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Anderson C, Eggert L, Fitzgerald K, Jackson D, Farr F. Calcium and Phosphate Solubility Curve Equation for Determining Precipitation Limits in Compounding Parenteral Nutrition. Hosp Pharm 2022; 57:779-785. [PMID: 36340622 PMCID: PMC9631008 DOI: 10.1177/00185787221104367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Clinicians have published research and reports on calcium and phosphate solubility within parenteral nutrition (PN) for over 40 years. Foundational empirical laboratory investigation in the 1980s motivated by the prevalence of neonatal rickets and osteomalacia in the Neonatal Intensive Care Unit (NICU) population led to precipitation curves that have guided PN prescribing and compounding. Over subsequent decades, numerous publications have expanded the knowledge of factors influencing calcium and phosphate solubility in formulating optimal and safe PN admixtures. Failure to adhere to known principles has led to serious injury and death. Known solubility curves are derived from empiric analysis of a finite number of conditions and concentrations, whereas custom PN orders vary widely and rarely match the admixture composition in the data set used to derive the published precipitation curves. Various commercial platforms have been developed to aid the pharmacist in assessing the potential for precipitation when evaluating a PN order. Some applications plot the calcium and phosphate concentrations of the prescribed PN against known published graphs most similar to the order, allowing the pharmacist to judge the risk of precipitation. Other approaches use intellectually protected trade secret algorithms to determine calcium and phosphate solubility across a continuum of conditions. This publication reports equations that have been used successfully for over 2 decades in our regional network of NICUs and shared with others to determine safe prescribing limits for calcium and phosphate concentrations using an electronic PN prescribing program.
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Affiliation(s)
| | - Larry Eggert
- Intermountain Healthcare, Salt Lake
City, UT, USA
| | | | | | - Fred Farr
- Primary Children’s Hospital, Salt Lake
City, UT, USA
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Huston RK, Christensen JM, Alshahrani SM, Mohamed SM, Clark SM, Nason JA, Wu YX. Calcium Chloride in Neonatal Parenteral Nutrition Solutions with and without Added Cysteine: Compatibility Studies Using Laser and Micro-Flow Imaging Methodology. PLoS One 2015; 10:e0136894. [PMID: 26317344 PMCID: PMC4552580 DOI: 10.1371/journal.pone.0136894] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/09/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous studies of compatibility of calcium chloride (CaCl2) and phosphates have not included particle counts in the range specified by the United States Pharmacopeia. Micro-flow imaging techniques have been shown to be comparable to light obscuration when determining particle count and size in pharmaceutical solutions. OBJECTIVE The purpose of this study was to do compatibility testing for parenteral nutrition (PN) solutions containing CaCl2 using dynamic light scattering and micro-flow imaging techniques. METHODS Solutions containing TrophAmine (Braun Medical Inc, Irvine, CA), CaCl2, and sodium phosphate (NaPhos) were compounded with and without cysteine. All solutions contained standard additives to neonatal PN solutions including dextrose, trace metals, and electrolytes. Control solutions contained no calcium or phosphate. Solutions were analyzed for particle size and particle count. Means of Z-average particle size and particle counts of controls were determined. Study solutions were compared to controls and United States Pharmacopeia (USP) Chapter 788 guidelines. The maximum amount of Phos that was compatible in solutions that contained at least 10 mmol/L of Ca in 2.5% amino acids (AA) was determined. Compatibility of these solutions was verified by performing analyses of 5 repeats of these solutions. Microscopic analyses of the repeats were also performed. RESULTS Amounts of CaCl2 and NaPhos that were compatible in solutions containing 1.5%, 2%, 2.5%, and 3% AA were determined. The maximum amount of NaPhos that could be added to TrophAmine solutions of > = 2.5% AA containing at least 10 mmol/L of CaCl2 was 7.5 mmol/L. Adding 50 mg/dL of cysteine increased the amount of NaPhos that could be added to solutions containing 10 mmol/L of CaCl2 to 10 mmol/L. CONCLUSION Calcium chloride can be added to neonatal PN solutions containing NaPhos in concentrations that can potentially provide an intravenous intake of adequate amounts of calcium and phosphorus.
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Affiliation(s)
- Robert K. Huston
- Northwest Newborn Specialists, PC and Pediatrix Medical Group, Portland, OR, United States of America
- * E-mail:
| | - J. Mark Christensen
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, OR, United States of America
| | - Sultan M. Alshahrani
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, OR, United States of America
| | - Sumeia M. Mohamed
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, OR, United States of America
| | - Sara M. Clark
- Neonatal Pharmacy, Providence St. Vincent Medical Center, Portland, OR, United States of America
| | - Jeffrey A. Nason
- School of Chemical, Biological, & Environmental Engineering, Oregon State University, Corvallis, OR, United States of America
| | - Ying Xing Wu
- Medical Data Research Center, Providence Health and Services, Portland, OR, United States of America
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Devlieger H, Meyers Y, Willems L, de Zegher F, Van Lierde S, Proesmans W, Eggermont E. Calcium and phosphorus retention in the preterm infant during total parenteral nutrition. A comparative randomised study between organic and inorganic phosphate as a source of phosphorus. Clin Nutr 2012; 12:277-81. [PMID: 16843326 DOI: 10.1016/0261-5614(93)90046-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/1992] [Accepted: 03/09/1993] [Indexed: 10/26/2022]
Abstract
The preterm infant fed parenterally is prone to some demineralisation due in part to insufficient Calcium (Ca) and Phosphorus (P) retention. In an attempt to augment Ca and P retention, we prepared a standardised parenteral solution containing calcium gluconate and glucose-1-phosphate (Phocytan) as source of phosphorus, yielding a daily supply of 75 mg/kg Ca and 45 mg/kg P. 28 very low birthweight infants were randomly assigned to receive either this solution (high Ca P ; n = 15) or a conventional formulation containing calcium gluconate and potassium mono- and dibasic phosphate delivering 42 mg/kg Ca and 36 mg/kg P daily (low Ca P ; n = 13). In the high Ca P daily retention was respectively 80% and 99% for Ca and P whereas in the low Ca P group, retention was 70% and 82%. Serum parathormone levels were significantly lower in the high Ca P group. We conclude that parenteral nutrition with a new high Ca P supplement results in an augmented Ca and P retention in very low birthweight infants. This may help to prevent neonatal bone demineralization.
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Affiliation(s)
- H Devlieger
- Departments of Paediatrics and Pharmacy, University Hospital Gasthuisberg, 3000 Leuven, Belgium
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Ribeiro DDO, Lobo BW, Volpato NM, da Veiga VF, Cabral LM, de Sousa VP. Influence of the calcium concentration in the presence of organic phosphorus on the physicochemical compatibility and stability of all-in-one admixtures for neonatal use. Nutr J 2009; 8:51. [PMID: 19857269 PMCID: PMC2772853 DOI: 10.1186/1475-2891-8-51] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 10/26/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Preterm infants need high amounts of calcium and phosphorus for bone mineralization, which is difficult to obtain with parenteral feeding due to the low solubility of these salts. The objective of this study was to evaluate the physicochemical compatibility of high concentrations of calcium associated with organic phosphate and its influence on the stability of AIO admixtures for neonatal use. METHODS Three TPN admixture formulas were prepared in multilayered bags. The calcium content of the admixtures was adjusted to 0, 46.5 or 93 mg/100 ml in the presence of a fixed organic phosphate concentration as well as lipids, amino acids, inorganic salts, glucose, vitamins and oligoelements at pH 5.5. Each admixture was stored at 4 degrees C, 25 degrees C or 37 degrees C and evaluated over a period of 7 days. The physicochemical stability parameters evaluated were visual aspect, pH, sterility, osmolality, peroxide formation, precipitation, and the size of lipid globules. RESULTS Color alterations occurred from the first day on, and reversible lipid film formation from the third day of study for the admixtures stored at 25 degrees C and 37 degrees C. According to the parameters evaluated, the admixtures were stable at 4 degrees C; and none of them presented precipitated particles due to calcium/phosphate incompatibility or lipid globules larger than 5 mum, which is the main parameter currently used to evaluate lipid emulsion stability. The admixtures maintained low peroxide levels and osmolarity was appropriate for parenteral administration. CONCLUSION The total calcium and calcium/phosphorus ratios studied appeared not to influence the physicochemical compatibility and stability of AIO admixtures.
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Affiliation(s)
- Daniela de Oliveira Ribeiro
- Departamento de Medicamentos, Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, CCS, Bloco B ss sala 15, Rio de Janeiro, RJ 21941-902, Brazil
| | - Bianca Waruar Lobo
- Departamento de Medicamentos, Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, CCS, Bloco B ss sala 15, Rio de Janeiro, RJ 21941-902, Brazil
| | - Nádia Maria Volpato
- Departamento de Medicamentos, Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, CCS, Bloco B ss sala 15, Rio de Janeiro, RJ 21941-902, Brazil
| | - Venício Féo da Veiga
- Instituto de Microbiologia Professor Paulo de Góes, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-902, Brazil
| | - Lúcio Mendes Cabral
- Departamento de Medicamentos, Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, CCS, Bloco B ss sala 15, Rio de Janeiro, RJ 21941-902, Brazil
| | - Valeria Pereira de Sousa
- Departamento de Medicamentos, Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, CCS, Bloco B ss sala 15, Rio de Janeiro, RJ 21941-902, Brazil
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Affiliation(s)
- A L Buchman
- Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Houston Health Science Center, Houston, Texas, USA
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Costello I, Powell C, Williams AF. Sodium glycerophosphate in the treatment of neonatal hypophosphataemia. Arch Dis Child Fetal Neonatal Ed 1995; 73:F44-5. [PMID: 7552597 PMCID: PMC2528378 DOI: 10.1136/fn.73.1.f44] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nineteen very low birthweight (mean (SD) gestational age 28 (3) weeks) were parenterally fed nutrition solutions containing inorganic calcium and phosphorus salts. All infants had hypophosphataemia. Plasma concentrations were maintained between 1.5 mmol/l and 2.2 mmol/l. Plasma phosphorus concentrations reached 1.5 mmol/l or greater in three patients after 12 hours, in a further nine patients after 36 hours, and in all patients by 60 hours. Changes in plasma calcium concentrations were not significant.
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Affiliation(s)
- I Costello
- Pharmacy Department, St George's Hospital, London
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Abstract
During the last trimester of pregnancy, there is a sixfold increase in fetal calcium and phosphorus accumulation. Unsupplemented human breast milk may not provide sufficient calcium and phosphorus for the rapidly growing preterm infant to match the accumulation that should have taken place in utero and to permit normal bone mineralization. Rickets of prematurity may present clinically between the 6th and 12th postnatal week. The clinical diagnosis may be confirmed using simple biochemical tests. Inadequate mineral substrate intake, particularly of phosphorus, is the most common cause, although a delay in the maturation of the renal enzyme, 1-alpha hydroxylase, with low plasma concentrations of 1,25-dihydroxyvitamin D, may also occur. The biochemical response to treatment can be determined by documenting a fall in plasma alkaline phosphatase activity and a rise in plasma phosphate concentration and urinary phosphate excretion.
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Affiliation(s)
- P D Mayne
- Department of Chemical Pathology, Charing Cross and Westminster Medical School, Westminster Hospital, London, UK
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Brennan A, Byrne M, Gorby A, Hoey H, Alfaham A, Goodchild MC, Campbell IA, Newcombe R, Philpot C, Fifield R, Edwards J, Conlon T, Griffin E, Clarke T, Hilary I, O’Connor A, Walsh J, Glasgow JFT, Robinson PH, Moore R, Crane J, McKiernan P, Fox G, Gormally S, Blakemore L, Matthews T, MacMahon P, Blair ME, Treweeke IZ, Kovar, Kemp A, Sibert J, Kemp A, Sibert J, Naughton E, Gill D, Hensey O, Cahalane S, Murphy D, Pierce A, Watson JBC, McKenna C, Flynn A, Morrissey PA, Sweetnam A, O’Haloran ET, Read M, Owen G, Dawson S, Madarikn BA, Rees BI, Goodchild MC, Lynch T, McMenamin J, Wallace SJ, Dowding VM, Barry C, Earley MJ, Fitzgerald R, Philips J, Garvey M, Donoghue VB, Gorman WA, O’Brien N, Murphy JFA, Reardon W, Genet S, Middleton-Price H, Feighery C, Rowland P, Jones RT, Doggah M, Costigan DC, Leavy P, Breathnach F, Hensey O, Fitzpatrick C, Keenan P, Corbally MT, Ryan P, Nanshanie A, Fitzpatrick J, Fitzgerald RJ, Dohil R, Jones V, Jenkins H, Roberts E, Lee PJ, Jones V, Kurien A, O’Donoghue E, Ward OC, Denham B, Duff D, Rao SJ, Aburawi EH, Denham B, Aburawi EH, Ward DC, Denham B. Irish paediatric association and welsh paediatric society. Ir J Med Sci 1991. [DOI: 10.1007/bf02947267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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MacMahon P, Mayne PD, Blair M, Pope C, Kovar IZ. Acid-base state of the preterm infant and the formulation of intravenous feeding solutions. Arch Dis Child 1990; 65:354-6. [PMID: 2110804 PMCID: PMC1590159 DOI: 10.1136/adc.65.4_spec_no.354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
An acidic intravenous source of phosphorus (Addiphos) was compared with dipotassium hydrogen phosphate in 25 preterm infants to study acid-base state. Eight infants were given either Addiphos or dipotassium hydrogen phosphate alternately for 48 hour periods and similar amounts of calcium and phosphorus were delivered. There were no significant differences in calcium and phosphorus intake, calcium and phosphate plasma concentrations, or acid-base state between study periods on the two solutions. Seventeen infants were given the two solutions alternately for 72 hour periods; Addiphos was used to increase the amounts of calcium and phosphorus being delivered. Calcium and phosphorus intake was decreased on dipotassium hydrogen phosphate, but Addiphos significantly increased calcium and phosphorus intake and plasma calcium and phosphate concentrations. It also lowered the pH of the urine and raised the titratable acidity. Acid-base state, however, was not significantly different. It is therefore possible to increase intake of calcium and phosphorus in preterm infants without causing a significant metabolic acidosis.
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Affiliation(s)
- P MacMahon
- Department of Child Health, Charing Cross and Westminster Medical School, London
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