Interactions related to trace elements in parenteral nutrition

Parenteral nutrition compatibility and stability: A comprehensive review

Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Stability and Compatibility Aspects of Drugs: The Case of Selected Cephalosporins

Intravenous drug incompatibilities are a common cause of medical errors, contributing to ineffective therapy and even life-threatening events. The co-administration of drugs must always be supported by studies confirming compatibility and thus guarantee the therapy's safety. Particular attention should be paid to the possible incompatibilities or degradation of intravenous cephalosporins in different infusion regimens since the administration of drugs with inadequate quality may cause treatment failure. Therefore, an appropriate stability test should be performed. The study aimed to present various aspects of the stability and compatibility of five cephalosporins: cefepime (CFE), cefuroxime (CFU), ceftriaxone (CFX), ceftazidime (CFZ), and cefazoline (CFL). The degradation studies in parenteral infusion fluids and PN admixtures were conducted for CFE and CFU. The interactions between CFX or CFZ and PN admixtures, as well as the compatibility of CFL with five commercial parenteral nutrition (PN) admixtures, were investigated. The content of CFX and CFZ in PN admixture after 24 h was >90%. CFL administered simultaneously with PN admixture by the same infusion set using Y-site was compatible only with Nutriflex Lipid Special. CFE and CFU were stable in all tested infusion fluids for a minimum of 48 h and decomposed in PN admixtures during storage.

In Vitro Assessment of Interaction Between Amino Acids and Copper in Neonatal Parenteral Nutrition

BACKGROUND

The repeated blackening of in-line filters has been observed during the infusion of parenteral nutrition 2-in-1 mixtures (binary parenteral nutrition [BPN]) delivered in a neonatal intensive care unit. This study aimed to examine the elemental content of precipitates isolated from infused BPN bags and determine the main physicochemical interactions occurring in these bags.

MATERIALS AND METHODS

The infusion of BPN mixtures was simulated in vitro following hospital practices. Filter membranes were examined by scanning electron microscopy and energy dispersion spectroscopy (EDS). Amino acid (AA) profiles were obtained from BPN mixtures to determine the concentrations of each AA.

RESULTS

Analyzed filter membranes revealed conglomerates of particles on filter surfaces. An EDS analysis generated spectra from isolated particles, identifying copper and sulfur as the major chemical elements. AA mean concentrations were relatively close to the expected value for each AA, except cysteine. Cysteine concentrations were very significantly lower than the expected values.

CONCLUSION

A specific interaction was identified between 1 AA (cysteine) and a trace element (copper) in our BPN mixtures.

Dosing and monitoring of trace elements in long-term home parenteral nutrition patients

BACKGROUND

Trace elements (TEs) dosing and monitoring in home parenteral nutrition (PN) patients vary with their underlying conditions.

METHODS

This retrospective observational study evaluated parenteral TE dosing, serum TE concentrations and monitoring, and dose-concentration relationships between TE doses and serum TE concentrations in 26 adult and adolescent home PN patients.

RESULTS

There was a total of 40,493 PN days. Average parenteral zinc doses of 9.1 mg/d and 7.6 mg/d resulted in the majority of serum zinc concentrations (90%) within normal range in patients with and without short bowel syndrome (SBS), respectively. Selenium at about 70 mcg/d resulted in about 60% of serum selenium concentrations within normal range, with 38% of values below normal in patients with and without SBS alike. Copper at 1 mg/d resulted in 22.5% of serum copper concentrations above the normal range. The majority of serum manganese (94.6%) and chromium (96%) concentrations were elevated. Serum TE concentrations were infrequently monitored. Significant relationships existed between doses and serum concentrations for zinc (P < .0001), manganese (P = .012), and chromium (P < .0001) but not for selenium or copper.

CONCLUSIONS

TE doses in home PN should be individualized and adjusted based on regular monitoring of TE status. In long-term home PN patients, higher zinc and selenium doses may be necessary to maintain their normal serum concentrations. Lower copper doses and restrictions of manganese and chromium supplementation may be needed to avoid their accumulation. Relationships between TE doses and serum TE concentrations vary for each TE and underlying clinical conditions.

Chromatography and atomic absorption spectrometry for the assessment of heavy metal distribution among amino acids used in parenteral nutrition formulations-studies with cadmium and lead

The distribution of Cd (II) and Pb (II) among amino acids in parenteral nutrition formulations was investigated by coupling ion-chromatography (HPLC/IC) and electrothermal atomic absorption spectrometry. The methodology was based on ion-exchange separation and fluorimetric amino acid detection after post-column derivatization. Cd (II) and Pb (II) were assayed in 500-µL fractions of the column effluent. The distribution of Cd (II) and Pb (II) in alanine (Ala), aspartic acid (Asp), glutamic acid (Glu), glycine (Gly), histidine (His), methionine (Met), phenylalanine (Phe), serine (Ser), and threonine (Thr) were analyzed by monitoring changes in the concentration of free amino acids by HPLC/IC. The results indicated that Cd (II) and Pb (II) were distributed according to the following trend: Gly-Cd > Gly-Pb > Ala-Cd > Ala-Pb > His-Cd ∼ His-Pb > Thr-Cd > Thr-Pb > Phe-Cd ∼ Phe-Pb ∼ Asp-Cd ∼ Asp-Pb ∼ Met-Cd ∼ Met-Pb ∼ Glu-Cd ∼ Glu-Pb > Ser-Cd ∼ Ser-Pb. The effects of amino acid concentration and stability constants of amino acid-metal complexes are discussed.

Methylprednisolone sodium succinate in pediatric parenteral nutrition: influence of vehicle injection

Many drugs can be administered in parenteral nutrient mixtures, but no work on the delivery of corticoids by such means is reported. We studied the influence of pediatric parenteral nutrient mixtures on the kinetic parameters of the corticoid methylprednisolone injected in an intravenous bolus in rabbits as its sodium succinate ester. Four groups of six male New Zealand rabbits were used. After extraction, the plasma drug concentrations were measured by high performance liquid chromatography. The distribution volume of the ester and the clearance rates of the two entities (ester and methylprednisolone) were lowered in the presence of a lipid emulsion. The description of these pharmacokinetic parameters provides a basis for a preclinical study of 24h administration of methylprednisolone in a parenteral nutrient mixture.

On-line preconcentration and determination of chromium in parenteral solutions by flow injection-flame atomic absorption spectrometry

An on-line chromium preconcentration and determination system implemented with flame atomic absorption spectrometry (FAAS) associated to flow injection (FI) was studied. For the retention of chromium, 4-(2-Thiazolylazo)-resorcinol (TAR) and Amberlite XAD-16 were used, at pH 5.0. The Cr-TAR complex was removed from the micro-column with ethanol. An enrichment factor of 50 was obtained for the preconcentration of 50 ml of sample solution. The detection limit value for the preconcentration of 50 ml of aqueous solution of Cr was 20 ng l(-1). The precision for ten replicate determinations at the 5 microg l(-1) Cr levels was 2.9% relative standard deviation (RSD), calculated from the peak heights obtained. The calibration graph using the preconcentration system for chromium was linear with a correlation coefficient of 0.9997 at levels near the detection limits up to at least 100 microg l(-1). The method was successfully applied to the determination of chromium in parenteral solution samples.

Basic principles for compounding all-in-one parenteral nutrition admixtures

Parenteral nutrition admixtures are complex pharmaceutical entities. The more closely they are examined, the more physico-chemical interactions emerge that could potentially affect stability. The move towards large scale hospital or commercial preparation, with a requirement for extended shelf life, and the increasing use of admixtures as vehicles for drugs and pharmaconutrients have created new formulation challenges for pharmaceutical scientists.