The Use of a Simplified Standardized Hyperalirn en fa tion 'Formula
Murray H. Seltzer, MD Mokhtar Asaadi, M D Albert Coco, RPh Edward T. Lucchino, RPh Anna L. Catena, RPh
Abstract: The use of a standardized hyperalimentation solution that can be modified is discussed. A comparison of in-hospital addition of electrolytes with factor addition of electrolytes is presented, in which both solutions are acceptable to patients and in which the labor and cost to the pharmacy are decreased in the factory-mixed additives. Once a decision has been made to provide a patient with hyperalimentation, the actual mechanics and details of writing orders and preparing solutions become important. The exact nature ofsuch details will vary from institution to 'institution depending upon available resources. Herein is presented a simplified, practical method for the writing of appropriate orders and preparation of suitable hyperalimentation solutions. A comparison between two standardized hyperalimentation formulae is presented. The details provided are intended to reduce the task of administering hyperalimentation fluids from the realm of the esoteric to that of the practical. It is hoped that such simplification will facilitate t h e use of parenteral nutrition in most hospitals. MATERIALS A N D METHODS
From the Departments of Surgery and Pharmacy, Saint Barnabas hledical Center, Livingston, New Jersey 07039. Dr. Seltzer is Associate At fendingin Surgery and Chairtnan, Surgical Nufrilion Commiffee, Saint Barnabas Medical Center, Clinical Assistanf Professor, New Jersey College of hledicine and Dentistry: Dr. Asaadi is Resident in Surgery, Saint Barnabas hledical Center; A. Coco and E. Lucchino are Pharmacists in Charge, Hyperalit,ietitation Solulions; and A. Catena is Direcfor of Pharmacy. Requests f o r reprints should be addressed to Alurraj 11. Seltzer, hlD. 201 South Livingston Avenue, Livingston, New Jersey 07039.
28
The Saint Barnabas Medical Center is a 750-bed general hospital, the largest of its kind in New Jersey, providing the entire spectrum of medical and surgical care. It has nine residency programs with a total of 92 housestaff. Orders are written by both attending physicians and housestaff, and are conveyed to the pharmacy by unit secretaries at each nursing station through the use of video matrix terminals as part of the Technicon Medical Information System. These orders are generated in the pharmacy on a multiprinter. The ordering of hyperalimentation solutions is not restricted to an exclusive team of physicians within the hospital. A Surgical Nutrition Committee consisting of physicians, pharmacists, nurses and dietitians oversees general policy related t o nutritional support. It was decided in 1973, because of the many different physicians writing orders including so manyadditivesper bottle of hyperalimentation solution, that efficiency and accuracy as well as patient care would be improved via the use of a standard hyperalimentation formula for all patients. Individual modifications were to be made according to a specific patient's needs. Thus, a standard formula was subsequently established consisting of components described in Table I. By agreement with the pharmacy, it was decided that one ampule of watersoluble and fat-soluble vitamins (MVI) would be added to VOLUhlE 2 I NUhlBER 1 I 1978
TAR1.E I
TABLE I I
S T A S D A R D I Z E D H Y P E R A L I S i E S T A T I O S FORXf ULA AS P R E P A R E D IS HOSPITAL PHAR51ACY
S T A S D A R D I Z E D If YPE R ALI 51 EXTATIOS FOR h.IU L A USISG FACTORY PREXIIXED ADDITIVES
I
Additke
I. Transfer 500 cc amino acid (8.55 FrrAmine II)* solution t o 500 cc 5 0 5 dextrose.
I. Add 500 cc amino acid (8.57 Travasol)* solution t o 500 cc 507.
2. Add 45 mEq sodium chloride.
2. Add 9.2 mEq calcium gluconate.
3. Add 30 mEq potassium acetate.
Final Electrolyte Composition
4. Add 10 mEq potassium acid phosphate.
Sodium 35 m E q ’ L .
5. Add 9.2 mEq calcium gluconate.
Potassium 30 mEq ‘L.
6 . Add 8.1 mEq magnesium sulfate. \... .
Additive
\’I
-
hlagnesium 5 mEq ’ L.
Final Electrolyte Composition
Acetate 65 m E q ’ L. Chloride 35 mEqlL.
Sodium 50 m E q / L . Potassium 40 m E q / L .
Phosphate 30 mEq 1L.
hiagnesium 8. I mEq/ L.
Calcium 9.2 mEq L.
Acetate 30 mEq/L. Chloride 45 mEq/L. Phosphate 20 mEq/L. Calcium 9.2 mEq/L. *Conrains sodiriiJi5 m E q aridphosphaic I0 tirEq
in 500 cc.
the first liter daily of hyperalimentation fluid for each patient, and that none would be added t o successive liters given during the same day. It was further agreed that the preparation of all solutions and any modifications of the formula were t o be performed only by the hospital pharmacy without exception. Folic acid, 1 mg/day, vitamin K, 20 mg twice weekly and vitamin B I Z , 1,000 pg monthly were to be given intramuscularly and not intravenously. Neither heparin nor insulin were added routinely t o solutions. Each bottle of hyperalimentation solution was labeled individually t o note all components and additives. With the establishment of the above format the physicians were then able t o merely write for the volume and rate of the hyperalimentation fluid, and would only designate changes in additives when necessary. For example, a typical order might read “1,000 cc hyperalimentation fluid every eight hours,” or “1,000 cc hyperalimentation fluid every eight hours and increase potassium to a total of 60 mEq per liter.” Patients routinely were monitored by at least daily complete blood count, blood sugar and electrolytes for the first three days, with the same studies subsequently ordered three times per week. An SMA-12 was ordered twice weekly. Fractional urines and, at times, T H E J O U R N A L OF P A R E K T E R A L A N D E N T E R A L KUTRITION
fractional blood sugars were monitored with appropriate sliding scale insulin coverage. The techniques described above were met with such acceptance, facility and patient tolerance that it was decided by the Surgical Nutrition Committee to further simplify the preparation of the hyperalimentation solution by changing t o a solution containing factory premixed additives (Table 11) rather than requiring the hospital pharmacy to provide and mix all additives. In an effort t o evaluate the effectiveness and efficiency of this latter change t o factory-mixed additives, a record was maintained within the pharmacy of all deviations required by physician orders from the prearranged formulae. Patient acceptance and homeostasis were adjudged by each physician caring for his own patient, based upon clinical’evaluation and the above-noted laboratory tests. Patient tolerance t o the prearranged formula was assumed if n o orders modifying the formula were written.
RESULTS One thousand consecutive bottles of FreAmine 11, as prepared for 20 patients in our hospital pharmacy (Table I), were compared with 1,000 consecutive bottles of Travasol 8.5% prepared for 32 patients (Table 11). The frequency and nature of deviations from the standardized formulae were recorded and compared (Table 111). Findings of note were that 13.3% of the FreAmine 11 liters required a change in formula with 13.1% of those 29
STANDARDIZED HYPERALIhf ENTATION FORhf ULA
TABLE 111
COhZPARISON O F FREQUENCY O F CHANGES IN STANDARDIZED SOLUTIOSS 1,000 Liters of Hospital Prepared Formula (FreAmine I1 8.5%) (Table 1)
1,000 Liters of Factory Premixed Formula (Travasol 8.5%) (Table 11)
Percent of liters not requiring any change.
86.7
83.3
Percent of total liters requiring any change.
13.3
16.7
Percent of liters requiring change as potassium change.
13.1
16.3
I
2.7
16.0
Percent of liters with decrease in potassium.
10.4
0.3
Percent of liters with increase in sodium.
0.2
0.3
Percent of liters with increase in calcium.
0
0.I
6,300
2,336
Total number of pharmacy transfers to prepare 1,000 liters.
changes related to potassium and 0.2% related to sodium. With the use of Travasol8.5%, 16,7%of the liters required a change in formula with 16.3% of the changes related to potassium, 0.3% related to sodium and 0.1% related to calcium. Ten patients were hyperalimented during the transition from FreAmine I1 to Travasol 8.5% and, therefore, received both solutions consecutively. Four of the ten patients required potassium changes in 25% of the total bottles administered to the group of ten patients while on FreAmine, and three of the ten patients required changes in 43% of the bottles when receiving Travasol8.5%, with 42% of the changes related to potassium and 1% related to sodium. Of further interest was the actual labor expended by the pharmacists in the preparation of either of the solutions. The addition of glucose to amino acids was considered as one step. The addition of each additive or vitamin preparation thereafter was considered an additional step with credit being given if an omission of an additive was necessary. The preparation of 1,000consecutive bottles of FreAmine utilizing the above-noted formula (Table I) with all additives being placed by the pharmacy resulted in 6,300 individual transfers. The preparation of 1,000 consecutive bottles of Travasol 8.5% required 2,336 transfers.
DISCUSSION The use of a standardized hyperalimentation formula that can be modified has proved quite acceptable at 30
-
Percent of liters with increase in potassium.
our institution. The ordering and preparation ofsolutions has been sufficiently simplified that a diversified number of physicians are able to use hyperalimentation solution without resorting to consultation with a hyperalimentation team. The ordering physician is also spared the task of defining multiple additives per liter daily. The fear that unknowledgeable physicians would misuse such a convenience has not in fact been true in our hospital. Furthermore, the number of technical errors committed by the housestaff and attending physicians has decreased. The pharmacy has also functioned as a qualitycontrol checkpoint in that it can question seemingly unreasonable alterations from the standardized formula. While only the above-noted studies are used on a routine basis to evaluate patient progress, these have been satisfactory in the clinical setting. The fact that over 80% of the hyperalimentation liters were used without modifying the basic formula was further evidence for patient acceptability of thissimplified method. It is to be noted further that in over 99% of the hyperalimentation bottles used, either the standard formula was used, or if a modification was required, it was in the form of a potassium alteration. Theconversion to a factory-mixed additive containing solution allowed the pharmacy to decrease the number of steps in solution preparation by 63%. There was the added theoretical advantage of decreased risk of contamination by decreasing the number of steps required for preparation. The use of a factory premixed electrolyte solution also allowed a financial savings to the pharmacy of approximately 25% of the former cost. VOLUME 2 / NUhfBER 1 / 1978
HISTORICAL PERSPECTIVES IN HOSPITAL NUTRITION
by Douglas W. Wilmore, M.D. Dr. Wilmore is with the Brooke Army Medical Center in Fort S a m Houston, Texas. Any ideas for future historical perspectives should be sent to Dr. Wilmore at U.S. Army Institute of Surgical Research, Brooke Army Medical Center, Fort S a m Houston, San Antonio, Texas 78234.
Editor’s Note: In the late 1800’s andearly 1900’sincreasedloss of body protein was describedin patients with infectious disease orfollowing blood letting. and during World War I, acceleratedprotein catabolism was suggested as a metabolic consequence of injury. Yet, it was not until Sir David Cuthbertson and his associates demonstrated the increased loss of nitrogen and other intracellular constituents following long bonefracture that alterations in protein economy became a recognized feature of the post-traumatic metabolic response to injury. At the time of this first observation, Sir David hadjust completed training as a clinical chemist and, encouraged by a senior orthopedic surgeon, set about to determine the metabolic abnornialities associated with fracture nonunion. Although n o major differences could be found between those patients with normal healing and those with nonunion, marked differences in excretion ofphosphorus and nitrogen occurred in all the injuredpatients when compared with the same individuals during convalescence or bed-rest controls. Further studies by Sir David, whose contributions to animal nutrition are as signijicant as his work in post-traumatic metabolism and nutrition, relate the increased loss of intracellular constituents to the extent of injury and describe the characteristic rise in oxygen constiniption and body tenrperature in traumatized patients. He later directed his interest toward modifying the post-trauntatic response by increasing nutritional support and raising ambient temperature. thereby improving care of critically ill hospitalized patients. T H E J O U R N A L OF PARENTERAL A N D ENTERAL NUTRITION
31
Murray H. Seltzer, MD Mokhtar Asaadi, M D Albert Coco, RPh Edward T. Lucchino, RPh Anna L. Catena, RPh
Abstract: The use of a standardized hyperalimentation solution that can be modified is discussed. A comparison of in-hospital addition of electrolytes with factor addition of electrolytes is presented, in which both solutions are acceptable to patients and in which the labor and cost to the pharmacy are decreased in the factory-mixed additives. Once a decision has been made to provide a patient with hyperalimentation, the actual mechanics and details of writing orders and preparing solutions become important. The exact nature ofsuch details will vary from institution to 'institution depending upon available resources. Herein is presented a simplified, practical method for the writing of appropriate orders and preparation of suitable hyperalimentation solutions. A comparison between two standardized hyperalimentation formulae is presented. The details provided are intended to reduce the task of administering hyperalimentation fluids from the realm of the esoteric to that of the practical. It is hoped that such simplification will facilitate t h e use of parenteral nutrition in most hospitals. MATERIALS A N D METHODS
From the Departments of Surgery and Pharmacy, Saint Barnabas hledical Center, Livingston, New Jersey 07039. Dr. Seltzer is Associate At fendingin Surgery and Chairtnan, Surgical Nufrilion Commiffee, Saint Barnabas Medical Center, Clinical Assistanf Professor, New Jersey College of hledicine and Dentistry: Dr. Asaadi is Resident in Surgery, Saint Barnabas hledical Center; A. Coco and E. Lucchino are Pharmacists in Charge, Hyperalit,ietitation Solulions; and A. Catena is Direcfor of Pharmacy. Requests f o r reprints should be addressed to Alurraj 11. Seltzer, hlD. 201 South Livingston Avenue, Livingston, New Jersey 07039.
28
The Saint Barnabas Medical Center is a 750-bed general hospital, the largest of its kind in New Jersey, providing the entire spectrum of medical and surgical care. It has nine residency programs with a total of 92 housestaff. Orders are written by both attending physicians and housestaff, and are conveyed to the pharmacy by unit secretaries at each nursing station through the use of video matrix terminals as part of the Technicon Medical Information System. These orders are generated in the pharmacy on a multiprinter. The ordering of hyperalimentation solutions is not restricted to an exclusive team of physicians within the hospital. A Surgical Nutrition Committee consisting of physicians, pharmacists, nurses and dietitians oversees general policy related t o nutritional support. It was decided in 1973, because of the many different physicians writing orders including so manyadditivesper bottle of hyperalimentation solution, that efficiency and accuracy as well as patient care would be improved via the use of a standard hyperalimentation formula for all patients. Individual modifications were to be made according to a specific patient's needs. Thus, a standard formula was subsequently established consisting of components described in Table I. By agreement with the pharmacy, it was decided that one ampule of watersoluble and fat-soluble vitamins (MVI) would be added to VOLUhlE 2 I NUhlBER 1 I 1978
TAR1.E I
TABLE I I
S T A S D A R D I Z E D H Y P E R A L I S i E S T A T I O S FORXf ULA AS P R E P A R E D IS HOSPITAL PHAR51ACY
S T A S D A R D I Z E D If YPE R ALI 51 EXTATIOS FOR h.IU L A USISG FACTORY PREXIIXED ADDITIVES
I
Additke
I. Transfer 500 cc amino acid (8.55 FrrAmine II)* solution t o 500 cc 5 0 5 dextrose.
I. Add 500 cc amino acid (8.57 Travasol)* solution t o 500 cc 507.
2. Add 45 mEq sodium chloride.
2. Add 9.2 mEq calcium gluconate.
3. Add 30 mEq potassium acetate.
Final Electrolyte Composition
4. Add 10 mEq potassium acid phosphate.
Sodium 35 m E q ’ L .
5. Add 9.2 mEq calcium gluconate.
Potassium 30 mEq ‘L.
6 . Add 8.1 mEq magnesium sulfate. \... .
Additive
\’I
-
hlagnesium 5 mEq ’ L.
Final Electrolyte Composition
Acetate 65 m E q ’ L. Chloride 35 mEqlL.
Sodium 50 m E q / L . Potassium 40 m E q / L .
Phosphate 30 mEq 1L.
hiagnesium 8. I mEq/ L.
Calcium 9.2 mEq L.
Acetate 30 mEq/L. Chloride 45 mEq/L. Phosphate 20 mEq/L. Calcium 9.2 mEq/L. *Conrains sodiriiJi5 m E q aridphosphaic I0 tirEq
in 500 cc.
the first liter daily of hyperalimentation fluid for each patient, and that none would be added t o successive liters given during the same day. It was further agreed that the preparation of all solutions and any modifications of the formula were t o be performed only by the hospital pharmacy without exception. Folic acid, 1 mg/day, vitamin K, 20 mg twice weekly and vitamin B I Z , 1,000 pg monthly were to be given intramuscularly and not intravenously. Neither heparin nor insulin were added routinely t o solutions. Each bottle of hyperalimentation solution was labeled individually t o note all components and additives. With the establishment of the above format the physicians were then able t o merely write for the volume and rate of the hyperalimentation fluid, and would only designate changes in additives when necessary. For example, a typical order might read “1,000 cc hyperalimentation fluid every eight hours,” or “1,000 cc hyperalimentation fluid every eight hours and increase potassium to a total of 60 mEq per liter.” Patients routinely were monitored by at least daily complete blood count, blood sugar and electrolytes for the first three days, with the same studies subsequently ordered three times per week. An SMA-12 was ordered twice weekly. Fractional urines and, at times, T H E J O U R N A L OF P A R E K T E R A L A N D E N T E R A L KUTRITION
fractional blood sugars were monitored with appropriate sliding scale insulin coverage. The techniques described above were met with such acceptance, facility and patient tolerance that it was decided by the Surgical Nutrition Committee to further simplify the preparation of the hyperalimentation solution by changing t o a solution containing factory premixed additives (Table 11) rather than requiring the hospital pharmacy to provide and mix all additives. In an effort t o evaluate the effectiveness and efficiency of this latter change t o factory-mixed additives, a record was maintained within the pharmacy of all deviations required by physician orders from the prearranged formulae. Patient acceptance and homeostasis were adjudged by each physician caring for his own patient, based upon clinical’evaluation and the above-noted laboratory tests. Patient tolerance t o the prearranged formula was assumed if n o orders modifying the formula were written.
RESULTS One thousand consecutive bottles of FreAmine 11, as prepared for 20 patients in our hospital pharmacy (Table I), were compared with 1,000 consecutive bottles of Travasol 8.5% prepared for 32 patients (Table 11). The frequency and nature of deviations from the standardized formulae were recorded and compared (Table 111). Findings of note were that 13.3% of the FreAmine 11 liters required a change in formula with 13.1% of those 29
STANDARDIZED HYPERALIhf ENTATION FORhf ULA
TABLE 111
COhZPARISON O F FREQUENCY O F CHANGES IN STANDARDIZED SOLUTIOSS 1,000 Liters of Hospital Prepared Formula (FreAmine I1 8.5%) (Table 1)
1,000 Liters of Factory Premixed Formula (Travasol 8.5%) (Table 11)
Percent of liters not requiring any change.
86.7
83.3
Percent of total liters requiring any change.
13.3
16.7
Percent of liters requiring change as potassium change.
13.1
16.3
I
2.7
16.0
Percent of liters with decrease in potassium.
10.4
0.3
Percent of liters with increase in sodium.
0.2
0.3
Percent of liters with increase in calcium.
0
0.I
6,300
2,336
Total number of pharmacy transfers to prepare 1,000 liters.
changes related to potassium and 0.2% related to sodium. With the use of Travasol8.5%, 16,7%of the liters required a change in formula with 16.3% of the changes related to potassium, 0.3% related to sodium and 0.1% related to calcium. Ten patients were hyperalimented during the transition from FreAmine I1 to Travasol 8.5% and, therefore, received both solutions consecutively. Four of the ten patients required potassium changes in 25% of the total bottles administered to the group of ten patients while on FreAmine, and three of the ten patients required changes in 43% of the bottles when receiving Travasol8.5%, with 42% of the changes related to potassium and 1% related to sodium. Of further interest was the actual labor expended by the pharmacists in the preparation of either of the solutions. The addition of glucose to amino acids was considered as one step. The addition of each additive or vitamin preparation thereafter was considered an additional step with credit being given if an omission of an additive was necessary. The preparation of 1,000consecutive bottles of FreAmine utilizing the above-noted formula (Table I) with all additives being placed by the pharmacy resulted in 6,300 individual transfers. The preparation of 1,000 consecutive bottles of Travasol 8.5% required 2,336 transfers.
DISCUSSION The use of a standardized hyperalimentation formula that can be modified has proved quite acceptable at 30
-
Percent of liters with increase in potassium.
our institution. The ordering and preparation ofsolutions has been sufficiently simplified that a diversified number of physicians are able to use hyperalimentation solution without resorting to consultation with a hyperalimentation team. The ordering physician is also spared the task of defining multiple additives per liter daily. The fear that unknowledgeable physicians would misuse such a convenience has not in fact been true in our hospital. Furthermore, the number of technical errors committed by the housestaff and attending physicians has decreased. The pharmacy has also functioned as a qualitycontrol checkpoint in that it can question seemingly unreasonable alterations from the standardized formula. While only the above-noted studies are used on a routine basis to evaluate patient progress, these have been satisfactory in the clinical setting. The fact that over 80% of the hyperalimentation liters were used without modifying the basic formula was further evidence for patient acceptability of thissimplified method. It is to be noted further that in over 99% of the hyperalimentation bottles used, either the standard formula was used, or if a modification was required, it was in the form of a potassium alteration. Theconversion to a factory-mixed additive containing solution allowed the pharmacy to decrease the number of steps in solution preparation by 63%. There was the added theoretical advantage of decreased risk of contamination by decreasing the number of steps required for preparation. The use of a factory premixed electrolyte solution also allowed a financial savings to the pharmacy of approximately 25% of the former cost. VOLUME 2 / NUhfBER 1 / 1978
HISTORICAL PERSPECTIVES IN HOSPITAL NUTRITION
by Douglas W. Wilmore, M.D. Dr. Wilmore is with the Brooke Army Medical Center in Fort S a m Houston, Texas. Any ideas for future historical perspectives should be sent to Dr. Wilmore at U.S. Army Institute of Surgical Research, Brooke Army Medical Center, Fort S a m Houston, San Antonio, Texas 78234.
Editor’s Note: In the late 1800’s andearly 1900’sincreasedloss of body protein was describedin patients with infectious disease orfollowing blood letting. and during World War I, acceleratedprotein catabolism was suggested as a metabolic consequence of injury. Yet, it was not until Sir David Cuthbertson and his associates demonstrated the increased loss of nitrogen and other intracellular constituents following long bonefracture that alterations in protein economy became a recognized feature of the post-traumatic metabolic response to injury. At the time of this first observation, Sir David hadjust completed training as a clinical chemist and, encouraged by a senior orthopedic surgeon, set about to determine the metabolic abnornialities associated with fracture nonunion. Although n o major differences could be found between those patients with normal healing and those with nonunion, marked differences in excretion ofphosphorus and nitrogen occurred in all the injuredpatients when compared with the same individuals during convalescence or bed-rest controls. Further studies by Sir David, whose contributions to animal nutrition are as signijicant as his work in post-traumatic metabolism and nutrition, relate the increased loss of intracellular constituents to the extent of injury and describe the characteristic rise in oxygen constiniption and body tenrperature in traumatized patients. He later directed his interest toward modifying the post-trauntatic response by increasing nutritional support and raising ambient temperature. thereby improving care of critically ill hospitalized patients. T H E J O U R N A L OF PARENTERAL A N D ENTERAL NUTRITION
31
