Safe Practices for Parenteral Nutrition

National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition: Safe practices for parenteral nutrition formulations. JPEN J Parenter Enteral Nutr. 1998;22:49–66.

O'Neal BC Schneider PJ Pedersen CA Mirtallo JM . Compliance with safe practices for preparing parenteral nutrition formulations. Am J Health-Syst Pharm. 2002;59:264–269.

A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26 (Suppl):1SA–138SA. (Errata:2002;26:144).

Food and Drug Administration. Safety Alert: Hazards of precipitation associated with parenteral nutrition. Am J Hosp Pharm. 1994;51:1427–1428.

Carey LC Haffey M. Incident: Home TPN formula order misinterpreted after hospital admission. Home Care Highlights. 1995; (spring):7.

Cobel MR . Compounding pediatric dextrose solutions. Medication error alert. ASHP Newsletter. 1995;(Aug):3.

Gebbart F. Test hyperal solutions? Florida mom says yes. Hosp Pharm Report. 1992;(Feb):35.

Iron overdose due to miscommunication of TPN order. Error alert. Pharmacy Today. 1995;(Sep).

Two children die after receiving infected TPN solutions. Pharm J. 1994;(Aug):3. 2.

www.hopkinsmedicine.org/Pressreleases/2003/12_19_03.html.

Ali A Walentik C Mantych GJ Sadiq HF Keenan WJ Noguchi A. Iatrogenic acute hypermagnesemia after total parenteral nutrition infusion mimicking septic shock syndrome: Two case reports. Pediatrics. 2003;112(1 Pt 1):e70–e72.

The U.S. Pharmacopeia Center for the Advancement of Patient Safety medication error reporting programs—MEDMARX^SM and the Medication Errors Reporting Program.

Petros WP Shank WA . A standardized parenteral nutrition solution: Prescribing, use, processing, and material cost implications. Hosp Pharm. 1986;21:648–656.

Mitchell KA Jones EA Meguid MM Curtas S. Standardized TPN order form reduces staff time and potential for error. Nutrition. 1990;6:457–460.

Cerra FB . A standardized TPN order form reduces staff time and potential for error [editorial]. Nutrition. 1990;6:498–499.

Potts TD Monheim H. Standard total parenteral nutrition and peripheral venous nutrition forms. Hosp Pharm. 1980;15:511–514.

Lewis JS . Drafting a parenteral nutrition order form utilizing a physician assessment process. Military Med. 1993;158:548–552.

Wright BT Robinson LA . A simplified TPN order form. Nutr Supp Serv. 1981;1:36, 39–41.

Foulks CJ Krenek G Maxwell K. The effect of changing the total parenteral nutrition order form on resident physician ordering behavior. Nutr Clin Pract. 1997;12:30–34.

Carmody G Hickman RE O'Dell KA . Order form improves documentation of administered TPN solutions. Am J Hosp Pharm. 1986;43:594, 596, 606.

Roberts MJ Teasley KM Roberts AW . Pharmacy program to reduce parenteral nutrition costs. Am J Hosp Pharm. 1981;38:1519–1520.

Fogel RS O'Brien JM Kay BG Balas AZ . Try this simple TPN order form. Nursing. 1987;Mar:58–59.

Maswoswe JJ Newcomer DR Quandt CM . Achieving parenteral nutrition cost savings through prescribing and formulary restrictions. Am J Hosp Pharm. 1987;44:1376–1381.

Lustig A. Medication error prevention by pharmacists — An Israeli solution. Pharm World Sci. 2000;22:21–25.

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Hicks RW Cousins DD Williams RL . Summary of the information submitted to MEDMARX in the year 2002: The quest for quality. USP Center for the Advancement of Patient Safety 2003. Rockville, MD.

National Coordinating Council recommends ways to reduce verbal order errors. NCC MERP press release, May 21, 2001.

ISMP list of error-prone abbreviations, symbols, and dose designations. ISMP Medication Safety Alert. 2003;8:3–4.

It doesn't pay to play the percentages. ISMP Medication Safety Alert. 2002;7(21):1–2.

Carey LC Haffey M. Incident: Home TPN formula order misinterpreted after hospital admission. Home Care Highlights. 1995; Spring:7.

Driscoll DF Bhargava HN Li L Zaim RH Babayan VK Bistrian BR . Physicochemical stability of total nutrient admixtures. Am J Health-Syst Pharm. 1995;52:623–634.

Food and Drug Administration. Safety Alert: Hazards of precipitation associated with parenteral nutrition. Am J Hosp Pharm. 1994;51:1427–1428.

Mirtallo JM . Cost effectiveness of nutrition therapy. IN Torosian MH , ed. Nutrition for the Hospitalized Patient. Basic Science and Principles of Practice. New York, NY: Marcel Decker, Inc; 1995:653–667.

Miller AS . Pharmacy issues: Total parenteral nutrition. Hosp Pharm. 2001;36:437–442.

O'Neal BC Schneider PJ Pedersen CA Mirtallo JM . Compliance with safe practices for preparing parenteral nutrition formulations. Am J Health-Syst Pharm. 2002;59:264–269.

Carey LC Haffey M. Incident: Home TPN formula order misinterpreted after hospital admission. Home Care Highlights. 1995; (spring):7.

Mirtallo JM Jozefzcyck KG Hale KM Grauer DW Ebbert ML Fabri PJ . Providing 24-hour nutrient infusions to critically ill patients. Am J Hosp Pharm. 1986;43:2205–2208.

Saltzman E Shah A Obesity Shikora S. in Gottschlich MM , ed. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Silver Spring, MD: A.S.P.E.N.; 2001:677–699.

Barak M Wall-Alonso E Sitrin MD . Evaluation of stress factors and body weight adjustments currently used to estimate energy expenditure in hospitalized patients. JPEN J Parenter Enteral Nutr. 2002;26:231–238.

Glynn CC Greene GW Winkler MF Albina JE . Predictive versus measured energy expenditure using limits-of-agreement analysis in hospitalized, obese patients. JPEN J Parenter Enteral Nutr. 1999;23:147–154.

Choban PS Flancbaum L. Nourishing the obese patient. Clin Nutr. 2000;19:305–311.

A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(Suppl 1):1SA–138SA. (Errata: 2002;26:144).

Delafosse B Viale JP Tissot S Effects of glucose-to-lipid ratio and type of lipid on substrate oxidation rate in patients. Am J Physiol. 1994;267(5 Part 1):E775–E780.

Stegink LD Freeman JB Wisps J Connor WE . Absence of biochemical symptoms of essential fatty acid deficiency in surgical patients undergoing protein sparing therapy. Am J Clin Nutr. 1977;30:388–393.

Dickerson RN Rosato EF Mullen JL . Net protein anabolism with hypocaloric parenteral nutrition in obese stressed patients. Am J Clin Nutr. 1986;44:747–755.

Mascioli EA Lopes SM Champagne C Driscoll DF . Essential fatty acid deficiency and home total parenteral nutrition patients. Nutrition. 1996;12:245–249.

Press M Hartop PJ Prottey C. Correction of essential fatty acid deficiency in man by cutaneous application of sunflower seed oil. Lancet. 1974;1:597–599.

Miller DG Williams SK Palombo JD Griffin RE Bistrian BR Blackburn GL . Cutaneous application of safflower oil in preventing essential fatty acid deficiency in patients on home parenteral nutrition. Am J Clin Nutr. 1987;46:419–423.

McEvoy GK (ed). American Hospital Formulary Service (AHFS) Drug Information. Bethesda, MD: American Society of Health-System Pharmacists Inc; 2003.

Federal Register. 2000; 65:21200–21201.

American Medical Association Department of Foods and Nutrition. Guidelines for essential trace element preparations for parenteral use. A statement by an expert panel. JAMA. 1979;241:2051–2054.

Fleming CR . Trace element metabolism in adult patients requiring total parenteral nutrition. Am J Clin Nutr. 1989;49:573–579.

Pluhator-Murton MM Fedorak RN Audette RJ Marriage BJ Yatscoff RW Gramlich LM . Trace element contamination of total parenteral nutrition. 1. Contribution of component solutions. JPEN J Parenter Enteral Nutr. 1999;23:222–227.

Kumpf VJ . Update on parenteral iron therapy. Nutr Clin Pract. 2003;18:318–326.

Holliday MA Seger WE . The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19:823–832.

Fitzgerald KA MacKay MW . Calcium and phosphate solubility in parenteral nutrient solutions containing TrophAmine. Am J Hosp Pharm. 1986;43:88–93.

Eggert LD Risho WJ MacKay MW Chan GM . Calcium and phosphorus compatibility in parenteral nutrition solutions for neonates. Am J Hosp Pharm. 1982;39:49–53.

Helms R Storm MC Christensen ML Hak EB Chesney RW . Cysteine supplementation results in normalization of plasma concentrations in children receiving home parenteral nutrition. J Pediatr. 1999;134:358–361.

Haumont D Deckelbaum RJ Richelle M Plasma lipid concentration in low birth weight infants given parenteral nutrition with twenty or ten percent lipid emulsion. J Pediatr. 1989;115:787–793.

A.S.P.E.N. Board of Directors. Nutrition support for low-birth-weight infants. JPEN J Parenter Enteral Nutr. 1993;17(Suppl):8SA–33SA.

American Academy of Pediatrics Committee on Nutrition. Nutritional needs of low-birth-weight infants. Pediatrics. 1985;76:976–986.

Green HL Hambidge KM Schanler R Tsang RC . Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: Report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition. Am J Clin Nutr. 1988;48:1324–1342.

Moukarel AA Song MK Buchman AL Excessive chromium intake in children receiving total parenteral nutrition. Lancet. 1992;339:385–388.

Klein GL . Aluminum contamination of parenteral nutrition solutions and its impact on the pediatric patient. Nutr Clin Pract. 2003;18:302–307.

Klein GL . Aluminum in parenteral solutions revisited—again. Am J Clin Nutr. 1995;61:449–56.

Koo WWK Kaplan LA Horn J Tsang RC Steichen JJ . Aluminum in parenteral solutions-sources and possible alternatives. JPEN J Parenter Enteral Nutr. 1986;10:591–595.

Milliner DS Shinaberger JH Shuman P Coburn JW . Inadvertent aluminum administration during plasma exchange due to aluminum contamination of albumin-replacement solutions. N Engl J Med. 1985;312:165–167.

Fell GS Shenkin A Halls D. Aluminum contamination of intravenous pharmaceuticals, nutrients, and blood products [letter]. Lancet. 1986;1:380.

Federal Register. 2000;65:4103–4111.

Federal Register. 2003;68:32979–32981.

Heller RM Kirchner SA O'Neill JA Skeletal changes of copper deficiency in infants receiving prolonged parenteral nutrition. J Pediatr. 1978;92:947–949.

Riella MC Broviac JW Wells M Scribner BH . Essential fatty acid deficiency in human adults during total parenteral nutrition. Ann Intern Med. 1975;83:786–789.

Anonymous. Death associated with thiamin deficient total parenteral nutrition. MMWR. 1987;38:43.

Alliou M Ehrinpreis MN . Shortage of intravenous multivitamin solution in the United States. [Letter]. N Engl J Med. 1997;337:54–55.

Travis SF Sugarman HJ Ruberg RL Alterations of redcell glycolytic intermediates and oxygen transport as a consequence of hypophosphatemia in patients receiving intravenous hyperalimentation. N Engl J Med. 1971;285:763–768.

Spotlight on the key elements of the medication system. ISMP Medication Safety Alert. 2003;2:3–4.

A.S.P.E.N. Board of Directors. Standards for nutrition support pharmacists. Nutr Clin Pract. 1999;14:151–162.

(797) Pharmaceutical Compounding—Sterile Preparations. United States Pharmacopeial Convention, Pharmacopeial Forum 2003;29:940–965.

American Society for Health-System Pharmacists, ASHP Guidelines on Safe Use of Automated Compounding Devices for the Preparation of Parenteral Nutrition Admixtures. Am J Health-Syst Pharm. 2000;57:1343–1348.

American Society for Health-System Pharmacists, ASHP. Guidelines on quality assurance for pharmacy-prepared sterile products. Am J Health-Syst Pharm. 2000;57:1150–1169.

Bozetti F Bonfanti G Regalia E Calligaris L Cozzaglio L. Catheter sepsis from infusate contamination. Nutr Clin Pract. 1990;5:156–159.

Howard L Chu R Feman S Mintz H Ovesen L Wolf B. Vitamin A deficiency from long-term parenteral nutrition. Ann Intern Med. 1980;93:576–577.

Gupta VD . Stability of vitamins in total parenteral nutrient solutions. Am J Hosp Pharm. 1986;43:2132.

Driscoll DF Bhargava HN Li L Physicochemical stability of total nutrient admixtures. Am J Hosp Pharm. 1995;52:623–634.

Driscoll DF . Total nutrient admixtures: Theory and practice. Nutr Clin Pract. 1995;10:114–119.

Driscoll DF Baptista RJ Mitrano FP Parenteral nutrient admixtures as drug vehicles. Theory and practice in the critical care setting. Ann Pharmacother. 1991;25:276–283.

Van den Berg G Wouters P Weekers F Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–1367.

McMahon MM Rizza RA . Nutrition support in hospitalized patients with diabetes mellitus. Mayo Clinic Proc. 1996;71:587–594.

Rosmarin DK Wardlaw GM Mirtallo J. Hyperglycemia associated with high continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract. 1996;11:151–156.

McCowen KC Malhotra A Bistrian BR . Stress-induced hyperglycemia. Crit Care Clin. 2001;17:107–124.

Boord JB Graber AL Christman HW Powers AC . Practical management of diabetes in critically ill patients. Am J Respir Crit Care Med. 2001;164:1763–1767.

Trissel LA Gilbert DL Martinez JF Baker MB Walter WV Mirtallo JM . Compatibility of parenteral nutrient solutions with selected drugs during simulated Y-site administration. Am J Health-Syst Pharm. 1997;54:1295–1300.

Trissel LA Gilbert DL Martinez JF Baker MB Walter WV Mirtallo JM . Compatibility of medications with 3-in-1 parenteral nutrition admixtures. JPEN J Parenter Enteral Nutr. 1999;23:67–74.

A.S.P.E.N. Board of Directors and the Clinical Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26 (Suppl):1SA–138SA (Errata: 2002;26:114).

Ford CD Vizcarra C. Parenteral nutrition. IN: Terry J , ed. Intravenous Therapy: Clinical Principles and Practice. Philadelphia, PA: Intravenous Nurses Society, WB Saunders; 1995:219–248.

Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR. 2002;51:RR–10.

Steiger E. Obtaining and Maintaining Vascular Access in the Home Parenteral Nutrition Patient. JPEN J Parenter Enteral Nutr. 2002;26(Suppl 5):S17–S20.

Krzywda EA Andris DA Edmiston CE Wallace JR . Parenteral access devices. IN Gottschlich MM , ed. The Science and Practice of Nutrition Support: A Case-Based Care Curriculum. Dubuque, LA: American Society for Parenteral and Enteral Nutrition, Kendall/Hunt; 2001:225–250.

Intravenous Nurses Society. Infusion Nursing: Standards of Practice. J Intraven Nurs. 2000;23 (Suppl):S1–S88.

Collier PE Goodman GB . Cardiac tamponade caused by central venous catheter perforation of the heart: A preventable complication. J Am Coll Surg. 1995;181:459–463.

Isaacs JW Millikan WJ Stackhouse J Hersh T Rudman D. Parenteral nutrition of adults with 900-milliosmolar solution via peripheral vein. Am J Clin Nutr. 1977;30:552–559.

Harden JL Kemp C Mirtallo J. Femoral catheters increase risk of infection in total parenteral nutrition patients. Nutr Clin Pract. 1995;10:60–66.

Bethune K Allwood M Grainger C Wormleighton C. British Pharmaceutical Nutrition Group Working Party. Use of filters during the preparation and administration of parenteral nutrition: Position paper and guidelines prepared by a British pharmaceutical nutrition group working party. Nutrition. 2001;17:403–408.

National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition: Safe Practices for Parenteral Nutrition Formulations. JPEN J Parenter Enteral Nutr. 1998;22:49–66.

Food and Drug Administration, Safety Alert: Hazardous of Precipitation Associated with Parenteral Nutrition. Am J Hosp. Pharm. 1994;51:1427–1428.

Dickerson RN . Di (2-ethylhexyl) phthalate as a plasticizer for intravenous bags and tubing: A toxicological quandary. Nutrition. 1997;13:1010–1012.

www.jcaho.org/accredited+organizations/patient+safety/04+npsg/04_npsg.html.

U.S. Department of Health and Human Services, Public Health Service Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health Settings (NIOSH). Preventing Needlestick Injuries in Health Settings. NIOSH Publication No. 2000–108. Cincinnati, OH: NIOSH; November 1999.

U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. Directives No. CPL 2–2. 44D. Effective Date: November 5, 1999.

U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). Occupational Exposure to Bloodborne Pathogens; Needlesticks and Other Sharp Injuries; Final Rule Federal Legislation, Public Law 106–430. Effective Date: April 18, 2001.

Barber JR Miller SJ Sacks GS . Parenteral feeding formulations. IN Gottschlich MM , ed. The Science and Practice of Nutrition Support: A Case-Based Care Curriculum. Dubuque, IA: American Society for Parenteral and Enteral Nutrition, Kendall/Hunt; 2001:251–268.

Rollins CJ . Total nutrient admixtures: Stability issues and their impact on nursing practice. J Intraven Nurs. 1997;6:299–304.

Strausberg KM . Parenteral nutrition admixture. IN Merritt RJ , ed. A.S.P.E.N. Nutrition Support Manual. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 1998:8–1–8–12.

Kumpf VJ Gervasio J. Pharmacotherapeutics. IN Gottschlich MM , ed. The Science and Practice of Nutrition Support: A Case-Based Care Curriculum. Dubuque, IA: American Society for Parenteral and Enteral Nutrition, Kendall/Hunt; 2001:287–299.

Klang MG Hayes EM Bloss CS . Drug-nutrient considerations-parenteral nutrition. IN Merritt RJ , ed. A.S.P.E.N. Nutrition Support Practice Manual. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 1998:10–1–10–11.

Trissel LA Gilbert DL Martinez JF Baker MB Walter WV Mirtallo JM . Compatibility of medications with 3-in-1 parenteral nutrition admixtures. JPEN J Parenter Enteral Nutr. 1999;23:67–74.

Sacks GS Driscoll DF . Does lipid hang time make a difference? Time is of the essence. Nutr Clin Pract. 2002;17:284–290.

Curry CR Quie PG . Fungal septicemia in patients receiving parenteral hyperalimentation. N Engl J Med. 1971;285:1221–1225.

Dankner WM Spector SA Fierer J Davis CE . Malassezia fungemia in neonates and adults: Complications of hyperalimentation. Rev Infect Dis. 1987;9:743–753.

Weiss SJ Schoch PE Burke AC . Malassezia furfur fungemia associated with central venous catheter lipid emulsion infusion. Heart Lung. 1991;20:87–90.

Okeke CC Bailey L Medwick T Grady LT . Revised USP standards for product dating, packaging, and temperature monitoring. Am J Health-Syst Pharm. 2000;57:1441–1445.

A.S.P.E.N. Board of Directors, Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition in Adults. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 1998.

Carpentier YA Kinney JM Sidedrova VS Hypertriglyceridemic clamp: A new model for studying lipid metabolism. Clin Nutr. 1990;9(Suppl 1):1–9.

Sacks GS Mouser JF . Is IV lipid emulsion safe in patients with hypertriglyceridemia? Nutr Clin Pract. 1997;12:120–123.

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