Parenteral nutrition safety

The benefits and safety of parenteral nutrition have been considerably improved in recent years by innovative strategies, such as supplementation with medium-chain triglycerides, glutamine, or branch-chain amino acids. 

Many of the safety issues in parenteral nutrition relate to the fact that the process is inherently unphysiological (5). Instead of periodic ingestion of nutrients via the gastrointestinal tract resulting in gradual entry of nutrients into the blood, nutrients are infused directly at a constant rate. The gastrointestinal tract as a mediator of nutrient absorption, the periodicity of nutrient administration, and the natural biorhjdhms of hormoue secretion are all lost. 

Iron is an essential element in nutrition, and its inclusion in any long-term parenteral nutrition regimen should be mandatory. However, it is not included in all trace element formulations, although this varies from country to country most European products include 20 pmol of iron in trace element formulations. While it might be considered unnecessary to include iron as a daily supplement, because of safety and pharmaceutical considerations, there is ample evidence that the use of iron-containing trace element formulations is both safe and efficacious, with no associated adverse effects. 

The United States Food and Drug Administration issued a safety alert in 1994 regarding the potentially life-threatening formation of precipitates in parenteral nutrition admixtures (148). They had received reports of two deaths and at least two cases of respiratory distress during intravenous infusion of a three-in-one parenteral nutrition mixture (amino acids, carbohydrates, lipids). The mixture contained 10% FreAmine III (amino acids -I- magnesium acetate -I- phosphoric acid -I- potassium chloride -I- sodium acetate -I- sodium chloride), dextrose, calcium gluconate, potassium phosphate, other minerals, and a lipid emulsion. The solution may have contained a precipitate of calcium phosphate. Autopsies revealed diffuse microvascular pulmonary emboli containing calcium phosphate. 

Hornsby-Lewis L, Shike M, Brown P, Klang M, Pearlstone D, Brennan MF. L-glutamine supplementation in home total parenteral nutrition patients stability, safety, and effects on intestinal absorption. J Parenter Enteral Nutr 1994 18(3) 268-73. 

Nightingale SL. Safety alert on hazards of precipitation associated with parenteral nutrition. JAMA 1994 271 1472. 

McQave SA, Greene LM, Snider HL, et al. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enter Nutr 1996 21 14-20. 

FDA Safety Alert Hazards of Precipitation Associated With Parenteral Nutrition The Food and Drug Administration warned against the risk of precipitations in parenteral nutrition mixtures in 1994 [55]. This warning occurred after two deaths and at least two patients with dyspnoea after infusion of all-in-one nutrition admixmres. The FDA suspected that these admixtures contained calcium phosphate precipitates. 

K. M. Gura, S. Lee, C. Valim, J. Zhou, S. Kim, B. P. Modi, D. A. Arsenault, R. A. Strijbosch, S. Lopes, C. Duggan and M. Puder, Safety and efficacy of a fish-oil-based fat emulsion in the treatment of parenteral nutrition-associated liver disease. 

In order to insure maximum safety to the patient, it is strongly recommended that any institution in which intravenous hyperalimentation is practiced should have a designated and qualified hyperalimentation or total parenteral nutrition team. The minimum team should consist of an attending physician who is well versed in nutrition and metabolism, a conscientious and interested house officer or research fellow, a pharmacist trained in aseptic solution formulation, and a technician or nurse. Other members of a complete hyperalimentation team include a nutritionist, clinical pathologist or biochemist, physical therapist, sociologist, and psychiatrist. 

In a prospective cohort study including 24 infants, the incidence and risk factors of parenteral nutrition-associated liver disease (PNALD) was determined. Eight infants developed PNALD. The concluded that the duration of enteral starvation, gastrointestinal surgery, duration of enteral nutrition, maximum caloric and carbohydrate intakes were significant risks of PNALD in newborn infants [lob ll. In a retrospective review of the safety and efficacy of PN among 105 paediatric patients with bum injuries (>30% total-body sxuface area), no respiratory or blood infections were observed with the use of parenteral nutrition, and the overall mortality rate was 4% [107 ]. 

Dylewksi ML, Baker M, Prelack K, Weber JM, Hursey D, Lydon M, et al. The safety and efficacy of parenteral nutrition among pediatric patients with bum injuries. Pediatr Crit Care Med March 2013 14(3) el20-5. 

After performing a nutrition assessment and estimating nutritional requirements, determine the optimal route to provide specialized nutrition support (e.g., oral, enteral, or parenteral). If PN is deemed necessary, venous access (i.e., peripheral or central see below) for PN infusion must be obtained. Finally, formulate a PN prescription, and administer PN according to proper safety guidelines. 

T. R. Ziegler, K. Benfele, R. J. Smith, et al. Safety and metabolic effects of 1-giutamine administration in humans. Journal of Parenteral and Enteral Nutrition 14, 1375 (1990). 

---