Computerized system for a nutritional support service.

The development of a computerized system for the assistance of a nutritional support service (NSS) is described. A cooperative program exists between the NSS and the Department of Laboratory Medicine, whose computer system is used to support the activities of the NSS. A record is maintained on each patient followed by the NSS (15-20 patients per day). Demographic and anthropometric data, nutritional disorder(s), laboratory data, nutritional support therapy, patient response criteria, and concomitant drug therapy are components of the computer program. Computer reports are provided to the NSS for daily rounds. An automated nutritional assessment program has also been developed. Computer assistance has proven to be a valuable tool to support the patient care, education and research program of the NSS.

Compatibility considerations in parenteral nutrient solutions.

Information on compatibility of nutrients and drugs with parenteral nutrient (PN) solutions is reviewed and evaluated. Precipitation of calcium phosphate when calcium and phosphate salts are added can be affected by pH, amino acid concentration, amino acid product, temperature, sequence of additives, specific salt used, and time since admixture; precipitate formation can occur gradually over 24 hours. Insulin is chemically stable in PN solutions, but adsorption to the infusion system can cause decreased availability. Poor delivery of vitamin A via PN solutions has been reported. The sodium bisulfite content of amino acid injections may cause degradation of thiamine, but studies simulating clinical use are needed. Folic acid stability in PN solutions has been demonstrated, and phytonadione appears to be stable. Drug administration via PN solutions may be advantageous when fluid intake is restricted or peripheral vein access is limited and in home PN therapy. Summarized are results of studies involving heparin, cimetidine hydrochloride, aminophylline, amphotericin B, iron dextran, hydrochloric acid, corticosteroids, narcotics, metoclopramide, digoxin, and fluorouracil. Many antibiotics are probably stable, especially when administered by co-infusion rather than by direct mixture in the PN solution container. When lipids are mixed in the same container with amino acid-dextrose solutions, compatibility and stability of electrolytes, vitamins, and trace elements must be reassessed. Practical research is needed, and availability of additives should be studied in specific patient populations and for specific PN formulations. Valid conclusions are dependent on careful study design.

Gastrointestinal disorders caused by medication and electrolyte solution osmolality during enteral nutrition.

Enteral feeding tubes represent convenient avenues for medication administration and electrolyte replacement. The frequent association of medication therapy with gastrointestinal disorders during enteral nutrition prompted this evaluation of medication and electrolyte solution osmolality. It is concluded that the hypertonicity of electrolyte replacement solutions and various medications may cause gastrointestinal intolerance in patients. Electrolyte supplementation by parenteral means or by appropriate dilution and mixture with an enteral formula is preferable to bolus administration of undiluted solutions via the feeding tube. Routine admixture of medications such as antibiotic suspensions to enteral formulas cannot be recommended at this time pending specific study of drug compatibility and availability from enteral tube feeding systems.

Stability of aminophylline injection in three parenteral nutrient solutions.

The stability of aminophylline injection in crystalline amino acid-dextrose solutions containing standard additions of electrolytes, vitamins, and minerals was evaluated. Aminophylline injection was added to three parenteral nutrition (PN) solutions in dosages of 0.25-1.50 mg/ml. All of the samples were prepared in duplicate, stored in sealed volumetric flasks, and allowed to stand under normal lighting at room temperature or under refrigeration for 48 hours. Samples were analyzed for theophylline content by reverse phase high-pressure liquid chromatography at 1, 24, and 48 hours. Mean percent theophylline recovery 24 hours after admixture was 101 +/- 10.9%, 101 +/- 4.3%, and 100 +/- 4.3% in the three PN solutions. Solution pH values were stable for 48 hours. Refrigeration and lower amino acid concentrations did not alter stability. Aminophylline is stable in PN solutions for 24 hours in concentrations up to 1.5 mg/ml.

Collaborative clinical pharmacokinetic services.

A program for routine pharmacokinetic interpretation of serum analyses of gentamicin, tobramycin, amikacin, phenytoin, phenobarbital, theophylline, lidocaine, digoxin, quinidine, and procainamide at the Medical University of South Carolina Hospital is described. Results of all analyses of serum for the drugs listed are evaluated by a pharmacist trained in clinical pharmacokinetics. Patient variables relevant to the determination of drug serum concentrations, drug elimination, distribution, and dosage are given appropriate consideration in each evaluation. A summary of the pharmacokinetic interpretation and any necessary modification of drug dosage regimens are then written into the progress notes of the patients' medical records. Approximately 12 patients and 20 drug concentrations are evaluated each day. The average charge for te service is +35. This service, which is reimbursed by third-party carriers, has resulted in improved use of laboratory personnel, equipment, and time and has provided a framework for education and research as well as a mechanism for direct contributions to patient care by the pharmacist.

Total parenteral nutrition solution preparation utilizing amino acid sources with and without pre-added electrolytes: a time and cost comparison.

A comparison study of the time and cost of preparation of total parenteral nutrition solutions using a crystalline amino acid source with pre-added electrolytes and an amino acid source without electrolytes is presented. Four pharmacists and 4 technicians each prepared 4 solutions, utilizing each of the two amino acid sources. Both time of preparation and time of checking were measured. Utilizing list prices as acquisition costs for ingredients and the average salary for pharmacists and technicians at Medical University Hospital to determine the labor ocst, the average cost of preparing each solution was determined. The results of this study demonstrated that a potential savings of 10.3% and 9.9% was possible for pharmacist-prepared and technician-prepared solutions, respectively, when amino acid solutions containing pre-added electrolytes are utilized. The authors concluded that the use of crystalline amino acid solutions with pre-added electrolytes could offer substantial savings of labor and money for the hospital pharmacy. These solutions could also represent a significant cost savings to home-prepared parenteral nutrition formulas.

Pharmacy-based infusion pump program.

A pharmacy-based program for the procurement, allocation and maintenance of infusion pumps is presented. Policies and procedures for various facets of the program, job descriptions for personnel, and training programs for pharmacy and nursing personnel are discussed. A plan for quality assurance, including in-use accuracy testing, preventive maintenance, repairs, and complete record keeping and documentation is outlined. Various aspects of equipment selection, economic justification of equipment, and revenue generation potential are addressed. It is concluded that an infusion pump program can be operated successfully by the hospital pharmacy department.

Involving staff pharmacists in management decisions.

Various administrative techniques used to bring staff pharmacists in a decentralized, satellite pharmacy system into the managerial decision-making process are discussed. These techniques include a staff pharmacist on-call procedure to discourage absenteeism, and the concept of a head pharmacist to serve as a link with departmental administration. The head pharmacist works in the satelite pharmacy, is responsible for its daily operation and is the spokesman for the satellite. Active roles for the head pharmacist in the selection and evaluation of technicians are outlines. Management skills are developed in head pharmacists through a program of special classes and discussion groups. It is concluded that this program has improved the credibility of administrative decisions and has tapped an underused source of ideas and talent.

Etiological factors of the Stevens-Johnson syndrome.

Etiologic factors of the Stevens-Johnson syndrome, both drug-related and nondrug-related, are discussed. A description of the Stevens-Johnson syndrome as a symptom complex is presented. Available literature is reviewed and critiqued as to its contribution in helping to define the role of drugs as specific etiologic factors in the syndrome. A patient case history is presented to demonstrate the difficulty of determining the causative agent for the syndrome, and to emphasize the need for a complete drug history before specific agents are implicated. The need for caution and discretion in reporting and implicating agents without the availability of a complete patient history is discussed.