Original Shanghai No.10 Hospital Pharmaceutical Service Shanghai No.10 Hospital Pharmaceutical Service
China’s population aging process is accelerating. In 2020, China’s population aged 60 and over has reached 18.70%. The elderly are at higher risk of malnutrition, especially those with multiple diseases or serious diseases. Once the elderly patients are diagnosed with malnutrition, comprehensive and detailed nutritional assessment should be made within 48 hours, and personalized nutritional intervention strategies should be formulated for patients to ensure adequate dietary intake and improve nutritional status. Oral nutritional supplements (ONS), enteral nutrition (EN) and parenteral nutrition (PN) are commonly used ways to supplement nutrition in clinic.
Our previous popular science article "Rumoured Enteral Nutrition" has introduced the relevant knowledge of enteral nutrition. Today, I will take you to understand what parenteral nutrition is.
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What is parenteral nutrition?
Parenteral nutrition (PN) refers to a way of intravenous infusion of nutrients such as amino acids, glucose, lipids, electrolytes, vitamins and trace elements, so that patients can maintain their nutritional status even if they can’t eat, and improve their clinical outcomes.
For elderly patients who need nutritional support treatment, when EN intake is lower than 60% of the body’s energy and protein’s target requirement, it is suggested to give supplementary parenteral nutrition. When the gastrointestinal function of elderly patients is seriously impaired or EN cannot be used, total parenteral nutrition is recommended.
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Is single bottle infusion better or "all in one" (total nutrient mixture)
Infusion is good?
"All-in-one" infusion means that various nutrients such as carbohydrates, fat emulsion, amino acids, vitamins, electrolytes and trace elements are fully mixed in an infusion bag according to a certain reasonable ratio (sugar-fat ratio, hot-nitrogen ratio, electrolyte concentration, etc.) and then infused.
Compared with single-bottle infusion, "all-in-one" infusion is more in line with the physiological metabolic process of the body, which can make the nutrients input into the body better metabolized and utilized: (1) It can reduce the occurrence of metabolic complications, and avoid increasing the metabolic load due to more glucose or fatty acids entering the body in a unit time when a single-bottle infusion of hypertonic glucose or fat emulsion is used, and even complicated with related metabolic complications, such as hyperglycemia or hyperlipidemia; (2) The nutrients can be diluted with each other, so as to reduce the overall osmotic pressure and reduce the stimulation to veins; (3) It can avoid the need to change the infusion bottle many times during single bottle infusion, simplify the infusion process, save nursing time, reduce the chance of pollution and reduce the risk of related infection.
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Classification and characteristics of total nutrient mixture
At present, the total nutrient mixture is mainly divided into two forms: industrial multi-cavity bag (including three-cavity bag and double-cavity bag) and hospital preparation (commonly known as "three-liter bag"). So what’s the difference between the two?
Industrialized multi-cavity bag is to divide a special preparation bag into several relatively independent cavities, and fill them with nutritional ingredients such as fat milk, amino acids and glucose respectively. When in use, just squeeze to open the inner cavity partition belt and mix several liquids fully and evenly. Multi-cavity bag has many specifications, and has the characteristics of reasonable prescription, stable quality and ready-to-use, which can reduce prescription and configuration errors, reduce microbial contamination and bloodstream infection, and meet the needs of parenteral nutrition for most patients.
However, for patients who need to strictly limit the amount of liquid and electrolyte intake, have serious metabolic disorders and have special nutritional needs, it is still necessary to prepare individualized parenteral total nutrition mixture in the hospital.
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How to prepare parenteral total nutrient solution in hospital?
The parenteral total nutrition mixed solution prepared in the hospital was prepared by PIVAS according to the personalized prescription prescribed by doctors and audited by pharmacists, and was mixed and mixed by pharmaceutical professionals in strict accordance with the operation sequence of parenteral nutrition mixed preparation under the clean environment of horizontal laminar flow table.
The prepared parenteral nutrient solution should be used now to avoid direct sunlight; If it needs to be stored, it should be placed in a refrigerator at 4℃ to avoid light and refrigerated, and it should be rewarming before infusion; Even in cold storage, the time from the end of infusion must be limited to 48 hours to ensure safety and effectiveness.
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Can other drugs be added to parenteral total nutrient solution?
In order to reduce the volume load of patients, parenteral nutrition mixture may be used as the infusion carrier of drugs in clinic. Strictly speaking, neither industrial three-cavity bags nor hospital preparations can be used as infusion carriers for other drugs.
The mixed total nutrient solution is a relatively stable system. If other drugs must be added, it is necessary to carefully evaluate the stability of the system and the effectiveness of each component, and closely monitor the adverse reactions and pharmacological activities of the drugs during the medication.
References:
[1] National Bureau of Statistics. Bulletin of the Seventh National Census: Population Age Composition.
[2] Geriatrics Branch of Chinese Medical Association. China Expert Consensus on Multidisciplinary Decision-making Model of Malnutrition in the Elderly (2023)
[3] Prevalence and outcomes of malnutrition among hospitalized COVID-19 patients: a systematic review and meta-analysis. ClinNutr ESPEN(2021)
[4] The impact of nutritional status,nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center, prospective cohort study in Chinese teaching hospitals. Nutr Cancer(2013)
[5] Cancer Nutrition Committee of China Anti-Cancer Association, Parenteral Nutrition Branch of Chinese Medical Association. China Expert Consensus on Safety Management of Parenteral Nutrition (2021).
Author: Xu Luzhong
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