan P. Garrahan / Registry of the use of parenteral nutrition at the Pediatric Hospital Juan P. Garrahan

La nutrición parenteral (NPT) en pediatría es un recurso que permite mantener el sostén clínico de aquellos pacientes que por la complejidad de la patología que presentan no pueden utilizar la vía enteral. El objetivos es analizar el registro de utilización de NPT en el Hospital de Pediatría Juan P. Garrahan. Estudio retrospectivo descriptivo. Se analizaron 95 solicitudes de NPT durante el período julio-agosto 2011. Se accedió a las historias clínicas, donde se constataron las variables principales: edad (meses), sexo, área de internación, patología asociada a su uso, duración promedio (días), tipo de NPT (Standard o personalizada) y evidencia de complicaciones. Se definió colestasis a valores de Bilirrubina directa mayor a 2 mg%. Sobre un total 114 indicaciones médicas de NPT, se accedió a 95 historias clínicas. Perfil de uso: Neonatología 34,5%, Cuidados Intensivos 35,7% y Cuidados Intermedios y moderados 29,8%. La media de edad 39 meses (0-192). Las patologías más frecuentes son quirúrgicas 52,6%, hematológicas y oncológicas 28,4%. La duración total de la indicación fue en promedio 16,5 días (0-187). Las soluciones personalizadas (a la carta) 83%. Las soluciones con lípidos sumaron un total de 73 (76%). Como complicaciones se observaron 13 casos de colestasis (13,68%) los cuales se asociaron a soluciones con lípidos. La mayoría de los pacientes que requirieron uso de NPT presentaron patologías que requerían cuidados críticos neonatales o pediátricos. Las soluciones personalizadas o "a la carta" fueron las más utilizadas. El tiempo de administración fue muy variable, la presencia de colestasis se relacionó con los usos más prolongados; superior a los 71 días promedio (AU)

In pediatrics, total parenteral nutrition (TPN) is a resource that allows to clinically support those patients who, due to the severity of their disease, do not tolerate the enteral route. The aim of this study was to analyze the registry of TPN use at the Pediatric Hospital Dr. Juan P. Garrahan. A retrospective descriptive study was conducted. Ninety-five requests for TPN made in July and August 2011 were analyzed. Clinical charts of the patients were assessed recording the main variables: Age (months), sex, area the child was admitted to, pathology associated with TPN use, duration of TPN (days), type of TPN (standard or personalized), and evidence of complications. Cholestasis was defined as direct bilirubin greater than 2 mg%. For a total of 114 medical indications for PN, access to 95 clinical charts was obtained. User's profile: Neonatology 34.5%, intensive care 35.7%, intermediate and moderate care 29.8%. Mean age of the patients was 39 months (0-192). The most common pathologies were surgical in 52.6% and hematological and oncological in 28.4%. Mean duration of TPN was 16.5 days (0-187). Personalized formulations ("a la carte") were used in 83%. Overall, 73 (76%) formulations with lipids were used. Complications observed were 13 cases of cholestasis (13.68%) that were associated with the use of lipid formulations. Most patients that needed TPN had pathologies requiring neonatal or pediatric critical care. Personalized or "a la carte" formulations were most often used. The duration of TPN administration was variable. Cholestasis was related with longer TPN use, with a mean of 71 days (AU)

Research progress of detecting large-diameter tail in lipid injectable emulsions / 药学学报

Injectable lipid emulsions have been routinely used in patients since 1960s as a nutritional supplement for patients requiring parenteral nutrition. In recent years, lipid injectable emulsions have been extensively studied as a kind of novel drug carrier, also the quality problems of the lipid emulsion attract more and more attentions gradually. Large diameter tail of injectable lipid emulsions as a significant quality control indicator should pay more attention. Regarding to the defect of detecting large diameter tail of lipid injectable emulsions in our country, the purpose of this article is to summarize the techniques of detecting large diameter tail, illustrate the impacts of large lipid droplet on the quality of lipid injectable emulsions, emphasize the importance of detecting large diameter tail in lipid emulsions and provide guidance for researching and developing lipid emulsions in domestic market.

Síndrome hemofagocítico secundario: reporte de 5 casos / Secondary hemophagocytic syndrome: report of 5 cases

Secondary hemophagocytic syndrome (HFS) is an uncommon entity with a high mortality rate in adults, if no therapy is given. It is characterized by a severehipercytokinemia due to a highly stimulated but ineffective immune system. Theprincipal causes are infections, malignancy or autoimmune diseases. It appears asa serious illness, similar to a multiorgan failure. Treatment is not well defined. Wereport five patients with HFS, aged 17 to 51 years (three females). The etiology wasonco-hematological in three patients. In two patients, the diagnosis was performedduring necropsy. One case was due to cytomegalovirus (CMV) infection in a hepatictransplant patient and the other, due to parenteral lipid administration. All presentedfever, cytopenia, hepatosplenomegaly and hemophagocytosis. Four of them requiredadmission in an Intensive Care Unit. All received different treatment modalities. Onlyone survived. Median survival time was 75 days. In conclusion, HFS has differentetiologies and a high mortality in adults.

Clinical impact of systematic nutritional care in adults submitted to allogeneic hematopoietic stem cell transplantation

BACKGROUND: The development of nutrition care programs for patients undergoing hematopoietic stem cell transplantation is necessity in view of the rapid and aggressive consequences frequently seen with this procedure. Patients require constant care to reduce complications and to contribute to the success of therapy. METHODS: In an attempt to ascertain the impact of systematic nutritional care on patients submitted to allogeneic hematopoietic stem cell transplantation, the present study assessed the nutritional and clinical status, use of parenteral nutrition, and complication and mortality rates in two groups of patients, who were submitted to transplantation between April 2003 and December 2004 (Non-intervention Group - NIG; n = 57) and between March 2006 and January 2008 (Intervention Group - IG; n = 34). RESULTS: There were no significant differences between groups in terms of clinical or nutritional profiles. Additionally, the length of hospital stay and complication and mortality rates were similar for both groups. However, time on parenteral nutrition during treatment was shorter for the IG [median 6.5 days (range: 1-28) for related donor recipients and 11 days (range: 1-21) for unrelated donor recipients] than for the NIG [median 20.5 days (range, 4-73) for patients submitted to myeloablative conditioning and 18.5 days (range: 11-59 days) for those submitted to nonablative conditioning]. CONCLUSION: The implementation of a nutritional follow-up and therapy protocol for adult patients submitted to hematopoietic stem cell transplantation shortens the duration of parenteral nutrition. It certainly has an impact on hospitalization costs and, potentially, on the rate of complications, even though this was not demonstrated in this study.

Hipercalcemia e lesão renal aguda causadas por abuso de um composto veterinário parenteral contendo vitaminas A, D e E / Hypercalcemia and acute kidney injury caused by abuse of a parenteral veterinary compound containing vitamins A, D, and E

Um rapaz de 19 anos, previamente hígido, procurou o hospital com queixas de anorexia, náuseas e vômitos. Exames laboratoriais revelaram hipercalcemia (valor máximo do cálcio de 14,8 mg/dL) e lesão renal aguda (valor máximo da creatinina de 2,88 mg/dL). O paciente admitiu utilizar uma formulação parenteral de vitaminas A, D e E de uso exclusivo veterinário, contendo 20.000.000 UI de vitamina A; 5.000.000 UI de vitamina D3 e 6.800 UI de vitamina E, por ampola de 100 mL. Ele refere ter usado cerca de 300 mL do produto no último ano. O jovem não estava interessado na quantidade maciça de vitaminas contida no produto, mas apenas no efeito local do veículo oleoso; o edema provocado pela injeção simulava um aumento de massa muscular. O produto, no entanto, foi absorvido e causou hipervitaminose. O nível sérico de 25(OH) vitamina D estava claramente elevado em 150 ng/mL (referência de 30 a 60 ng/mL), mas não tanto quanto em outros casos publicados de intoxicação por vitamina D. A maioria dos casos de hipercalcemia por hipervitaminose D se associa a níveis de 25 (OH)D bem maiores do que 200 ng/mL. O PTH estava indetectável, e outras causas de hipercalcemia foram excluídas. Deste modo, conclui-se que a gravidade da hipercalcemia encontrada neste caso foi resultado do efeito sinérgico da intoxicação pelas vitaminas A e D. O paciente foi tratado com soro fisiológico, furosemida e ácido zolendrônico e evoluiu com normalização rápida dos níveis séricos de cálcio e da função renal.

A previously healthy 19 year-old male presented to the hospital with anorexia, nausea, and vomiting. Laboratory studies were significant for hypercalcemia (peak calcium value of 14.8 mg/dL) and acute kidney injury (peak serum creatinine of 2.88 mg/dL). He admitted to using a parenteral formulation of vitamins A, D and E restricted for veterinary use containing 20,000,000 IU of vitamin A; 5,000,000 IU of vitamin D3; and 6,800 IU of vitamin E per 100 mL vial. The patient stated to have used close to 300 mL of the product over the preceding year. Interestingly, the young man was not interested in the massive amounts of vitamins that the product contained; he was only after the local effects of the oily vehicle. The swelling produced by the injection resulted in a silicone-like effect, which gave the impression of bigger muscles. Nevertheless, the product was absorbed and caused hypervitaminosis. The serum level of 25(OH) vitamin D was clearly elevated at 150 ng/mL (reference range from 30 to 60 ng/mL), but in most published cases of vitamin D toxicity, serum levels have been well above 200 ng/mL. His PTH level was undetectable and other potential causes of hypercalcemia were excluded. Therefore, we posit that the severity of the hypercalcemia observed in this case was the result of a synergistic effect of vitamins A and D. The patient was treated with normal saline, furosemide and zolendronic acid, with rapid normalization of calcium levels and renal function.

Rotafolio de consejería sobre alimentación, desarrollo y enfermedades prevenibles de la niñez / Counseling flipchart on childhood feeding, development and preventable diseases

El rotafolio, como instrumento usado para la presentación de información, sirve de guía tanto para el personal de salud, como para la orientación de los pacientes, particularmente de madres con niños recién nacidos, lactantes y preescolares (menores de cinco años). En él, van paso a paso con los detalles sobre la alimentación del niño, incluyendo temas como peso, vacunación, suplementación y hasta recetas de cocina pensadas para los niños de las edades señaladas. Un instrumento didáctico de gran calidad fotográfica.

Contaminación extrínseca de soluciones parenterales y medicamentos en frascos multidosis / Extrinsic contamination of parenteral solutions and multiple-dose vials

Las infecciones nosocomiales ocurren durante las 48-72 horas después del ingreso a un centro de salud o luego de un periodo definido tras el alta, uno de los vehículos para este tipo de infección son las soluciones parenterales (SP) y los medicamentos en frascos multidosis (FMD). Se determinó la frecuencia de contaminación extrínseca de SP y FMD en algunos servicios de hospitalización del Complejo Hospitalario Universitario “Ruiz y Páez” en Ciudad Bolívar-Venezuela. Se analizaron 95 SP y 82 FMD para un total de 177 muestras, las cuales se cultivaron y los microorganismos aislados fueron identificados a través de pruebas bioquímicas convencionales. De las 177 muestras evaluadas, 42 (23,73%) presentaron crecimiento de microorganismos. El 27,36% de las SP y el 19,51% de los FMD resultaron contaminados. Los microorganismos más frecuentemente aislados fueron Bacillus sp. (55,30%), Candida albicans (14,88%) y Staphylococcus coagulasa negativos (8,52%). Se concluyó que durante el periodo estudiado en las soluciones parenterales predominó la contaminación por microorganismos ambientales, mientras que las levaduras predominaron en los frascos multidosis especialmente en los de sulfato de magnesio.

Nosocomial infections occur during the 48-72 hours after admission to a health centre or after a defined period after discharge, one of the vehicles for this type of infection are the parenterals solutions (PS) and parenteral drugs in multidose vials (MDV). We determinated the prevalence of extrinsic contamination of PS and MDV hospitalization in some services of the Hospital Universitario “Ruiz and Páez” in Ciudad Bolívar-Venezuela. We analyzed 95 PS and 82 MDV for a total of 177 samples, which were cultivated and isolated microorganisms were identified by conventional biochemical tests. Of the 177 samples tested, 42 (23.73%) had growth of microorganisms. The 27.36% of the PS and the 19.51% of MDV were contaminated. The most commonly isolated microorganisms were Bacillus sp. (55.30%), Candida albicans (14.88%) and coagulase negative Staphylococcus (8.52%). It was concluded that during the period studied in parenteral solutions prevailing contamination by environmental microorganisms, while yeast predominated in especially in multidose vials of magnesium sulfate.