A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing

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Abstract

Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation.

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Most cited references 148

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GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.

Gordon Guyatt, Andrew D Oxman, Elie A. Akl … (2011)

This article is the first of a series providing guidance for use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments (HTAs), and clinical practice guidelines addressing alternative management options. The GRADE process begins with asking an explicit question, including specification of all important outcomes. After the evidence is collected and summarized, GRADE provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations are characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of the alternative management options. GRADE suggests summarizing evidence in succinct, transparent, and informative summary of findings tables that show the quality of evidence and the magnitude of relative and absolute effects for each important outcome and/or as evidence profiles that provide, in addition, detailed information about the reason for the quality of evidence rating. Subsequent articles in this series will address GRADE's approach to formulating questions, assessing quality of evidence, and developing recommendations. Copyright © 2011 Elsevier Inc. All rights reserved.

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GRADE guidelines: 3. Rating the quality of evidence.

Howard Balshem, Mark Helfand, Holger Schünemann … (2011)

This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence. Copyright © 2011 Elsevier Inc. All rights reserved.

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GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias).

Gordon Guyatt, Andrew D Oxman, Gunn Elisabeth Vist … (2011)

In the GRADE approach, randomized trials start as high-quality evidence and observational studies as low-quality evidence, but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias. Well-established limitations of randomized trials include failure to conceal allocation, failure to blind, loss to follow-up, and failure to appropriately consider the intention-to-treat principle. More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results. Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance. Risk of bias may vary across outcomes (e.g., loss to follow-up may be far less for all-cause mortality than for quality of life), a consideration that many systematic reviews ignore. In deciding whether to rate down for risk of bias--whether for randomized trials or observational studies--authors should not take an approach that averages across studies. Rather, for any individual outcome, when there are some studies with a high risk, and some with a low risk of bias, they should consider including only the studies with a lower risk of bias. Copyright © 2011 Elsevier Inc. All rights reserved.

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Author and article information

Journal

Title: Journal of Parenteral and Enteral Nutrition

Abbreviated Title: JPEN J Parenter Enteral Nutr

Publisher: SAGE Publications

ISSN (Print): 0148-6071

ISSN (Electronic): 1941-2444

Publication date Created: March 03 2014

Publication date Created: March 2014

Publication date (Electronic): February 14 2014

Publication date (Print): March 2014

Volume: 38

Issue: 3

Pages: 334-377

Affiliations

[1 ]University of Pennsylvania, Philadelphia, Pennsylvania

[2 ]Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

[3 ]Auburn University, Auburn, Alabama

[4 ]Carl Vinson VA Medical Center, Macon, Georgia

[5 ]University of Tennessee Health Science Center, Memphis, Tennessee

[6 ]Medical College of Wisconsin, Milwaukee, Wisconsin

[7 ]Vanderbilt University Medical Center, Nashville, Tennessee

[8 ]Moffitt Cancer Center, Tampa, Florida

[9 ]Nationwide Children’s, Columbus, Ohio

[10 ]A.S.P.E.N., Silver Spring, Maryland

Article

DOI: 10.1177/0148607114521833

PubMed ID: 24531708

SO-VID: 009f7e53-6b3e-4b7d-a3dc-d69b5848af29

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http://journals.sagepub.com/page/policies/text-and-data-mining-license

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A.S.P.E.N. Clinical Guidelines : Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing

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Abstract

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Karger: Nutrition and Dietetics

Most cited references 148

GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.

GRADE guidelines: 3. Rating the quality of evidence.

GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias).

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Cited by 53

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