Premix TPN

[Zoe Brown]

May I know your opinion in the use of premix adult TPN. Smofkabiven peripheral emulsion. Does it replace the manually mixed TPN? is it safe?

Thanks

[Alchemist]

The pre-mixed products are not clinically useful to be used on unstable either acute or occasionally chronic PN patients. Currently, I don’t use these products because they are expensive and also they aren’t suitable to be used on IBD، short gut syndrome, and oncology patients. These patients are on 12-14 hrs cycle PN and occasionally experience episodes of dehydration when they are off PN.

[Kay Little]

Recently, I have looked into the utilization of premix PN (three chamber bag system). Below steps may help in assessing the utilization of premix PN

• Assess current PN utilization and patient population by performing utilization review
• Retrospective or prospective PN utilization review. (looking at the below criteria)
  • Age group (Adult, pediatric, neonates)
  • Central or peripheral PN
  • Indications, comorbidity​​
  • Short term or long-term
  • Number of PN orders per day

• You may also asses pros and cons of each customized versus premix

1- Safety: Measured by ADR (Complication)

2- Efficacy: Since there is no single indicator to assess nutritional status. Efficacy can be assessed by comprehensive evaluation of weight, electrolytes level, hydration status, prealbmuin etc.

3- Cost: Direct (Cost of the PN bag customized versus premixed) and indirect (staffing and equipment)

Usually, stable young patients with no co-morbidity will tolerate ready-made PN and it’s a cost saving to the institution. However, if the majority of patient population is pediatric and neonates then customized can’t be replaced by ready-made.

Hope this will help

[Troy Jacques]

Although from a paediatric view point but our network has been using standard PN solutions for quite some time now and it’s seems to be the growing trend throughout major paediatric tertiary hospitals throughout the country.

It was a little strange at the beginning for me when I started this role as I always learnt that “from scratch” bags are usually the best for paediatric patients and hard to have a “one size fits all” solution.

However, with careful calculations and ensuring PN is prescribed by specialised teams – standard solutions have worked well. We have recently reviewed our current standards and we have managed to keep the options to a small number (excluding the neonatal group for their PN solutions have been standardised on a state level some time ago – this was an impressive project!).

We are guided by Baxter manufacturing whenever we manipulate standard bags in our sterile suite and a renewed shelf life or expiry of a manipulated solution is allocated by Baxter according to their in house studies. Usually our additions involve adding trace elements and multivitamins and some extra electrolytes. Fat emulsions are given separately.

Deletion of any electrolyte component will obviously require a bag to be made up from scratch.

It does save on labour costs for us and free up pharmacists from being in the hood most of their day. Our pharmacy trading hours and dynamics and technology in the sterile suites differ quite a bit to standards abroad, hence why PN premixes have been a life saver for resource challenged settings.

Hope this helps you see things from a different angle.

[Ezra Scott]

I think it can be a good starter for a new patient
I met the company previously and they have three different bags with different calories.
My concern about mixing the lipid with PN, which can increase the risk of precipitation for any reason without catching the small particles.
As I recognized from my experience some units they have a hot climates and manipulate the PN frequently and that can increase the risk.
But it’s optional to add the lipid to PN.
I have some valuable information about the product.
Please, let me keep now if you need anymore help.

[Ezekiel Collins]

Regarding your question to this specific product, Smofkabifen, peripheral formula, It is indicated for the age for 2 years and above.
The formula comes in volume in 1904 ml. The electrolytes content in the whole volume if patient used all provides less than maintenance requirement,
I support to use this formula for stable patient for short term if he/she doesn’t have any major diseases like heart, liver r renal failure, fluid restriction or multiple or severe electrolyte imbalances,.
It can be infused over between 12 to 24 hrs. it provides almost 1239 KCal for the whole volume (1904 ml) around 20 kcal/kg/day for 60 kg patient weight. and Calories and other Macro and Micro nutrients will be reduced if the volume is reduced.

It is stable for 24 hours after activation the bag. The rate of PN Premix is based on total fluid requirement for the patient.
It has to be attention that fat included in smofkabiven contains different fat sources soya bean, MCT, olive oil, and fish oil). So, it is important to check any allergy to these products.

[Lewis Coates]

I agree with Ezekiel, it can be used for short term and medically stable patients, because one of its major drawbacks is that one bag fits all, which is not the case in reality, even when the company has 2 or 3 choices, you still need to choose the most suitable among them.

On the other hand, premixed TPN may be cost effective if you have less number of preparations daily, or when you don’t have a safe protocol and a reliable location for sterile compounding services at your hospital. It can be used also as a starter and on the pharmacy-off days (if you have any).

I would like also to notify you, there are other premixed bags from other companies, such as Baxter Olimel bags (for 2 years and above), you should have a look on them or other companies as well before making your purchase decision.

One final point, it is not recommended to add any electrolytes or others to these bags (except compatible vitamins), otherwise you may compromise their sterility and/or stability. This rule is also applied to Pharmacy prepared TPN bags, not only the premixed.

[Ezekiel Collins]

I agreed what Lewis said
“One final point, it is not recommended to add any electrolytes or others to these bags (except compatible vitamins), otherwise you may compromise their sterility and/or stability’

In addition to adding additional electrolytes to premix PN will increase the osmolarity of PN which may not suitable for peripheral administration.

[Author]

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