药学热点话题：ASHP优势：USP与肠外营养——菜单上有何新变化

欢迎收听ASHP Advantage播客，与ASHP官方专家对话，聆听顶尖从业者关于药学和医疗保健领域最新议题的讨论。

Welcome to the ASHP Advantage podcast, engaging the experts on ASHP official, featuring conversations with top level practitioners about the latest issues in pharmacy and health care.

感谢收听本期药学热点话题节目，我们将与内容专家座谈，探讨当前药学界的焦点问题。

Thanks for joining us for this episode of pharmacy hot topics, where we sit down with content matter experts and discuss what's currently top of mind in the world of pharmacy.

我是迈克·加尼奥。

My name is Mike Gagneo.

我是ASHP药学实践与质量高级总监，今天与我同台的嘉宾有：Cardinal Health认证与用药安全总监帕蒂·基恩利，以及密西西比浸信会医疗中心临床药学服务主任、密西西比大学杰克逊分校药学院临床药学实践副教授菲尔·艾尔斯。

I'm senior director of pharmacy practice and quality with ASHP, and I'm joined today by Patty Keenley, director of accreditation and medication safety at Cardinal Health, and Phil Ayers, chief clinical pharmacy services at Mississippi Baptist Medical Center and a clinical associate professor of pharmacy practice at the University of Mississippi School of Pharmacy in Jackson, Mississippi.

本期节目是ASHP Advantage播客系列'对话专家'的一部分，呈现与顶尖从业者的深度访谈。

Today's episode is part of the ASHP Advantage podcast series, engaging the experts, featuring conversations with top level practitioners.

本播客由辉瑞公司教育基金赞助，可为药师和药技人员提供0.5学时的继续教育学分认证。

This podcast is supported by an educational grant from Pfizer Incorporated and is accredited for zero point five contact hours of continuing education credit for pharmacists and pharmacy technicians.

获取继续教育学分请访问elearning.ashp.0rg。

To process CE, visit elearning.ashp.0rg.

以下活动内容负责人存在相关财务关系声明：

The following persons in control of this activity's content have relevant financial relationships.

发言人兼顾问菲尔·艾尔斯与费森尤斯卡比、美国瑞健及Vipron公司存在顾问关系。

Phil Ayers, who's a speaker and consultant for Fresenius Kabi, a consultant for American Regent, and a consultant for Vipron.

其他内容负责人均不存在认证教育中定义的'不合格公司'相关财务关系，符合诚信与独立性标准。

All other persons in control of content do not have any relevant financial relationships with an ineligible company as defined by the standards of integrity and independence in accredited education definition of ineligible company.

所有相关财务关系已在继续教育活动前完成合规处理。

All relevant financial relationships have been mitigated prior to the CE activity.

帕蒂、菲尔，感谢二位今天的参与。

Patty, Phil, thank you for joining us today.

我们开始吧。

Let's go ahead and get started.

目前在肠外营养领域，你们认为最具挑战性的议题有哪些？

What are some of the most challenging topics that you both see in parenteral nutrition today?

要知道，我们在这方面拥有相当广泛的专业知识。

You know, we have pretty broad expertise here.

在开始之前，我想先分享几个来自ASHP全国医院药学实践调查的快速数据。

And as we get started, I wanna throw out a couple of quick facts from the ASHP National Survey of Hospital Pharmacy Practice.

2023年，约半数受访者正在使用市售多腔室即混系统。

In 2023, about half of respondents were using commercially available multi chamber ready to mix systems.

相信我们稍后会深入讨论这些。

I'm sure we'll get into those.

约20%的机构将PN生产外包，13%在使用某种自动配药设备。

About 20% are outsourcing their PN production, and about 13% are using some sort of automatic compounding device.

其余受访机构主要不在其设施中使用TPN。

The rest of our respondents primarily don't use TPN in their facilities.

由此可见，各医院在PN的制备、调剂和给药方式上存在很大差异。

So we have a pretty wide range of how our hospitals are preparing, dispensing, and administering PN.

帕蒂，你在实践中观察到哪些与PN相关的情况？

Patty, what are some of the things you see in relation to PN in your practice?

嗯，确实存在一些挑战，比如人们需要明确七月份的工作重点，以及其中涉及的稳定性和无菌性限制问题。

Well, certainly, there's the challenge of folks knowing what the priorities are in July and some of the stability as well as the sterility limits that are in there.

这就是其中一个问题。

So that's one issue.

确实，短缺问题一直存在，我们处理这个问题似乎已有几十年了，在某些组件方面。

Certainly, the shortages come up all the time, and we've been dealing with this for decades, it seems like, at this point for some components.

我认为另一个重要问题是培训与能力，不仅涉及调配静脉输液的人员，还包括开具医嘱和监控的人员。

And I think the other big thing that comes up is the training and competence of not only the folks mixing the IVs, but also those who are writing the orders and monitoring them.

那你呢？

And so how about you?

你是营养学专家。

You're you're a specialist in nutrition.

你看到很多人正在面临哪些挑战？

What challenges do you see that many are struggling with?

是的。

Yeah.

帕蒂提出了一些很好的观点，我也想到了一些其他问题。

Patty brought off some great points, some other things I thought of too.

你知道，我们的营养治疗方案中新增了一些内容，虽然令人兴奋，但也带来了挑战。

You know, we've had some some newer additions to our nutrition, regimens, which have been exciting, but have also been challenges as well.

美国现在有一些以前没有的新型脂肪乳剂。

We do have some new lipid emulsions now in The US that we've not had, previously.

因此我们在适当剂量、相容性以及该领域知识匮乏方面遇到了一些问题。

And so we're got some issues in terms of appropriate dosing, compatibility, lack of understanding in that area.

我们还看到美国现有的多种微量元素产品进行了重新配方。

We've also seen some reformulations on multi trace elements available in The US.

所以，再次出现了一些与此相关的剂量错误。

And so, again, some dosing errors have occurred related to that.

多腔袋的使用正在增加，但在由谁来激活这些袋子、应该由谁操作、是否应在药房完成等方面存在挑战。我们确实认为应该在药房的无菌条件下进行激活。

The multi chamber bags, we're starting to see increased use of those, but there have also been some challenges there in terms of who's going to activate those, who should be doing that, should they be done, you know, in the pharmacy, which we do believe they should be activated in the pharmacy under sterile conditions.

此外，我们发现一些报告显示患者没有激活腔室，导致他们无法获得适量的营养，而且治疗方案也不完整。

And then, you know, in terms of we've been doing some reports of people not activating the the chamber, so patients not getting the appropriate amount of nutrition and then also they're not complete regimens.

因此我们必须添加多种成分和微量元素，才能使这些营养方案完整。

So we have to add things like multiple items and trace elements to those to make them complete nutrition regimens.

另一个现象是，虽然我们明显转向了电子健康记录（这很好），但在肠外营养与电子健康记录系统的功能对接方面仍存在不足。

The other thing we've seen too, we've obviously moved more toward electronic health records, which is great, but we've also seen somewhat a lack of functionality related to parental nutrition and EHRs.

有些电子健康记录系统可能无法与自动配药设备通信。

Some of the EHRs may not communicate with automated compounding devices.

如果无法通信，就可能出现转录错误。

And so if they don't, then you have that the possibility of transcription errors that have occurred.

护理过渡也是肠外营养领域的热门话题。

Transition of care, that's also another hot topic in in parental nutrition.

我们在实践中发现，当患者从医院转到家庭护理或从家庭返回医院时，机构间缺乏沟通，这在美国确实造成了一些错误。

We're we're seeing some gaps there in practice where people are going from maybe the hospital to the home or the home back to the hospital and a lack of communication there between those organizations has actually created some errors in The United States.

迈克，你提到了自行配药和外包配药之间的这种二分法。

And, you know, Mike, you mentioned about that kind of dichotomy between folks mixing up themselves and those who are outsourcing it.

我认为有时当工作外包时，医院或医疗机构内部人员并不完全了解其中涉及的复杂性。

And I think some of the times when things are outsourced, there isn't that knowledge inside the hospital or the health care setting that they're doing of the complexity of what's going on there.

我觉得有时候信息在这个流程中丢失了。

I think sometimes things get lost in that process.

我完全同意。

I agree totally.

你知道，我们提到了教育缺失的问题。

You know, we mentioned the lack of education.

这不仅存在于药学领域，在医学和护理领域也同样如此。

Not only has that been in pharmacy, but in medicine and nursing as well.

我们发现关于父母营养方面的教育存在不足。

We've seen a lack of education regarding parental nutrition.

所有这些学科在PN过程中都非常重要。

All those disciplines are very important in the PN process.

因此我认为这其中肯定存在一些机会。

And so I think there's definitely some opportunity there.

这无疑是我们正面临的一个挑战。

Certainly a challenge that we're facing.

说得很对。

It's a good point.

随着更多转向多室袋或外包，我们正在丧失这项技能。

And as there's more of a shift toward multi chamber or outsourcing, we're losing that skill.

我需要指出的是，当我列出那些统计数据时，小型医院更倾向于使用某种市售的多室袋系统。

And I should point out when I listed those statistics, smaller hospitals are much, much more likely to use some sort of commercially available multi chamber system.

外包在不同规模的医院中相当普遍，但自动配药设备的使用在大型医院中更为常见。

Outsourcing is fairly even throughout different bed sizes, but but the use of an automated compounding device is much more prevalent in larger hospitals.

所以这些关于PN制备或分发方式的全国调查数据或许并不令人意外。

So perhaps not surprising, those are the data from the national survey about how PN are prepared or dispensed.

好的，基于大家正在面临或听到的挑战和关切，我们有很多内容需要深入探讨。

Well, we have a lot to get into then based on the the challenges and concerns that you all are facing or hearing about.

让我们从BUDs开始讨论。

Let's kick off with the BUDs.

我知道这是个热门话题。

I know this has been a hot topic.

USP第787章显然经过了修订，相对较新发布并已生效。

USP chapter seven eight seven was obviously revised, has relatively newly been published and enforceable.

帕蒂，对于肠外营养产品中的BUD，我们应该关注哪些方面？

Patty, what should we be looking for for a BUD in a parenteral nutrition product?

人们似乎仍然困惑的一个问题是：无菌限度（定义为BUDs和797）与储存时间之间的区别——从开始混合到开始给患者用药的时间段。

One of the things that people still seem to be confused about is that difference between the sterility limits, which are defined as BUDs and seven ninety seven, and think of that as a storage time from the time you start mixing something until the time it starts to be administered to the patient.

但我们不能忽视稳定性问题。

But we can't lose sight of the fact of stability issues.

这在PN（肠外营养）中尤为重要，因为其中含有太多成分。

And this really comes into play with PN because there's so many components in there.

人们往往认为797表格中列出的使用期限是默认日期，但实际上并非如此。

People tend to think that the seven ninety seven beyond use dates that are listed in the table are default dates, and they're really not.

这些实际上是我们需要考虑的最长期限。

They're really maximum dates that we need to think of.

因此当我们处理像PN这样含有多成分的制剂时，必须牢记其中的稳定性问题。

So when we're dealing with preparations like PN that have multiple components, we have to remember that stability piece in there.

如果你查阅Aspen和Bill及其同事等人的大多数文献，主要讨论的通常是室温下30小时限制，以及需要时冷藏9天的期限。

And if you look at most of the articles that Aspen and other Bill and his colleagues and others have done, primarily, we're talking about a usually a thirty hour limit for room temperature and certainly that nine day refrigerated if we need to go that long.

不过我也对Phil关于此事的评论很感兴趣，因为人们总是不假思索地直接采用7月表格中列出的时间，而忽略了稳定性与无菌性之间的相互作用。

But I'm interested in Phil's comments too on that because people tend to think, oh, gee, we can use those times that are listed in July without thinking of that interaction between the stability and sterility.

是的。

Yeah.

这些观点很棒，帕蒂。

Those are great point, Patty.

感谢你提出这一点。

Thanks for bringing that up.

当你考虑PN（肠外营养）时，它可能是我们使用的最复杂的药物之一，ISMP实际上已将其列为高风险药物。

And it is when you think about PN, it is probably one of the most complex medications that we use, and ISMP actually listed on high alert medication.

我认为人们常常把它当作营养，但它实际上是一种药物。

And I think oftentimes think of it as nutrition, but it's really a medication.

它非常复杂，而且时间和温度等因素对这些产品的稳定性起着巨大作用。

It's very complex that and also things like time and temperature play a huge role in terms of stability of these products.

因此，在考虑所有这些成分时，我们必须考虑到这一点，特别是如果我们考虑将脂肪乳添加到PM中，形成三合一或全营养混合液。

And so we have to take that in in consideration when we're looking at all these components, especially if we're looking at adding maybe lipid emulsions to the PM where we have a three zero one or a total nutrient admixture.

我们知道，如果超过30小时室温存放，会出现一些稳定性问题。

We know that there's some stability issues if we go out past thirty hour room temperature.

你实际上可以看到脂肪乳可能发生一些分离现象。

You can actually see some separation there in terms of your lipid emulsions that may occur.

其他方面，随着温度升高，磷酸钙确实会沉淀。

Other things, calcium phosphate certainly can precipitate as it starts to warm up as well.

这就是为什么我们不超过30小时室温存放或患者挂液后24小时的悬挂时间。

And so that's why we don't exceed that thirty hour room temperature or a twenty four hour hang time once we hang that in the patient.

不应超过24小时。

It should not exceed twenty four hours.

显然，在家庭环境中，我们经常使用九天期限的产品，这些是发送给患者的。

The nine days, obviously, we use a lot in the home environment where we're sending these out to the patients.

因此，确保不超过九天期限非常重要，我们还会指导患者如何添加多种维生素。

And so it's very important that we we not exceed that nine days and we even teach the patients what to add multivitamins to those.

但我们必须意识到，在发送这些产品时仍存在稳定性问题。

But we need to be cognizant of the fact that we still do have stability issues sending those out.

我们认为九天是最合适的期限。

Nine days, we feel is the most appropriate.

现在我要说明，我们确实有一些神经脂质乳剂进入了美国市场。

Now I will say we do have some neuro lipid emulsions to The US market.

您可以咨询一些掌握最新信息的制造商。

You may can check with some manufacturers that have some more updated information.

但总体而言，Aspen已确定室温下30小时、冷藏9天的标准，这涵盖了肠外营养中所有可能使用的成分，我们认为这是最安全的产品处理方式，与第797章相关。

But as a whole, Aspen has decided that the thirty hours at room temperature, nine days refrigerated, really encompasses all the components that we would use in parenteral nutrition and believe that's the safest way in terms of handling these products as related to chapter seven ninety seven.

您提到了冷藏九天的标准，特别是在家庭护理环境中，因为我们显然需要以某种方式照顾这些患者。

And, you know, you mentioned the nine day for refrigerated and particularly from the home care environment because obviously we have to take care of those patients somehow.

但在急性护理方面，我们通常不需要那么长时间，可以在更短的时间内完成，使用期限可以大大压缩。

But we really don't need that usually, that length of time on an acute care side that can be done in a much shorter, much more compressed beyond use state.

没错。

That's correct.

对。

Right.

正是如此。

Exactly.

比尔，你提到了一些新型脂肪乳剂，其中有些已经使用了几十年，积累了丰富的使用经验。

Bill, you mentioned some of the newer lipid emulsions, and some of these have been around for decades and there's a lot of experience with them.

有些是较新的产品。

Some are newer.

对于正在考虑更换配方脂肪乳剂，或因短缺被迫更换的临床医生，你有什么建议吗？

Do you have any recommendations for practitioners as they're maybe looking at formulary change for their lipid preferred lipid or perhaps unintentional forced change because of a shortage?

关于脂肪乳剂，你有什么经验之谈可以分享吗？

Is there any words of wisdom that you have for for lipid emulsions?

是的。

Yeah.

我想说，首先它们之间不能随意替换。

I would say they're they're first of all, they're not interchangeable.

自上世纪七十年代以来，我们一直使用100%大豆油产品。

Since the nineteen seventies, we used a 100% soybean oil.

它一直是我们的主力产品，确实是个不错的选择。

That's been a workhorse for us, and and it's been it's been a good product to have around.

这使我们能够减少葡萄糖用量，同时满足必需脂肪酸需求。

We've been able to reduce the amount of dextrose we've given people, and we've also been able to meet those essential fatty acid needs.

但现在美国市场上出现了双油和四油脂肪乳剂，它们确实存在一定差异。

But now that we have now the two oil and a four oil lipid emulsion on The US market, they certainly are somewhat different.

要知道，四油产品含有鱼油成分，这在患者评估时需要纳入考量。

You know, the four oil actually contains fish oil, so that's something to take into consideration when you're looking at patients.

双油产品则是大豆油与橄榄油的组合。

The two oil is a soy olive oil combination.

因此，当我们查看部分稳定性兼容性数据时，大部分实际上是在20世纪70年代和80年代完成的，所以它并不一定与新型脂肪乳剂相对应。

And so when we're looking at some of the stability compatibility data, most of that actually was done in the 1970s and '80s, and so it doesn't necessarily correspond to the newer lipid emulsion.

所以我们必须牢记这一点。

So we we need to keep that in mind.

但当我们考虑配方选择时，我认为必须考虑患者群体。

But when we're looking at, you know, formulation selections, I think you have to look at your patient population.

例如，对于一些长期患者，使用大豆油含量较低的新型脂肪乳剂可能更有益，因为其植物甾醇含量更低。

For instance, for some of our long term patients, it may be more beneficial to use one of the newer lipid emulsions with less soybean oil because of phytosterol content is lower in those.

我们知道植物甾醇是一种植物固醇，也可能具有肝毒性。

We know that phytosterol is a plant sterol that also could be hepatotoxic.

这一点可能需要纳入考量。

That may be something to take into consideration.

现在我要说的是，人们常问我关于单一脂肪乳剂的问题，有时这有点困难，特别是当你研究某些新型脂肪乳剂时。

Now I will say that people ask me about, you know, one lipid emulsion, and and sometimes that's a little difficult, especially if you're looking at some of the newer lipid emulsions.

我们可能仍需要在医院处方中保留100%大豆油制剂，用于毒性处理和麻醉。

We still probably need to have a 100% soybean oil on the hospital formulary for toxicities, anesthesia.

关于神经脂肪乳剂的信息或数据并不多。

There's not a lot of information or data with the neural lipid emulsions.

但我确实认为使用某些神经脂肪乳剂肯定有益处，特别是当我们考虑鱼油等不同成分以及更低的植物甾醇含量时。

But I do think there's certainly some benefit from using some of the neural lipid emulsions, especially when we're looking at various components like fish oil and maybe less phytosterol.

我分享的关于多腔袋使用普遍性的数据让你们感到惊讶吗？

The data that I shared about the prevalence of multi chamber bags surprise either of you.

对于多腔袋的使用，你们有什么建议吗？

And do you have any words of wisdom for the use of multi chamber bag?

或许是一些注意事项或安全考量。

Maybe some dos or don'ts or some safety considerations.

确实，ISMP提供了一些很好的信息，人们可以参考以了解这些要素及潜在的安全问题。

Well, there's certainly some good information from ISMP that people can take a look at to see what those elements are and what the safety issues can be.

一个关键问题是这些药物在何处被激活，以及如何在急症护理环境中处理。

One thing comes up is where do these get activated and how are they handled in the acute care setting?

显然，有不少地方通过自动分发柜或其他库存区域供护理人员在病房激活这些药物。

And there's a good number of places, apparently, that provide these through automated distribution cabinets or other stock areas for nursing to activate on the units.

因此，这就涉及到这种治疗方式是否紧急到需要以这种方式进行，还是应该在药房完成。

So, you know, there's that issue of is this an emergent enough form of therapy that that needs to be done in that manner or should it be done in the pharmacy?

我认为我们都清楚，不仅是最佳实践，更是出于安全考虑，这些操作确实应该由药房来完成。

And I think we all kind of know not only best practice but really kind of past best practice into more safety issues that it really needs to be done by pharmacy.

不过我猜菲尔对此会有一些高见。

But I bet Phil has some words of wisdom on that.

我完全同意这一点。

I I totally agree with that.

我认为我们需要在药房激活这些药物。

I think we need to be activating these in pharmacy.

我们在阿斯彭重点强调的一点是不使用‘预混’这个术语。

I I one thing that we have focused on in Aspen is not using the term premixed.

我发现很多人都在用‘预混’这个词。

I think a lot of people are using the term premixed.

如果你查阅早期文献，这些产品常被标注为预混产品，但实际上它们并非如此。

If you look at the older literature, these products were often listed as premixed products, and they're really not.

正如帕蒂所说，它们需要被激活。

As Patty says, they need to be activating.

你知道，在美国我们有双室和三室袋。

You know, we have a two chamber and a three chamber bag in The US.

双室袋含有氨基酸葡萄糖，三室袋含有氨基酸葡萄糖和脂肪乳。

The two chamber's amino acid dextrose, the three chamber's amino acid dextrose, and lipid emulsion.

因此它们必须——实际上这些腔室之间有密封层——所以首先必须激活它们。

So they have to be, they actually have a seal between all those chambers, so they have to be activated, number one.

所以它们并非真正预混好的。

So they're not really a premixed.

我们在实践中经常看到的第二点是人们会激活这些袋子，但没有添加重要成分如复合维生素和微量元素。

The second thing that we see quite often in practice is people will activate those, but they don't add important components like multivitamins and trace elements.

这些患者确实需要这些，因为很多时候这是唯一的营养来源，如果不添加这些成分，他们确实会出现微量元素和维生素缺乏症。

And these these patients really need these because this is really the many times, only source of nutrition, and they can certainly develop trace element deficiencies and vitamin deficiencies if we don't add those.

所以这些成分非常重要。

So that's those components are really important.

另外如果我们使用双室袋，必须意识到它只含氨基酸和葡萄糖，因此仍需同时给予脂肪乳，否则患者可能发生必需脂肪酸缺乏。

And also if we're using the two chamber bag, we have to realize that's only amino acids and dextrose, so we still need to give lipid emulsions with that or those patients are at risk of developing essential fatty acid deficiency.

我们在实践中还发现，这些袋子可能在病房未被激活，导致患者只接受了一个腔室的内容。

Another thing that we've seen in practice is that the bags maybe are on the unit and not activated and so the patient only receives one chamber.

很遗憾，这样他们就无法获得完整的营养方案。

So unfortunately, they don't get the complete regimen in that way.

其中有些袋子容量各异，剂量通常基于给患者提供的蛋白质量来决定。

And some of these are they're all in various volumes or different sizes and you base the dose usually on the amount of protein you're giving the patient.

因此可能出现患者无法获得整袋以满足需求的情况，但遗憾的是，由于容量问题，我们有时会看到这些输液袋悬挂超过24小时。

So it could be that a patient may not get the entire bag to meet their needs, but unfortunately, there are times we've seen these bags hang over twenty four hours because of the volume.

患者并不需要全部容量，但却允许悬挂24小时，这会增加感染风险。

The patient doesn't need the entire volume but they're allowed to hang over twenty four hours which increases the risk for infection.

这确实也是个值得关注的问题。

That's certainly a concern as well.

你知道，关于悬挂时间或给药管理——无论你们机构怎么称呼——最近有越来越多相关信息出现，虽然主要不是针对TPN（全肠外营养），而是关于在合理范围内允许输液袋根据需要悬挂的时间。

You know, that hang time issue or administration or however it's termed in your organization, there's been more and more information coming out on that, not so much on TPNs, but the allowance for allowing a bag to hang for as long as it needs you within reason.

我认为人们需要在政策中认识到，他们应该针对24小时给药时间制定一些关于持续营养的条款。

And I think people need to recognize in their policies that they need to put something in about perennial nutrition for that twenty four hour administration time.

说得好。

Great point.

是的。

Yeah.

我认为这是个很好的观点。

I think that is a good point.

要知道，飓风海伦导致的无菌液体短缺，促使许多机构重新评估了关于悬挂时间的政策。

And, you know, hurricane Helene and the resulting shortages of sterile fluids had a lot of organizations reevaluating their policies for hang time.

听众可能熟悉ASHP（美国卫生系统药师协会）关于应对短缺的建议——感谢许多协助整理这些建议的人——但每当我查阅可接受的悬挂时间时，这始终是个反复出现的主题，不包括肠外营养或脂肪乳剂，也不包括血液制品。

And wherever the listeners may be familiar with the ASHP recommendations on managing their shortages, Thanks to many people who helped pull those together, but that was a repeated theme every time I looked for what was acceptable hang time, excludes parenteral nutrition or lipid emulsion and excludes blood products.

人们必须明确区分这与典型的维持性静脉输液不同，后者可能除了穿刺外未经其他处理。

It really is important for people to distinguish that this is not the same as a as a typical maintenance IV fluid that perhaps has not been manipulated other than being spiked.

这个激活环节让我想起——大概是二十年前——当时有些审计数据和可用信息。

The activation piece actually reminds me of, I don't know, maybe twenty years ago, there were audits and some information available.

或许是通过ISMT，那些专有的袋装和文件系统被挂载了起来。

Maybe it was through ISMT that the proprietary bag and file systems, they would hang those.

患者会得到50毫升或100毫升的生理盐水，但从未有人启动或对接过，完全对接并混合了附着的抗生素。

The patient would get fifty mls or hundred mls of saline, and no one ever activated or docked, fully docked and mixed the antibiotic that was attached.

所以这是个非常好的观点，这种风险并非新概念。

So it's a really good point and something that it's not a new concept that that's a risk.

我很感谢提到这一点。

So I appreciate the mention of that.

我们在讨论可能更换脂肪乳剂产品时稍微提到了短缺问题。

We touched a little bit on shortages when talking about maybe shifting between lipid emulsion products.

我知道微量元素曾出现过间歇性短缺。

I know trace elements have have had some intermittent shortages.

实际上，我记得在哪里看到过一份清单，列出了TPN或PN可能添加的20种成分，每种成分包括胰岛素在内都曾出现过短缺。

Actually, I believe somewhere I saw a list of maybe 20 potential additives to TPN or PN, and every single one of them at some point, even insulin, has been in shortage.

Phil，对于管理这些因更换盐类或脂肪乳剂配方导致的短缺，你有什么建议吗？

To Phil, do you have any words of wisdom for managing those shortages shifting between maybe different types of salts, different formulations of lipids?

你如何确保患者一方面获得所需营养，另一方面所有制备过程都尽可能安全？

How do you make sure that the patient's, one, getting the nutrition they need, but two, that everything is being prepared as safely as possible?

对。

Right.

我认为现在确实有一些很好的资源可用。

I think that's some really good resources out there.

美国肠外与肠内营养学会（Aspen）联合美国卫生系统药师协会（ASHP）提供了一些关于肠外营养短缺的优秀资源，详细说明了如何处理氨基酸、葡萄糖、脂肪乳、微量元素和维生素的短缺问题，为医疗机构提供了实用指导。

Aspen, along with along with ASHP, has some really nice resources source resources regarding parental nutrition shortages that really addresses amino acids, dextrose, lipids, trace elements, vitamins that give you some insight as to how to deal with those, you know, in your facility.

举个例子，在MBI或复合维生素短缺时期，你可能需要将某些患者的给药频率从每日一次降至每周三次。有趣的是，我们通过Aspen的调查发现，许多年轻临床医生从业以来从未经历过非短缺时期。

You know, for instance, maybe during a time of MBI or multivitamin shortage, you may go from daily down to three times a week on some of your patients, which an interesting point is that we actually, through Aspen, through some surveys, we realized that a lot of our younger clinicians have never practiced when there was not a shortage.

迈克，你刚才提到了目前存在的多种短缺问题。

You know, Mike, you mentioned the multiple shortages out there.

因此很遗憾，他们中很多人可能接受的就是这类限制性培训，比如MBI每周三次或微量元素每周三次的给药方案。

So a lot of them, unfortunately, maybe were trained to do some of these limitations like MBI three times a week or trace elements three times a week.

所以在实际工作中，他们延续了这种做法，即便短缺结束后也没有恢复每日给药方案。

So, again, in practice, they continue that and don't go back to maybe the daily delivery of this once the shortage is is is finished.

这意味着我们还需要在这方面加强教育。

So, I mean, there's, again, some education that needs to be done there as well.

但我认为ASHP和Aspen协会都提供了非常优质的资源。

But I think use ASHP Aspen has some excellent resources.

另一点是，在肠外营养短缺时期，我们必须确保这些患者确实是肠外营养的合适候选者。

I think the other point is that during these times of PN shortages, it's really important to make sure that these are really patients are truly appropriate candidates for parenteral nutrition.

这方面也需要我们仔细评估。

I think we have to look at that as well.

有时候我们给本可以实施肠内营养的患者使用了肠外营养。

And sometimes we have patients maybe that we could do enteral feeds in that we're doing parenteral nutrition.

因此我认为与医疗团队和处方医生保持密切沟通非常重要。

So I think, you know, working with your providers and your prescribers, I think, is really important.

他们必须了解这些产品可能存在的供应限制。

And they have to understand the limitations that may be out there regarding some of these products.

每当我们以为短缺即将结束，新的短缺又接踵而至。

And just when we think we're over shortage, here comes another one.

我认为我们很可能会看到，ISMP的调查也会显示，许多人在这些短缺时期使用过多室产品，尤其是对那些蛋白质或电解质需求不高的患者。

I think that also we're going to see probably and I think the survey will tell you the ISMP survey will tell you that many people have used some of the multi chamber products during these times of shortages, especially in those patients that don't have, high protein needs or electrolyte needs that are are large.

他们实际上可以开具多室袋以满足这些患者的营养需求。

They may actually be able to prescribe a multi chamber bag to meet the nutritional needs in those patients.

因此这是许多人也在利用的一个缺口。

So that's kind of a a gap that a lot of people have used as well.

但我确实认为通过ASHP和Aspen提供的那些资源，能为你提供关于如何处理这些短缺时期及正确应对方式的深刻见解。

But I do think that those source those resources through ASHP and Aspen to give you some really good insight as to how to handle these, these times of shortages and the appropriate way to do that.

再次强调，与所有人沟通非常重要，特别是要让医疗人员、护理人员以及所有药房工作人员都理解应对这些短缺的正确方法。

Again, communicating with everybody, think, is so important, especially your medical staff and your nursing staff and all your pharmacy staff as well need to understand the appropriate way to handle these shortages.

感谢提及Aspen资源。

Thanks for mentioning the Aspen resources.

我还'荣幸'地担任ASHP负责短缺问题的专职人员。

I have the dubious honor of also being the ASHP staff person who's responsible for shortages.

所以我们确实与Aspen保持联系。

So we do correspond with Aspen.

当出现PN组件短缺或可能影响PN输送的情况时，比如几年前自动配药设备的混合阀问题。

And when there's a shortage of a PN component or something that may affect PN delivery, like the mixing valves for the automated compounding devices from a few years ago.

我们会与Aspen的工作人员召开电话会议，有时ISMP也会参与。

We we get on the call with the folks at Aspen and we pair up and sometimes it's ISMP as well.

我们努力确定需要哪些资源来解决具体短缺问题，Aspen的工作人员做得非常出色。

We we try to figure out what resources are needed to address the specific shortage, but Aspen staff there do a fantastic job.

感谢你指出这一点。

So thank you for calling that out.

我认为你们做得非常出色。

And I think you guys did a great job.

你们只是遇到了葡萄糖短缺，人们不得不使用替代品。

You only had the dextrose shortage, and people were having to use glucose.

再说一次，那是完全不同的进口产品。

And, again, that was imported product that was totally different.

所以我认为与Aspen、ASHP等机构的合作非常成功。

So I think teaming up together with, you know, Aspen, ASHP have done a really nice job.

我对此表示衷心感谢。

So I appreciate all the effort there.

Patty，你在前线看到PN（肠外营养）短缺的情况了吗？

Patty, anything you see from the front lines on on shortages in PN?

正如你提到的，可能是阀门、输液装置短缺，人们不得不想办法临时应对，但这并不合适。

As you mentioned, it could be valves, it could be sets, IV sets we've had, you know, shortages with or people trying to, you know, jury rig things when that really isn't appropriate.

我们确实需要重新审视患者是否真的需要这个，以及如何以正确方式提供。

And we really have to take a look back as does a patient really need this and how do we get it to them the correct way?

Phil，就像你提到的多管齐下的方法。

And, Phil, like your mention of sort of a a multipronged approach.

可以继续为需要的患者配制PN，但对其他患者使用多室系统可能更合适。

You know, you can continue to compound PN for the patients that need it, but maybe it's clinically appropriate to use a multi chamber system for for others.

这在正常情况下可能不会采用。

That that might not be under blue sky normal conditions.

这可能不是医疗系统的常规做法。

It may not be the the approach of a health system.

也许他们把一切都复杂化了。

Maybe they compound everything.

但在这些情况下，他们开始寻找替代方案。

But in these cases, they they start looking at alternatives.

你知道，肯定还有其他挑战，我认为短缺问题让我想起你今天早些时候在播客中提到的关于错误风险、转录以及系统间不互通的问题，菲尔。

You know, there's certainly other challenges, and I think the shortages kind of bring me back to what you said earlier today during the podcast, Phil, about risk of error, transcription, the systems that don't talk to each other.

而且我认为短缺也增加了这方面的风险。

And I think shortages increase the risk there too.

你可能会有条形码在检查产品时映射不正确的情况，有些东西可能没有完全集成到电子健康记录系统中。

You might have barcodes that aren't mapped correctly as you're as you're checking products, things that maybe are not built fully in the EHR.

但你提到了一些其他电子健康记录系统的局限性。

But you mentioned some other EHR limitations.

所以你想花点时间多谈谈这个问题，也许还有如何解决或预防其中一些问题？

So you wanna take a minute to talk a little bit more about that and maybe how to address or prevent some of those issues?

是的。

Yeah.

除了界面问题，电子健康记录系统在如何开具肠外营养处方方面确实存在一些问题。

Other than the interface, there's certainly some EHR issues in terms of how maybe the PN is being prescribed.

它是按每日剂量还是按每升剂量开具的？

Is it being prescribed in amounts per day or amounts per liter?

所以你也必须注意这些事情。

So you have to watch for those things as well.

因此电子健康记录系统的功能需要与你的肠外营养订单表单的样式保持一致。

So the functionality of the EHR needs to align with maybe how your PN order form looks like.

我认为关键在于我们要做到这一点。

I think that's really important is that we do that.

此外，能够在电解质方面设置上限、下限和基准值也非常重要。

And also, you know, having the ability to put in backs and maximums and minimums in terms of electrolytes is really important as well.

可以说，我们需要将某种'硬性软限制'纳入其中。

Kind of hardened soft stops, if you will, need to be part of that.

我认为这是我们在肠外营养领域存在改进机会的一个方面。

I think that's, an area where we've got some opportunity for improvement, especially in the parenteral nutrition arena.

但所有这些无疑都是安全问题。

But all those things are certainly safety issues.

要知道，情况已经发生了很大变化——我是1980年开始执业的。

And, you know, the thing that has really changed I I started practicing in 1980.

在我刚入行时，开具肠外营养处方的主要是内科医生，比如外科医生、肺科医生。

So so when I started practicing, we primarily saw physicians, you know, maybe surgeons, pulmonologists, prescribing PN.

但现在我们有药剂师、营养师、医师助理、执业护士。

But now we have pharmacists, dietitians, PAs, NPs.

说实话，现在有多学科人员在不具备充分培训的情况下开具这类处方。

We have a number of disciplines that are actually ordering these with maybe not a lot of training to be quite honest.

因此我认为，只要能在电子病历系统中设置这些安全拦截、最大值、最小值和推荐值，就能让处方更安全。

And so I think anytime we can have these these safety catches and maxes and minimums and and recommendations there within the EHR, I think it just makes for safer prescribing.

这归根结底也关系到专业能力的问题。

And again, really kind of boils down to competency too.

我认为这是整个环节中非常重要的一环。

I think that's really important part of this.

市面上已有一些关于处方、医嘱审核、药物配制乃至行政管理的胜任力模型。

So there are some competency models out there for prescribing, for order review, for compounding, even for administration.

我认为在培训医疗机构全体人员时，建立这些评估体系和核查清单至关重要。

So I think having those in place, those checklist, if you will, I think is really important when you're looking at training your overall staff within your facility.

我觉得这一点非常重要。

I think that's so important.

电子健康记录系统确实能在处方开具、医嘱审核以及与AECD系统通讯方面发挥作用。

And and the EHR certainly could play a role in that in terms of prescribing and even order review and communication with AECD.

关键问题在于我们长期意识到教育必要性，却未能区分人员培训与能力认证的界限。

I think that's a big issue is that we've known so long that education is needed, but we haven't made that distinction between educating people and documenting competency of them.

从监管和认证角度来看，当前重点是要确保人员具备所从事工作的书面能力证明。

And there's a big focus from a regulatory and an accreditation perspective now on identifying that people have documented competency in what they're doing.

是的。

Yeah.

我们当时正在编写作为共识建议的肠外营养指南。

We were writing the PN guidelines that consensus recommendations.

在整个指南中，我们反复强调了专业胜任力。

And and all through there, we we talked about competency.

后来我们开始收到反馈，说大家需要具体指导来帮助落实这些要求。

Then we started hearing comments from people that we need some help here, you know, kinda guide us into how we can do this.

因此我们制定了这些能力评估文件，其中包含的核查清单对之前提到的各个专业领域都很有帮助。

And so that's why we developed these competency papers and even checklists within these papers that I think have been very beneficial for a number of folks out there in all those disciplines that I mentioned previously.

另一个常被忽视的参考资料是静脉治疗护理学会的实践指南，其中专门设有肠外营养章节。

One of the other references and resources that comes up that sometimes gets pushed under the table is the IV Nursing Society has guidelines on practice, and there's a chapter in there on parenteral nutrition.

所以我总是喜欢参考他们自己的学科来做这件事。

So I always like to refer from, you know, their own disciplines to do it.

所以当你和护理人员交谈时，我认为引导他们关注那些有类似指南的同行群体非常有价值。

So when you're talking to nursing, I think it's very valuable to draw their attention to their own groups that have these same kind of guidelines.

而且它们不会那么全面。

And they're not gonna be as extensive.

它们不会涉及复合相关的部分，但关于如何正确给药的信息，里面也有相关内容可以填补空白。

They're not gonna be, you know, the compounding related pieces, but to fill in the blanks on how do we administer this appropriately, there's information in there as well.

说得好，帕蒂。

That's a good point, Patty.

还有一个话题，菲尔，一开始你也提到了护理交接的问题。

One more topic, I think, Phil, at the beginning, you also mentioned transitions of care.

你知道吗，我们讨论时我一直在想这个问题，对于像肠外营养这样的治疗，交接过程似乎风险很高。

You know, as we've been talking, I've been thinking about that one, and that seems like a very risky handoff for something like PN.

就像任何护理交接一样，存在漏洞和出错的风险，但这不仅仅是简单的交接。

You know, as with any transition of care, there's vulnerability and risk of error, but you're not just handing off.

你可能还要改变肠外营养的给药方式。

You're likely changing how that PN is being delivered.

对吧？

Right?

如果是家庭护理，可能由家庭护理人员负责。

So if it's a if it's home, it might be home care.

如果是转往其他机构，他们可能会使用多腔袋而不是患者在急性治疗时使用的给药方式。

If it's to another facility, they may use a multi chamber bag instead of whatever the the patient was receiving at the acute site.

在预防错误或最佳实践方面，你见过哪些能确保护理过渡无缝衔接的措施？

What have you seen as far as either error prevention or best practices to make sure that that transition of care happens seamlessly?

我认为非常关键的是要尽早识别那些可能出院或转院的患者，无论是否有营养支持服务或负责肠外营养监督的人员，都要确保他们与接收机构沟通。

I think it's really important very early on to identify those patients who might be going home or to another facility and whether you have a nutrition support service or whomever's charged with oversight of parental nutrition, being sure they communicate with that accepting facility.

就像你说的，他们可能不进行复合配制。

Like you said, they may not do compounding.

他们可能使用多腔袋。

They may do multi chamber.

很多时候我不得不介入，决定哪种多腔袋最适合该患者。

So many times, I've had to intervene and and decide maybe what the most appropriate multi chamber bag would be for that patient.

另外在物资短缺时期，我们遇到过一些产品变更的情况。

The other thing, you know, during the times of shortages, we've seen some product changes.

因此要能够与下一位医疗提供者沟通：'我们一直这样做，这对你可行吗？'

And so being able to to communicate with that that next provider, if you will, this is what we've been doing, you know, is this gonna work for you?

有时他们会说：'我们没有这种脂肪乳'或'无法获取这种脂肪乳'，或是'无法获取MBI/微量元素'等成分。

And and sometimes I'll they'll say, you know, I don't have this lipid or we're not able to get this lipid or we can't get MBI, we can't get trace, whatever that component may be.

所以我认为尽早开始这种沟通非常重要。

So I think very early on, it's very important to start that communication.

不幸的是，这种情况经常发生在周五下午。

Unfortunately, what happens a lot, you know, happens on Friday afternoon.

对吧？

Right?

于是所有人都忙着收尾工作，而患者却无法理解护理人员的安排。

And so everybody's trying to pull everything together, and then the patient doesn't understand the caregiver.

最重要的是要尽早让他们参与进来，确保他们理解，特别是当他们要回家时，他们需要明白这是什么以及相关的安全事项。

And that's really important to start including them very early on to make sure they understand, especially if they're going home, that they understand, you know, what this is and some safety components of that as well.

尽早进行教育，与下一位医护人员沟通，确保所有人达成共识。

Educating them very early on, talking to that next provider, making sure everyone's on the same page.

老实说，越早开始越好。

Can't start early enough, to be quite honest.

我的意思是，我们要确保交接过程顺利，而不是临时抱佛脚，因为那样容易出问题。

I mean, we wanna be sure that it's an easy hand off and not a last minute cause those are the disasters.

对吧？

Right?

这些情况下患者可能不理解，或者他们没完全明白需要什么——无论是电解质、氨基酸还是其他任何成分。

They're where the patient, you know, doesn't understand or, you know, maybe they didn't get exactly what they needed to in terms of whatever component electrolyte, amino acid, could be anything.

但最重要的是所有人都要达成共识。

But it's it's really important that everyone's on the same page.

所以我认为，或许应该在你们机构内部制定一份检查清单。

And so, again, I think developing maybe within, you know, your facility a checklist.

这可能不仅涉及药房、护理和医疗人员，还包括病例管理等其他部门。

And that may not may involve not only pharmacy and nursing and and provider, but case management, for instance.

要知道，很多医疗系统和医院实际上主导着这个流程。

You know, a lot of health systems and hospitals really kind of drives this process.

因此要确保他们与你们步调一致，所有人都在同一个频道上——这样能实现顺利过渡。

So being sure that they're on the same page as you are and that everyone's, you know, singing from the same songbook, if you will, I think makes for a good transition.

然后我们还要考虑患者需要操作的泵的复杂性，以及不同转介机构之间操作方式的差异。

And then we add in the complexity of the pump that the patient is gonna have to handle too and how different that is in each of the agencies that maybe get referred to.

说得好，佩蒂。

That's a great point, Patty.

因此我们努力建立这种联系，让他们来看望病人，通常我们医疗系统内有协调员负责向病人解释他们将要做的事情，以及他们的泵有何不同。

So what we try to do is we try to make that connection and so they do come and see the patient and they usually have coordinator within the our health system that helps to describe to the patient what they're gonna be doing, what how their pump looks differently.

因为我不会用我的泵来教育他们，因为我的泵和他们在家使用的会完全不同。

Because I'm not gonna educate them on my pump because my pump's gonna be totally different what they're using at home.

所以我认为让他们参与进来也非常重要。

So I think that's very important to pull them in as well.

说得好。

Good point.

佩蒂，这个观点很好。

That is a good point, Patty.

我其实想问，像TN这样的产品用于家庭时，其配制过程与我们在医院或医疗系统内通常的做法有什么不同吗？

I was actually gonna ask you if there's anything different about compounding for home use of a product like TN versus what we would normally do in a in a hospital or a health system or inpatient setting.

泵是个好例子，但我知道有些成分通常需要在给药前立即添加。

A pump is a good example, but I know some ingredients usually have to be added right before the administration.

在797条款或其他法规框架下，有什么我们需要特别注意的事项吗？

Are there any considerations under seven ninety seven or or under other regulatory framework that we should know about?

必须记住797条款针对的是医疗场所，严格来说家庭不算医疗场所，但我们确实需要考虑家庭护理护士和其他辅助人员，以及我们为支持这种实践所做的一切。

Well, have to remember that seven ninety seven talks about healthcare settings, and technically the home isn't a healthcare setting, but certainly we have home care nurses and other aids and whatever we're doing to support that practice that we need to consider.

尽管可能需要自行完成肠外营养最后步骤的患者严格来说不受797条款约束，但我们必须采取正确培训的方式，教会他们无菌技术、操作流程、所需物资以及出现问题时的应对措施。

Even though the patient who may be making some final additions to their parenteral nutrition may not technically be under seven ninety seven, I think we have to take the approach that we need to train people the right way and certainly teach them aseptic technique and how they're gonna do it and what supplies they need and what to do if something goes wrong.

哦，说得好。

Oh, good points.

好的，请你们每人最后说一句。

Well, one last word from each of you.

还有什么参考资料、资源或智慧箴言要分享给听众的吗？

Any other references, resources, words of wisdom for our listeners?

菲尔提到了现有的阿斯彭资源，我认为它们非常出色。

Phil mentioned the Aspen resources that are there, and I think they're excellent.

而且你知道，ASHP会及时发布优质内容，阿斯彭也是如此。

And they're you know, ASHP puts out great things in a timely manner and so does Aspen.

当你真正需要咨询专家时，阿斯彭网站上会及时提供PN相关信息，特别是在物资短缺或其他相关问题时。

And when you really need to go to the specialists, the PN information is there on the Aspen site in a very timely manner when things are in shortage or other concerns that are there.

迈克，我还想提到阿斯彭和ASHP合作推出了一项认证课程。

And, Mike, I'd also like to mention that Aspen and ASHP have worked together on a certificate that's out there.

课程时长约19到20小时，全面涵盖了PN流程的各个领域。

I think it's about nineteen or twenty hours, and I think it really covers all the various areas of the PN process.

虽然内容偏基础，但对于需要额外培训的人来说是绝佳资源，我们收到很多反馈说学员已在机构中实际应用。

It's really foundational in nature, but for those who feel like they need additional training, I think it's an excellent resource and heard back from a number of people, and they've used it in their facilities.

这项认证确实为肠外营养及相关安全操作培训提供了很好的补充。

And it's been really a nice addition to the training in terms of parental nutrition and safe practices related to parenteral nutrition.

好的，谢谢二位。

Well, thank you both.

看来是时候结束讨论了。

It feels like a good place to wrap up.

在此我要感谢帕蒂和菲尔今天参与这场精彩的讨论。

So I would like to thank Patty and Phil for joining us today for this great discussion.

提醒我们的听众访问elearning.ashp.0rg网站，为药剂师和药房技术人员申请本播客的继续教育学分。

And a reminder to our listeners to visit elearning.ashp.0rg to claim CE for both pharmacists and pharmacy technicians for this podcast.

希望您喜欢今天的对话，请务必通过您喜爱的播客平台订阅ASHP播客。

We hope you'd enjoy today's conversation, and be sure to subscribe to ASHP Podcasts through your favorite podcast provider.

谢谢。

Thank you.

感谢您收听ASHP优势播客《专家对话》。

Thanks for joining us for the ASHP advantage podcast, engaging the experts.

请访问ashp.org/podcast发现更多精彩节目，获取节目笔记并下载文字稿。

Be sure to visit ashp.org/podcast to discover more great episodes, access show notes, and download the episode transcript.

如果您喜欢本期节目并想收听更多内容，请务必订阅、评分或留下评论。

If you loved the episode and wanna hear more, be sure to subscribe, rate, or leave a review.

下次节目我们将带来更多ASHP官方的专家观点，敬请期待。

Join us next time for more expert perspectives on ASHP official.