Many studies have documented the prevalence of malnutrition in hospitalized patients. When the gut cannot function, the provision of proper nutrition through either a central or a peripheral vein can correct this state and reduce significantly the morbidity and mortality from many diseases. As parenteral nutrition has become widely available, numerous issues have arisen concerning infectious complications of this therapy.In the early 1970s, there occurred an epidemic of sepsis that was related to contaminated intravenous fluid. This led to a better appreciation of solutions as a possible source of sepsis in patients.' However, there have been only a few reports of sepsis related to microorganism contamination of nutritional formulas. Articles in the literature have documented that a variety of organisms, when inoculated into amino acid, glucose, or lipid solutions, may reach high concentrations in 24 hr, and lipid solutions may show no detectable change in color or appearance.2-4 This led the Center for Disease Control (CDC) and others to recommend for lipid containing solutions, a maximum infusion time of 12 hr.5 In 1982, the Food and Drug Administration approved the use of the admixture of amino acid, dextrose, andlipid. At that time our hospital routinely was hanging the amino acid-glucose solution for 24 hr with fat given separately. In 1985, for cost saving and reduced handling time, we began to add the lipid solution (Intralipid 10% or 20%) to the amino acid-glucose solution to make a one bag formula, (3-in-1 admixture) to be administered over a 24-hr period. This practice conflicted with the 1982 CDC guidelines recommending that lipid emulsions be infused within 12 hr of hang time. We therefore undertook an audit to see if these solutions became contaminated and supported growth in the routine clinical setting and whether this had a clinically observable association.
MATERIALS AND METHODSOur audit was done at Proctor Community Hospital, a 250-bed general hospital. From January to May 1986, 99 admixed iv bags from 23 patients were collected and cultured. Of the iv catheters used during the study, central venous catheters were placed by attending physicians or surgeons, and peripheral catheters were placed by RNs. Each followed a previously developed set of policies and procedures for skin preparation, sterile techniques, and catheter insertion as recommended by the standards of the American Society for Parenteral and Enteral Nutrition and the National Intravenous Therapist Association All patients receiving parenteral feedings that included amino acids, glucose, and lipid were eligible for the audit if the solution infused over a full 24 hr. The solutions were mixed in large plastic bags in the pharmacy using aseptic technique under a laminar flow hood according to recommendations of the company supplying the solution, Kabi-Vitrum, and ASPEN. These containers were sealed and kept refrigerated in the pharmacy and then transported to the nursing units within 4 hr. The nurses then aseptically spiked the bag ac...
