Safe care transitions for patients receiving parenteral nutrition.

Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Update on the Use of Filters for Parenteral Nutrition: An ASPEN Position Paper.

Intravenous in-line filters play a critical role in promoting patient safety during parenteral nutrition (PN) administration. Guidelines for using filters for PN have been issued by a number of professional organizations and manufacturers of PN components. Yet despite this guidance, filter use remains controversial. Recent changes in recommendations for filtering lipid injectable emulsions have added to confusion and created considerable variation in practice. This Position Paper aims to review past guidance regarding the filtration of PN, examine the clinical consequences of infusing particulate matter, discuss the challenges and issues related to filtration, and clarify the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations for the use of filters for PN administration. This paper was approved by the ASPEN Board of Directors.

Investigation of the role of infusate properties related to midline catheter failure in an ovine model.

PURPOSE: Infusate osmolarity, pH, and cytotoxicity were investigated as risk factors for midline catheter failure. METHODS: An experimental, randomized, controlled, blinded trial was conducted using an ovine model. Two 10-cm, 18-gauge single-lumen midline catheters were inserted into the cephalic veins of sheep. The animals were divided into 6 study arms and were administered solutions of vancomycin 4 mg/mL (a low-cytotoxicity infusate) or 10 mg/mL (a high-cytotoxicity infusate), doxycycline 1 mg/mL (an acidic infusate), or acyclovir 3.5 mg/mL (an alkaline infusate) and 0.9% sodium chloride injection; or 1 of 2 premixed Clinimix (amino acids in dextrose; Baxter International) products with respective osmolarities of 675 mOsm/L (a low-osmolarity infusate) and 930 mOsm/L (a mid-osmolarity infusate). Contralateral legs were infused with 0.9% sodium chloride injection for control purposes. Catheter failure was evaluated by assessment of adverse clinical symptoms (swelling, pain, leakage, and occlusion). A quantitative vessel injury score (VIS) was calculated by grading 4 histopathological features: inflammation, mural thrombus, necrosis, and perivascular reaction. RESULTS: Among 20 sheep included in the study, the overall catheter failure rate was 95% for test catheters (median time to failure, 7.5 days; range, 3-14 days), while 60% of the control catheters failed before or concurrently (median time to failure, 7 days; range, 4.5-14 days). Four of the 6 study arms (all but the Clinimix 675-mOsm/L and acyclovir 3.5-mg/mL arms) demonstrated an increase in mean VIS of ≥77% in test vs control legs (P ≤ 0.034). Both pain and swelling occurred at higher rates in test vs control legs: 65% vs 10% and 70% vs 50%, respectively. The mean difference in rates of occlusive pericatheter mural thrombus between the test and control arms was statistically significant for the vancomycin 10-mg/mL (P = 0.0476), Clinimix 930-mOsm/L (P = 0.0406), and doxycycline 1-mg/mL (P = 0.032) arms. CONCLUSION: Administration of infusates of varied pH, osmolarity, and cytotoxicity via midline catheter resulted in severe vascular injury and premature catheter failure; therefore, the tested infusates should not be infused via midline catheters.

Home Parenteral and Enteral Nutrition During Natural Disasters: A Guide for Clinicians and Consumers.

Natural disasters are most often weather related but can also be unrelated to weather. Either way, these disrupt "normal" life for a short or extended period of time. When someone depends on electricity, clean water, and transportation services for life-sustaining therapies such as home nutrition support, it is important to have a plan in place-even if it is never used. Understanding supply needs, access to home utilities, and when to change location should be discussed, determined, and defined. In this article, the authors strive to provide this information for home parenteral and enteral nutrition support patients (consumers), caregivers, and clinicians.

Hydration Strategy for Endurance Running in an Athlete Requiring Home Parenteral Nutrition.

PURPOSE: The purpose of this report is to share our experience with optimizing home parenteral nutrition (HPN) and hydration therapy for an HPN consumer who desired to run a marathon. METHODS: A 34-year-old woman with idiopathic gastroparesis necessitating HPN and intravenous (IV) hydration desired to train for a marathon. For short runs, prerun and/or postrun hydration were adequate, but a marathon (26.2 miles) would be too long to run without IV hydration. During training, we instructed our consumer to record weights (pre/post run), ambient temperature, running distance, and duration of time. These data were used to calculate her sweat rate and estimate hydration volume during the marathon. RESULTS: Ambient temperature was a significant factor influencing sweat rate. The estimate temperature for the marathon was 65 °F; therefore, our consumer would have an estimated sweat rate of approximately 720 mL/h. This exceeded the amount of fluid that could be infused during the marathon; therefore, we advised our consumer to overhydrate prior to the race. Initial postrace urine output was low and concentrated but returned to baseline after postrace hydration. Our consumer did not experience any symptoms of dehydration and had only minor muscle soreness. CONCLUSIONS: Our consumer was able to complete a marathon with IV hydration. We have shown that with careful preparation, calculation, and planning, our HPN consumer was able to adequately maintain her state of hydration and accomplish her goal of running a marathon.

Micronutrients in parenteral nutrition: too little or too much? The past, present, and recommendations for the future.

This research workshop in 2009 grew out of a concern in the United States, Europe, and other countries with advanced medicine that it was time to revisit the parenteral requirements for a number of micronutrients. Critical questions sought to be answered included the following: Were there micronutrients not routinely added that should be part of a parenteral nutrition (PN) formula? Were other micronutrients present but in inappropriate amounts? How are various micronutrient requirements altered in the critically or chronically ill?