Paul Reynolds, PharmD, BCPS

• Critical Care Pharmacy Specialist, University of Colorado Hospital
• Clinical Assistant Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado

http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx

Note risk of medications increase losses (eg phosphataemia) interaction between calcium and diuretics) quadriceps pain treatment aspirin 100 pills cheap. In general prescription pain medication for shingles generic aspirin 100 pills with amex, Blood glucose level rises in stress (hyperglycaemia) nutrition provision should not be and sepsis pain and headache treatment center in manhasset ny buy aspirin overnight. Uncontrolled compromised in order to control blood hyperglycaemia is associated with 116 109 knee joint pain treatment order 100 pills aspirin amex,110 sugar levels period pain treatment uk buy cheap aspirin on line. Moderate insulin should be reviewed pain treatment center pasadena drive lexington ky aspirin 100 pills amex, and control of blood glucose (6 endocrinology consulted if needed. A higher-lipid (lower nutrition infusions abruptly can 80,81 glucose) formulation may help here. In general, Abruptly stopping parenteral 80,81 (hypoglycaemia) parenteral nutrition should not be used to nutrition can (rarely) cause a < 3. This can be prevented by running the infusion at half the goal rate for an hour, or replacing it with 5% or 10% dextrose for an hour, before stopping completely. If weight) can lead to fatty liver (hyper triglycerides are persistently above this (abnormal liver function tests, esp. Using a 20% lipid emulsion is better Confirm result by repeating the test after utilised than 10% emulsion due to parenteral lipid has been stopped for 2 the more physiological hours. Check that the patient is not being (chylomicron-like) ratio of overfed with fat or glucose as either can phospholipid to triglycerides in the 25 contribute to serum triglycerides (fat lipid droplets. Giving parenteral lipid continuously along Consider carnitine deficiency (see with the rest of the nutrition rather than Micronutrients). Gastrointestinal intermittently (such as twice per week) has fistula is a risk factor for high been shown to lead to improved triglycerides and in this case 31,32 metabolism of the lipid. It may be necessary to change to a parenteral nutrition solution with a more moderate level of protein. Bilirubin high Parenteral-nutrition-related liver disease Haem is released from red blood usually causes an increase in bilirubin in the cells at the end of their life and first 1-2 weeks of parenteral nutrition, recycled by the body. No action converted to bilirubin, and carried is required, apart from ensuring that the to the liver where one of the patient is not being overfed. Haemolysis (eg from abnormal blood cells being destroyed by the Increased bilirubin also occurs in spleen) increases bilirubin level by cholestasis (where there is a biliary releasing more haem. Allow some oral/enteral intake if possible; in particular foods high in fat can stimulate bile flow (eg regular oral/enteral dose of oil; or ice cream! The cell mitochondria of skeletal muscle, aspartate cannot take in more than about heart, pancreas as well as the liver, aminotransferase 7mg/minute/kg. Overnutrition, especially so may be increased in general and alanine with excessive carbohydrate, can lead to trauma. Liver damage due to choline deficiency can be another cause of increased transaminases. If high levels are confirmed, be reduced or omitted for some dose should be reduced. Review energy and if there is ongoing inflammation or protein requirements to ensure that these infection (acute phase response). Trivalent and manufacturer instructions cations like iron are unstable in a three-in should be followed carefully. If extra iron is not recommended in the critically needed it should be a separate infusion. In particular, the liver prioritises the manufacture of inflammatory proteins (such as c-reactive protein) and the levels of these are greatly increased. Normal proteins, such as those involved in carrying vitamins and hormones, are downregulated and their levels decrease independently of nutritional status or the current level of nutrition. This means that these proteins do not indicate nutritional status during the acute phase response. They will decrease, but this does not indicate malnutrition, instead it just reflects the severity of the acute phase response (ie how sick the patient is). Similarly, increasing nutrition support during the acute phase response will not cause an increase in albumin level. Levels of normal proteins will slowly rise on their own as the acute phase response resolves. Central venous access Central venous access means that the infused solution is delivered to the superior vena cava, right atrium or less commonly the inferior vena cava. The venous access device will usually enter the body at another location (so the visible part of a central line might be peripheral on the body) but it is the location of the delivery tip, not the insertion point, that determines whether the access is central or peripheral. Exit site of venous access device the point at which a venous access device initially pierces the skin. Extravasation If a venous access device becomes misplaced, solution may leak into body tissue. If the solution is a vesicant (irritating) substance, this leakage is called extravasation. Extravasation of vesicant substances can cause blistering or necrosis, killing tissue and resulting in large deep ulcerated wounds. Some examples of vesicant substances include parenteral nutrition solutions, electrolytes and drugs. Infiltration If a venous access device becomes misplaced, solution may leak into body tissue. If the solution is a non-vesicant (non-irritating) substance such as saline, this leakage is called infiltration. Insertion site of venous access device the point at which a venous access device pierces the blood vessel (may be some distance from where it entered the skin, when the device is tunnelled subcutaneously). Examples include heparin lock, which is used to prevent clotting when the line is not being used; and antibiotic lock, which may be used to treat an infected line. These lumens can be used to infuse solutions that are incompatible with one another, as they remain separate for the entire length of the device. Osmolality the concentration of a solution, expressed in terms of the amount of osmotically active solute particles per kilogram of solvent. A mole of glucose in solution is osmotically active, but does not dissociate into smaller particles, so it will contain one osmole. Osmolarity the concentration of a solution, expressed in terms of the amount of osmotically active solute per litre of the final formula solution. This is a less common way of describing the concentration, because of the way that volume can change with temperature, altering the measurement. In peripheral delivery, usually the tip of the venous access device is in the axillary or subclavian veins. The smaller size of the vein and slower blood flow mean that the osmolality of the infusion must be limited, and this affects its nutritional profile: see Peripheral Venous Access. Peripheral parenteral nutrition is less commonly used than central parenteral nutrition in Australian hospitals. Phlebitis can be caused by chemical or mechanical irritations (such as highly-concentrated infusions, or infections, or the presence of a venous access device). Pain, tenderness, redness and swelling may occur around the site of the phlebitis. Refeeding the starved or semi-starved patient causes acute cellular uptake of phosphate, potassium and magnesium in particular, and the resulting drop in serum levels can cause a variety of problems that can be fatal if not managed appropriately. Thrombosis Thrombosis means clotting of the blood, and is a problem if the clot occurs within a blood vessel, as it can potentially block blood flow, causing a stroke or a heart attack or ischaemia in a limb. Thrombosis in a vein may occur in connection with inflammation (see Phlebitis, above). Vesicant A substance that is harmful to body tissue, causing damage such as blistering or necrosis. In parenteral therapy, a vesicant substance is one that will kill tissue if extravasation occurs. Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Prevalence and documentation of malnutrition in hospitals: a case study in a large private hospital setting. Most infectious complications in parenterally fed trauma patients are not due to elevated blood glucose levels. A quick guide to ethical theory in health care: solving ethical dilemmas in nutritional support situations. Role of a nutrition support team in reducing the inappropriate use of parenteral nutrition. An interdisciplinary nutrition support team improves quality of care in a teaching hospital. Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. Optimal protein requirements during the first 2 weeks after the onset of critical illness. Energy expenditure and caloric balance after burn: increased feeding leads to fat rather than lean mass accretion. Glutamine supplementation in serious illness: a systematic review of the evidence. Investigation of factors determining the optimal glucose infusion rate in total parenteral nutrition. Effects of glucose-to-lipid ratio and type of lipid on substrate oxidation rate in patients. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Metabolic utilization of intravenous fat emulsion during total parenteral nutrition. Continuous versus intermittent infusion of fat emulsions during total parenteral nutrition: clinical trial. Parenteral infusion of long and medium-chain triglycerides and reticuloendothelial system function in man. Effects of intravenously infused egg phospholipids on lipid and lipoprotein metabolism in postoperative trauma. Plasma lipid and plasma lipoprotein concentrations in low birth weight infants given parenteral nutrition with twenty or ten percent lipid emulsion. The prevalence of coagulation abnormalities in hospitalized patients receiving lipid based parenteral nutrition. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. New Food and Drug Administration requirements for inclusion of vitamin K in adult parenteral multivitamins. Choline deficiency causes reversible hepatic abnormalities in patients receiving parenteral nutrition: proof of a human choline requirement: a placebo-controlled trial. Carnitine balance and effects of intravenous L-carnitine in two patients receiving long-term total parenteral nutrition. Subnormal carnitine levels and their correction in artificially fed patients from a neurological intensive care unit: a pilot study. Trace element monitoring and therapy for adult patients receiving long-term total parenteral nutrition. Trace element supplementation after major burns modulates antioxidant status and clinical course by way of increased tissue trace element concentrations. Magnesium, calcium, zinc, and nitrogen loss in trauma patients during continuous renal replacement therapy. Considerations in choosing a parenteral nutrition formulation 69 Centers for Disease Control and Prevention. Total nutrient admixtures appear safer than lipid emulsion alone as regards microbial contamination: growth properties of microbial pathogens at room temperature. Cardiac tamponade as a complication of catheterization of the subclavian vein prevention and principles of management. Survival times and complications of catheters used for outpatient parenteral antibiotic therapy in children.

A smoking history was also higher proportion (65%) of the sensi studies show that dentine hypersensitiv recorded for each subject the pain treatment center of the bluegrass cheap 100pills aspirin otc. Each subject tivity group had gingival recession of ity is a common problem among the quanti ed their personal perception of! Each subject dichotomised in a logistic regression analysis with the and plaque is complex (Addy et al pain treatment for shingles purchase cheapest aspirin and aspirin. It can be seen from Table3 that frequently pain treatment for carpal tunnel syndrome buy aspirin in united states online, and frequent toothbrushing whether the individual had noticed their within the multivariate analysis the equated with once or more per day pain treatment centers of america colorado springs purchase cheapest aspirin. The extent and severity of gingival recession in cases and controls It can be seen from Table4 that the number of teeth which responded to an Cases with Controls with sensitivity no sensitivity air blast was signi cantly higher in males (P 0 pain treatment center of illinois new lenox generic aspirin 100 pills amex. It is possible that very differ sociated with increasing recession pain medication dogs can take 100 pills aspirin free shipping, such sult of pain resulting from exposed root ent factors are acting in different popu as noticing the teeth getting longer, surfaces. It has been reported that the lations to cause gingival recession and were more prevalent in the cases than act of toothbrushing rarely causes pain ultimately select those individuals who the controls. In ad proximal cleaning reported signi cantly excessive or forceful brushing with re dition, one third (34%) of the controls less severe sensitivity than those who cession. When there is forceful brushing had at least one tooth with recession of performed less frequent plaque re this is often associated with abrasion, 3mm or more. This might suggest that those however, no attempt was made to assess clusions of Addy et al. On the has a multifactorial aetiology and that lower plaque levels had less severe other hand, in populations with little or many people with recession do not ex symptoms. However, it has been sug no access to dental care, gingival re perience sensitivity. One variable high gested that plaque does not itself pro cession is associated with poor oral hy lighted by Absi et al. High levels of recession have been reported in young individuals in Tanzania (van Pal Table4. The number of teeth which responded to an air blast by characteristics of those within enstein Helderman et al. All data shown as mean (standard deviation) some support for the view that different mechanisms can operate simultaneously Factor on different teeth within the same sub Sex Male Female ject. This study was Brush twice or more Yes No not designed to investigate the different per day 11. The multivariate analysis Factor strengthened the association between Sex Male Female recession (! Further studies have been the result of sampling vari associated with an increased severity of which take into account the differences ation. It is probable that poor correlation between the extent of Zusammenfassung smoking was a confounding variable as recession and the self assessed severity Dentinuberemp ndlichkeit bei jordanischen it was almost exclusively a male habit in of sensitivity. This can be com Methoden: Eine kontrollierte Fallstudie wur smoking (Linden & Mullally 1994). Jeder Fall quanti zierte sei the view that smoking was a risk factor a desensitizing toothpaste (Gillam et al. Studies in South-east Asia re Markieren auf einer sichtbaren analogen in the male Jordanian subjects studied. Eine nach Alter was no method of assessing cervical and only 2% in South Korea (Gillam und Geschlecht gemischte Kontrollgruppe dentine hypersensitivity which could be et al. Innerhalb der multivariaten Analyse Because this study was based in several desensitizing toothpastes seems to have wardieOdds-ratiofurdieRezessionenvon! Gillam & New reporting bene cial effects in a compar Zahne, die auf den Luftstrom reagierten, war signi kant hoher bei Mannern (p 0. The relationship with bei jordanischen Zahnarztbesuchern, jedoch which exhibited a sensitive response to gingival recession was not clear cut as die Beziehungen komplex sind. In the current study, multi schlie lich ein Habit der Manner war, waren of recession. Journal of Periodontology 69, des facteurs comme la recession gingivale, les vitro evaluation of treatment agents. Chaque cas quanti at sa vision person and cigarette smoking as risk factors for Kanapka, J. Un grou ` cervical dentine sensitivity in a population rette smoking and periodontal destruction pe controle analogue en age et en sexe de 134 of patients referred to a specialist Period in young adults. Dans cette analyse multivariee, les (1992) Prevalence and distribution of cer in man. Journal of Periodonto sion de plus de 3 mm et la sensibilite etait de tion in Rio de Janeiro, Brazil. This study investigated the prevalence of the male to female ratio of dentine hypersensitivity dentine hypersensitivity in the adult population of was 1:1 5. A multi-stage, strati ed, random ity was highest in the 40 to 49-year age group at sampling method was used to investigate the study 43 9%. Subjects occurred predominantly in the premolars (49 6%), were divided into age groups (10 years per age followed by the anterior teeth (30 5%). A total of group) and included the same number of male 84 3% of dentine hypersensitive patients had and female subjects in each group. The prevalence of dentine completed a dentine hypersensitivity questionnaire hypersensitivity in Shanghai adults was 34 1%, and underwent clinical examination. Therefore, of dentine hypersensitivity was con rmed clinically public education about the condition and effective as a sharp well-localised pain in response to admin treatment of dentine hypersensitivity are required. Dentine hypersensitivity is a logical studies between 1964 and 2003 and found that common oral problem in adults (3). With ageing people the prevalence of dentine hypersensitivity varied from in populations worldwide keeping their teeth longer, 4% to 74%. In Switzerland, Graf and Glase survey methods and different target populations also (5) found that 15% of 351 subjects showed dentine in uence the determined prevalence of dentine hyper hypersensitivity. To accurately determine the prevalence of lence of dentine hypersensitivity in Brazil was 17%, dentine hypersensitivity and identify in uential factors while Clayton et al. For examination, the participants report on dentine hypersensitivity in Shanghai, China. Any teeth with obvious caries or Methods fractures or large restorations were excluded. In addition, gingival recession of hypersensitive teeth Population was examined with a 1 mm graduated periodontal the survey group was comprised of ve adult age probe (Williams periodontal probe). P <0 05 was considered statistically sig and two suburban counties were randomly selected ni cant. For the urban districts, three streets were randomly selected as Results investigation points for each urban district. Forty-four people (22 males and 22 females) were randomly Of the 2120 participants participating in the survey, 804 selected from each of the ve age groups at each urban (37 9%) complained of current or previous symptoms investigation point. Of those complaining of from the six investigation points in the two urban hypersensitive teeth, males accounted for 40 5% districts. For the suburban counties, two villages towns (326 804) while females accounted for 59 5% were randomly selected from each suburban county as (478 804). Forty people (20 males and 20 complained of current hypersensitive teeth and 18 8% females) were randomly selected from each of the ve (151 804) of participants complained of previous tooth age groups at each investigation point. However, only 35 1% (282 804) of people were selected from the four investigation points the participants had visited a dentist regarding the in the suburban counties. A total of 24 5% (197 804) of the participants from two urban districts and two suburban participants reported < 1 year of hypersensitive teeth, counties were included in the study population. A questionnaire survey was conducted by trained Clinical examination found that 723 of the 804 interviewers through face-to-face interviews. The ques participants reporting hypersensitive teeth had tionnaire included questions about participant age, sex, symptoms of dentine hypersensitivity. Therefore, the occupation, years of education, previous or present prevalence of dentine hypersensitivity was 34 1% tooth hypersensitivity, duration of hypersensitivity and medical history. The male to female ratio of dentine 7 hypersensitivity was 1:1 5 (295 males: 428 females). While the prevalence of Age (years) dentine hypersensitivity in suburban areas was slightly Fig. The lower than that in urban areas, the difference was not 20 to 29-year-old age group showed signi cant difference statistically signi cant (Table 1). A total of group at 38 4% (163 424), 60 to 69-year-old 30 5% (699 2291) of the teeth exhibiting dentine age group at 37 7% (160 424), 30 to 39-year-old age hypersensitivity were anterior teeth, where upper group at 33 7% (143 424) and 20 to 29-year-old age anterior teeth accounted for 12 9% (296 2291) and group at 16 7% (71 424) (Table 2). In total, 2291 hypersensitive teeth were detected Overall, molars accounted for 19 9% (456 2291) of among the 723 participants with dentine hypersensi dentine hypersensitive teeth, where upper molars tivity. The average number of hypersensitive teeth per accounted for 10 1% (231 2291) and lower molars person was 3 2 (2291 723) with a range from 1 to 17 accounted for 9 8% (225 2291) (Fig. Among the ve age groups, the 50 to 59-year Overall, 84 3% (1931 2291) of dentine hypersensi old age group had the highest number of hypersensitive tive teeth had gingival recession. Most participants Dentine hypersensitivity occurred predominantly on (92 8%) had gingival recession between 1 and 3 mm premolars at 49 6% (1136 2291), where upper premo (Fig. The prevalence of dentine hypersensitivity in 28 35 Shanghai adults was 34 1%, which was at a medium 60 62 68 59 level compared to other studies. Other studies have also reported the Lower right relationship between the prevalence of dentine Fig. The different age distribution of dentine hypersensitiv >3 mm ity prevalence for different studies could arise from the age compositions of the study populations. There was no signi cant difference in the prevalence Discussion of dentine hypersensitivity between suburban and Investigation of dentine hypersensitivity is usually urban areas. However, further study is required of carried out by either questionnaires or clinical exam differences resulting from different economic standards, inations. The prevalence of dentine hypersensitivity lifestyle and eating habits between urban and rural can be overestimated if using only questionnaires as a areas that may affect dentine hypersensitivity. In clinical examinations only, the choice of participants this study, the male-to-female ratio of dentine hyper can bias the results. For example, many studies sensitivity was 1:1 5 which is consistent with the ratio reported a higher than 50% prevalence of dentine of 1:1 6 reported by Orchardson and Collins (16). Rees hypersensitivity (14, 15), which might be due to the and Addy (17) reported an even higher ratio of 1:2 5. However, other studies (12, 24) found that thank all the subjects for their kind participation in this molars were most susceptible in patients with study. Dentine hypersensitivity: its prevalence, incisors, resulting in gingival recession and exposed aetiology and clinical management. Consensus-based recommendations for the diagnosis and the number of dentine hypersensitive teeth per management of dentin hypersensitivity. The prevalence of reported age group had the highest number of sensitive teeth per hypersensitive teeth. In 96 1% of the tion of cervical dentine hypersensitivity in a population in Rio affected teeth, gingival recession was located in the de Janeiro, Brazil.

Addition of phosphate gallbladder pain treatment diet buy discount aspirin, magnesium and calcium to the parenteral admixture is limited due to stability issues northside pain treatment center atlanta buy generic aspirin 100 pills online. Note that different forms of electrolyte supplementation will have different effects on acid-base balance (for example potassium chloride versus potassium 68 acetate) medial knee pain treatment purchase cheapest aspirin and aspirin. A solution that is to be delivered peripherally should have an osmolality below 900mOsm/kg to avoid irritation to the blood vessels spine and nerve pain treatment center traverse city mi order 100 pills aspirin otc. In the case of intradialytic parenteral nutrition (see Sites of Delivery pain medication for dogs for arthritis order aspirin 100pills without a prescription, below) neuropathic pain treatment guidelines discount aspirin online visa, the osmolality is not restricted in this way as the solution is infused along with the blood, which 10 dilutes it. Lipid has a much lower osmolality than amino acids, glucose or electrolytes, so peripheral solutions are high in fat. Several different factors affect the shelf-life and hang-time of parenteral nutrition solutions. Firstly, interaction between the macronutrients and/or micronutrients reduces the availability of the nutrients and the stability of the solution. Shelf-life is prolonged by keeping macronutrients separate (as in a multi-chamber bag) and/or by loading micronutrients into the solution as close as possible to the time of starting the infusion. For example, lipid solutions have a lower osmolality and acidity than amino acids or glucose solutions, and therefore form a better growth medium for bacteria. Consequently the hang time for lipid on its own is shorter (usually 12 hours) than for three-in-one or two-in-one 69 solutions (24 hours). Stability Loss of stability (eg where the lipid ceases to be fully emulsified or where compounds precipitate out of solution) can make the parenteral nutrition formula unsafe for infusion. Several factors can have an impact on the stability of a parenteral nutrition solution. Multi chamber bags usually have a long shelf-life at room temperature because their reactive components are kept separate; individually-compounded bags, and those with the micronutrients already added, usually need to be kept refrigerated and have only a short shelf life. Specialty parenteral formulations Specialty formulae are available in addition to the ones listed above. Standard solutions are appropriate for the majority of patients, but they are relatively low in protein and contain a standard amount of electrolytes. Therefore, particular groups who might benefit from an individualised formulation include: patients with increased protein or electrolyte requirements (such as with burns, critical 21 illness, trauma, post major surgery or where there are increased losses such as with fistula or intestinal failure); patients requiring restricted fluid or electrolytes (such as renal patients); and home parenteral nutrition patients who will benefit from having their full daily fluid and nutrient requirements provided by one bag of the correct volume. Other alternatives Instead of using expensive individualised formulations, it may be possible to increase protein or electrolyte input separately from the parenteral nutrition. Additional protein can be given in the form of protein modular solution, using another lumen of the central line or (less desirably, because of infection risk) by piggybacking it onto the same lumen as the parenteral nutrition infusion. Note that these methods do provide additional fluid, which needs to be taken into consideration. Additives to parenteral nutrition Each solution has an upper limit for nutritional additives, such as electrolytes or micronutrients, and these additives should be discussed with a pharmacist to ensure that the resulting solution will be stable. In general, because parenteral nutrition solutions are so complex (containing a large number of different substances, many of which are reactive), it is not recommended to 10 mix any medications with parenteral nutrition or infuse them through the same lumen. The most common exceptions to this rule are ranitidine (for gastric acid suppression) and insulin, both of which are added to parenteral nutrition solutions in some facilities. Adding insulin to parenteral nutrition can be a convenient way to provide a continuous insulin infusion to provide baseline requirements, with the advantage that it is automatically stopped when the parenteral nutrition is stopped. Also note that some of the insulin will be lost via adsorption to the bag surface, so the patient will require a dose that is slightly different from that in a separate infusion or injection. If insulin is added to the parenteral nutrition bag, frequent blood glucose monitoring is essential for the entire time that the parenteral nutrition is infusing. Propofol Propofol is a short-acting sedative delivered in a 10% lipid solution, ie providing 1. Sometimes patients are receiving a continuous infusion of propofol for several days and this adds to the amount of intravenous lipid that the patient is receiving. See Drug-Nutrient Interactions in the Troubleshooting section for more details on Propofol. From there, the solution is carried in the blood to the heart for immediate circulation around the body. Central venous access means the fluids are delivered to the superior vena cava or right atrium, or less commonly the inferior vena cava (from a femorally-inserted line). The central position of the line tip is always confirmed by chest x-ray (unless the line was placed under fluoroscopy/x ray in the first place). In peripheral venous access, the tip of the line is usually in the axillary or subclavian veins. Intradialytic parenteral nutrition is another form of peripheral access (see Sites of Delivery, below). Access problems are the most common barrier to successfully establishing and maintaining parenteral nutrition. If the patient has existing intravenous access, it is important to check whether the device is suitable for parenteral nutrition, is placed centrally, and has a lumen available that can be dedicated for nutrition: it may be the case that the current line is fully occupied and an extra line must be inserted before nutrition can commence. A line that has become infected is not suitable for parenteral nutrition and has to be removed. Central venous access Whilst all central venous access devices, by definition, have their delivery tip in the vena cava or right atrium, different types will be inserted via different sites on the body and vary in how long they can be used, and how complicated the insertion and removal methods are. More lumens make the line thicker, stiffer, and more complicated to insert, increasing infection risk but allowing simultaneous infusion of multiple solutions. Can last ~12 months unless vein problems (eg phlebitis) occur necessitating replacement, but rarely used longer than 2 months at many hospitals. Inserted under x-ray in operating theatre under general anaesthetic (due to painful tunnelling process). A connection needle is aseptically stabbed through the skin into the port for use. Inserted in operating theatre, under image intensifier, usually with a general anaesthetic due to painful subcutaneous placement process. Chest x-ray is required before use to confirm correct placement and exclude pneumothorax. Line is silastic, attached to a plastic disc with silastic septum that the needle stabs into, through the skin. It may be indicated in a limited range of situations (where some nutrition is better than nothing, and there is no central access) but requires a high level of expertise in placing the access device and caring for the site in order to maintain access and spare the patient from frequent repeated cannula insertions. Situations that may be indications for peripheral parenteral nutrition Peripheral parenteral nutrition may be indicated if: * parenteral nutrition is indicated but the likely duration of use is less than two weeks * patient is malnourished, has been on central parenteral nutrition and central access has been lost (eg due to line displacement or infection) or is not yet available, where it is undesirable for them to receive no nutrition while waiting for their new central line to be placed Solutions that can be used peripherally must usually be limited to less than 900mOsm/kg to minimise blood vessel damage. This means that peripheral parenteral nutrition solutions are a larger volume, more dilute solution, with a higher proportion of fat (eg 40-60% of total energy) because fat has lower tonicity. Uses vein in arm (in general, the blood flow needs to be at least 150mL/minute, so the veins on the hand are too small). The smallest cannula available (eg 22 gauge) should be used with the largest straightest vein available, to allow blood to flow around the catheter. If the tube is incorrectly positioned, the infusion fluid may cause serious damage to the blood vessel or surrounding tissue. Apart from portacaths that are not currently being used (where the intact skin covering protects against infection once the incision is healed), central lines require careful attention to the exit site, the insertion site and the hub. To reduce infection risk, the exit site (the area where the device enters the skin) is usually covered with a breathable transparent dressing that needs to be kept dry, ie protected from water with plastic when showering. Tunneled cuffed catheters can often be managed without a dressing once the incision is healed, as the subcutaneous tunnel and cuff are sufficiently protective against infection, however in hospital a dressing would still normally be used. The hub (the port or stopper at the end of the device which receives the infusion) is the other major source of potential infection. Risk increases when there are more manipulations of the hub (such as connecting and disconnecting bags of solution, flushing) so it is good to minimise these as far as possible. The hub is wiped with 70% alcohol before and after anything is connected or disconnected. In general, one lumen of the venous access device should be reserved for parenteral nutrition only, and other substances should not be administered using that lumen. While not recommended, if other substances are to be given into that lumen, the line should be flushed with 5mL normal saline before and after they are given. Additionally, central lines are sometimes flushed with a solution of heparin to prevent them blocking with blood-clot or fibrin. Flushing usually occurs daily, although portacaths need to be flushed only once per month. In parenteral nutrition, in contrast, any manipulations of the line or giving set will increase contamination risk and therefore for infusions without lipid it is recommended not to change the giving set more frequently than 72 hours unless infection is suspected. Infusions containing lipid may need more frequent changes and every 24 hours is 69 10 usually recommended. The small-sized filters that stop bacteria cannot be used with lipid as they do not allow lipid droplets to pass intact, and thus destabilise the emulsion. Filters therefore tend not to be used in places where three-in-one solutions are in wide use. Increasingly, this bottle system has been replaced by combination 1000mL, 1500mL or 2000mL bags. Sturdy plastic light-protective cover bags are provided with most parenteral nutrition products, but sometimes need to be ordered separately. An opaque plastic shopping bag or brown-paper medications bag, or aluminium foil, are all reasonable alternatives if the covers are temporarily unavailable. Any covering should be folded or taped closed at the bottom for maximum protection. Opaque giving sets are also available for ambulatory patients who will regularly be outside in direct sunshine during infusion. Pumps should be kept clean by wiping daily with a cloth moistened in mild detergent and water. Check that the supplier provides maintenance service as this can be another cause of nutrition interruptions for home patients. The goal is to provide safe parenteral nutrition and hydration appropriate to the clinical status of the patient, taking quality of life issues into consideration. Note that each facility will normally have its own standard parenteral nutrition formulations and typical regimens. There may be nursing procedures that set out what time parenteral nutrition bags are changed, and which staff have the authority to order or hang the bags or add vitamin and trace element additives to them. Continuous parenteral nutrition Parenteral nutrition infuses for 24 hours continuously. Cyclic infusions are commonly used in long-term parenteral nutrition, especially for home patients who may receive infusions overnight only, or only on some days of the week. The availability of close monitoring is usually the factor that determines whether it is safe to start at the goal rate in a particular 80,81 setting. Starting parenteral nutrition infusions abruptly can (rarely) cause temporary hyperglycaemia, particularly if the solution is high in glucose. Starting the infusion with a lower glucose solution or at half the goal rate for an hour or two, before increasing to goal rate, can prevent this, and may be recommended in patients with known glucose intolerance.

Purchase genuine aspirin. HERCULES - finding solutions to drug resistance in high-grade serous ovarian cancer.