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Berlana D, López-Hellín J, Pau-Parra A, Ferrer-Costa R. Comparing Aluminum Concentrations in Adult and Pediatric Parenteral Nutrition Solutions: Multichamber-Bag versus Compounded Parenteral Nutrition. Nutrients 2024; 16:1024. [PMID: 38613056 PMCID: PMC11013817 DOI: 10.3390/nu16071024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Aluminum contamination in parenteral nutrition (PN) solutions can lead to neurotoxicity, reduced bone mass, and liver toxicity, especially in pediatric patients. Ingredients commonly used in PN compounding, such as vitamins, trace elements, calcium, and phosphate salts, contain significant amounts of aluminum. This study aimed to compare aluminum concentrations in multichamber-bag (MCB) and compounded PN for adults and pediatrics. A prospective study assessed aluminum concentrations in various types of MCB and compared them with compounded PN formulations with similar compositions. The types of MCB included Lipoflex® (without electrolytes), Omegaflex®, Finomel®, Smofkabiven® (with and without electrolytes), Olimel®, Clinimix®, and Numeta®. Overall, 80 aluminum determinations were included: 36 for MCBs and 44 for compounded PN. MCBs showed significantly lower aluminum concentrations than compounded PN: 11.37 (SD 6.16) vs. 21.45 (8.08) µg/L, respectively. Similar results were observed for adult (n = 40) and pediatric (n = 40) PN formulations (12.97 (7.74) vs. 20.78 (10.28) µg/L, and 9.38 (2.23) vs. 22.01 (5.82) µg/L, respectively). Significant differences were also found between MCBs depending on the manufacturing company. These findings suggest that MCBs PN offer a safer option for reducing aluminum contamination in PN. Harmonizing regulations concerning aluminum concentrations in PN solutions could help mitigate differences between PN formulations.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall d’Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain
- Pharmacology, Toxicology and Therapeutic Chemistry Department, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
| | - Juan López-Hellín
- Biochemistry Department, Vall d’Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain
- Biochemical Chemistry, Drug Delivery & Therapy (BC-DDT) Research Group, Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain
| | - Alba Pau-Parra
- Pharmacy Department, Vall d’Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain
| | - Roser Ferrer-Costa
- Biochemistry Department, Vall d’Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain
- Biochemical Chemistry, Drug Delivery & Therapy (BC-DDT) Research Group, Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain
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Aljohar HI, Nawawi RA, Albanyan NS, Aljarboa S, Orfali RS. An Assessment of aluminum contamination in neonatal parenteral nutrition solutions based on measured versus labeled content. Saudi Pharm J 2024; 32:101941. [PMID: 38292404 PMCID: PMC10825339 DOI: 10.1016/j.jsps.2023.101941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024] Open
Abstract
Aluminum can potentially cause toxicity in pediatrics and neonates receiving parenteral nutrition. Some PN solutions and ingredients in Saudi Arabia do not comply with US FDA regulations regarding aluminum exposure. This study aims to determine the aluminum concentration in samples of PN solutions and ingredients used to feed infants in Saudi Arabia. The aluminum in the samples was determined using inductively coupled plasma mass spectrometry. The concentration of metal contaminants in each sample was determined in triplicate. The aluminum content of 38 samples was investigated, 15 of which originated from components included in the prepared PN solutions. Among the 15 samples, the least measurable aluminum content was detected in potassium chloride solutions (0.81 mcg/L). In contrast, the greatest amount of aluminum was detected in potassium phosphate and calcium gluconate (141,64 mcg/L and 462.7 mcg/L), respectively. The results showed that the final PN solution (PNS) product contained more aluminum levels than the content ingredients; in addition, the study found a statistically significant relationship among 18 pediatric patients at KFMC who had intestinal failure and needed long-term parenteral nutrition. Specifically, their high aluminum levels, exceeding the normal range of 0.6 ng/ml, indicate that the current use of PN solutions will likely cause toxicity due to aluminum contamination in additives. Hence, reducing aluminum in PN solutions is imperative to ensure patient safety.
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Affiliation(s)
- Haya I. Aljohar
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Rania A. Nawawi
- Pharmacy Services Administration, King Fahad Medical City, P.O. Box 59046, Riyadh 11525, Saudi Arabia
| | - Nora S. Albanyan
- Clinical Pharmacy Department, Pharmacy Services Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Suliman Aljarboa
- Central Laboratory, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh 11451, Saudi Arabia
| | - Razan S. Orfali
- Clinical Research Groups Department, Research Centre, King Fahad Medical City, Riyadh, 12231, Saudi Arabia
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Bakrey H, Shivgotra R, Abdu A, Soni B, Shahtaghia NR, Jain SK, Thakur S. Use of Total Parenteral Nutrition (TPN) as a Vehicle for Drug Delivery. Curr Drug Targets 2024; 25:306-329. [PMID: 38454772 DOI: 10.2174/0113894501284598240226102943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024]
Abstract
Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.
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Affiliation(s)
- Hossamaldeen Bakrey
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Riya Shivgotra
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Abdulkadir Abdu
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Bindu Soni
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Navid Reza Shahtaghia
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Subheet Kumar Jain
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
- Centre for Basic and Translational Research in Health Sciences, Guru Nanak Dev University, Amritsar, 143005, India
| | - Shubham Thakur
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
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Schönenberger KA, Saxer C, Neyer PJ, Huwiler VV, Reber E, Hammerer-Lercher A, Stanga Z, Mühlebach S. Aluminum and other chemical elements in parenteral nutrition components and all-in-one admixtures. Clin Nutr 2023; 42:2475-2483. [PMID: 38411019 DOI: 10.1016/j.clnu.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/04/2023] [Accepted: 10/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN) can lead to high or even toxic exposure to aluminum (Al). We aimed to quantify concentrations of Al and other chemical elements of all-in-one (AIO) PN admixtures for adults prepared from commercial multichamber bags (Olimel® 5.7%, Omegaflex® special, SmofKabiven®, all with and without electrolytes) and vitamin and trace element additives over a 48-h period. Secondly, we determined the level of Al contamination resulting from admixing and infusion set use. METHODS We used dynamic reaction cell and kinetic energy discrimination inductively coupled plasma mass spectrometry (ICP-MS) to quantify Al, arsenic (As), cadmium (Cd), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), magnesium (Mg), manganese (Mn), molybdenum (Mo), nickel (Ni), antimony (Sb), selenium (Se), tin (Sn), vanadium (V), and zinc (Zn) in AIO PN admixtures. We extracted samples for analysis via the bag injection ports and infusion sets over a 48-h period after admixing. We compared the measured Al concentrations of AIO PN admixtures with calculated values based on the measured concentrations of individual chamber contents and additives. RESULTS Mean (standard deviation) baseline Al concentrations in AIO PN admixtures ranged from 10.5 (0.5) to 59.3 (11.4) μg/L and decreased slightly over the 48 h (estimate [standard error] -0.09 [0.02] μg/L/hour, p <0.001). Thus, certain products exceeded the widely accepted limit of 25 μg/L. There was no significant difference in Al concentrations between samples extracted via the bag injection ports or infusion sets (p = 0.33), nor between measured and calculated Al concentrations of AIO PN admixtures (p = 0.91). CONCLUSION Because certain commercially available PN admixtures for adults proved to contain excessively high levels of Al in our study, regulations and corresponding quality requirements at the authority level (e.g., Pharmacopoeia and regulatory authorities) are urgently required. Our results showed that the PN handling process (admixing and supplementing additives) or the materials of the infusion set did not lead to additional Al contamination to any extent. Moreover, calculated Al concentrations of AIO PN admixtures derived from individual chamber contents and additives are valid.
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Affiliation(s)
- Katja A Schönenberger
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland.
| | - Christoph Saxer
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Peter J Neyer
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Valentina V Huwiler
- Institute of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | | | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Spitalstrasse 26, 4056 Basel, Switzerland
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Barbieri J, Cober MP. Select micronutrients for the preterm neonate. Nutr Clin Pract 2023; 38 Suppl 2:S66-S83. [PMID: 37721469 DOI: 10.1002/ncp.11054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 09/19/2023] Open
Abstract
If premature neonates are not provided with adequate nutrition, they will quickly become deficient because of increased requirements and a lack of nutrient stores to achieve adequate growth. The provision of many of the recommended micronutrients for pediatric and adult patients is challenging in premature neonates because of the limited data surrounding the true needs of premature neonates and the difficulty in assessing adequate serum levels of these nutrients in this patient population. Parenteral and enteral nutrition shortages further complicate providing adequate micronutrients to premature neonates. This review will discuss select micronutrients and their importance to the preterm neonate, with special emphasis on micronutrients with limited evidence and more challenging supplementation and repletion strategies.
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Affiliation(s)
- Jessica Barbieri
- Department of Nutritional Services, Akron Children's Hospital, Akron, Ohio, USA
| | - Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pharmacy Practice, Northeast Ohio Medical University, Rootstown, Ohio, USA
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Smazal AL, Ilahi IM, Raucci J, Robinson DT. Administering Parenteral Nutrition in the Neonatal Intensive Care Unit: Logistics, Existing Challenges, and a Few Conundrums. Clin Perinatol 2023; 50:557-573. [PMID: 37536764 DOI: 10.1016/j.clp.2023.04.004] [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: 08/05/2023]
Abstract
Use of parenteral nutrition (PN) in the neonatal intensive care unit (NICU) requires evaluating the need for central venous catheters, potential drug incompatibilities, unintentional exposures, and suboptimal energy and nutrient intake during the transition to full enteral nutrition. Risks of photooxidation reactions in PN components, refeeding syndrome, and excess early amino acid intake should prompt the reevaluation of routine practices. The goal of this paper is to review the practicalities, challenges, and conundrums of administering PN in the NICU.
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Affiliation(s)
- Anne L Smazal
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Imran M Ilahi
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Janice Raucci
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Wang HJ, Hsieh YT, Liu LY, Huang CF, Lin SC, Tsao PN, Chou HC, Yen TA, Chen CY. Use of sodium glycerophosphate in neonatal parenteral nutrition solutions to increase calcium and phosphate compatibility for preterm infants. Pediatr Neonatol 2020; 61:331-337. [PMID: 32199865 DOI: 10.1016/j.pedneo.2020.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/26/2019] [Accepted: 02/15/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Preterm infants require higher calcium and phosphate intake than term infants to facilitate adequate bone growth, but this is rarely met in parenteral nutrition (PN) solution because of the limited solubility of calcium and phosphate. This study aimed to evaluate the solubility of organic phosphate with calcium gluconate in neonatal PN solutions, simulating its clinical use. METHODS PN solutions were composed of calcium gluconate at 50 mEq/L and sodium glycerophosphate (NaGP) at 25 mmol/L. Another component included 1% or 4% amino acid and 10% or 20% dextrose. For comparison, PN solution composed of potassium phosphate was also evaluated. Each solution was evaluated using the following methods: visual inspection, light obscuration particle count test, and pH measurement. To simulate the clinical condition, the solution was tested after compounding, after being stored at 25 °C for 24 h, and after being stored at 2°C-8°C for 2 or 9 days and subsequently at 25 °C for 24 h. RESULTS There was no visual deposition in PN solution using NaGP in any of the concentrations and under any stored condition. The solution fulfilled the criteria of physical compatibility as < 25 particles/mL measuring ≥10 μm in diameter and <3 particles/mL measuring ≥25 μm in diameter. On the contrary, visual deposition was evidently noted in PN solution using potassium phosphate after its formulation, and the particle count significantly exceeded the range of physical compatibility. CONCLUSION NaGP and calcium gluconate have significantly good compatibility in PN solution. The use of NaGP in neonatal PN prevents calcium and phosphorus precipitation, hence increasing their supply to preterm infants in meeting their growth requirement.
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Affiliation(s)
- Hsueh-Ju Wang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Ting Hsieh
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Ling-Yu Liu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fen Huang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Chiao Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Children's Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Children's Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ting-An Yen
- Department of Pediatrics, National Taiwan University Children's Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Children's Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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Watrobska-Swietlikowska D. Compatibility of Maximum Inorganic and Organic Calcium and Phosphate Content in Neonatal Parenteral Solutions. Sci Rep 2019; 9:10525. [PMID: 31324864 PMCID: PMC6642204 DOI: 10.1038/s41598-019-46987-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 07/05/2019] [Indexed: 11/09/2022] Open
Abstract
The purpose of the study was to determine the maximum safe concentration of calcium and phosphate in neonatal parenteral nutrition (PN) solutions when various combinations of inorganic and organic salts are applied. Twelve PN solutions for neonatal use were aseptically prepared. Increasing concentrations of inorganic and organic calcium and phosphate were added to the standard formulas. Each admixture was separately tested according to the following conditions; after mixing, at 37 °C for 24 hr, and the maximum safe combination of calcium and phosphate were stored at 4 °C for 30 days and followed by 24 hr at 37 °C. Visual inspections and microscopic observation of undiluted PN solutions as well as the membrane filter after filtration of the PN solution, pH evaluation, and absorbance were examined. The safe maximum concentration of organic and inorganic calcium and phosphate were proposed individually for each composition of parenteral nutrition solutions. Surprisingly, organic calcium with organic phosphate showed precipitation but over the therapeutic range. The protective effect of amino acid was observed and higher concentrations of calcium and phosphate were free of precipitation. This work is valuable in daily practice as it allows an increase in the limits of calcium and phosphate in PN solutions for infants.
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Maruyama H, Saito J, Nagai M, Mochizuki M, Ishikawa Y, Ito Y. Maximization of calcium and phosphate in neonatal total parenteral nutrition. Pediatr Int 2018; 60:634-638. [PMID: 29654605 DOI: 10.1111/ped.13579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/22/2018] [Accepted: 04/03/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Appropriate calcium and phosphate supplementation is essential for bone growth in preterm infants. Using Rehabix-K2™ (AY Pharmaceuticals, Tokyo, Japan) and Pleamin-P Injection™ (Fuso Pharmaceutical Industries, Osaka, Japan) as the total parenteral nutrition (TPN) and amino acid solution, respectively, we investigated ways of maximizing calcium and phosphate in the TPN solution. METHODS Rehabix-K2, Pleamin-P, calcium gluconate, sodium phosphate, 50% glucose, and water were mixed in varying proportions to create 16 formulations. Precipitation assessment was done three times for each of the 16 formulations, and was based on the Japanese Pharmacopeia. RESULT Precipitation was observed 24 h after mixing when the calcium and phosphate were 60 mEq/L and 30 mmol/L or 80 mEq/L and 40 mmol/L, respectively. No precipitation was observed when the calcium and phosphate were 20 mEq/L and 10 mmol/L, respectively. Precipitation was observed once out of three times, when the calcium and phosphate were 40 mEq/L and 20 mmol/L, respectively, and the amino acids were 2% and 3% (mean pH, 6.13 and 6.26, respectively). No precipitation was observed, however, when the calcium and phosphate were 40 mEq/L and 20 mmol/L, respectively, and the amino acids were 0% and 1% (mean pH, 5.88 and 6.05, respectively). CONCLUSION Not only the concentration of calcium and phosphate, but also the pH of the TPN solution, are crucial factors for precipitation. Based on these results, a well-balanced TPN solution maximizing calcium and phosphate availability will be able to be formulated.
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Affiliation(s)
- Hidehiko Maruyama
- Division of Neonatology Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Miki Nagai
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Mochizuki
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Yoichi Ishikawa
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Lombardi J, Semama D. Stabilité physico-chimique des nutritions parentérales individualisées en néonatologie. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:154-162. [DOI: 10.1016/j.pharma.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 11/25/2022]
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Dickerson RN, Kumpf VJ, Bingham AL, Cogle SV, Blackmer AB, Tucker AM, Chan LN, Canada TW. Significant Published Articles for Pharmacy Nutrition Support Practice in 2016. Hosp Pharm 2017; 52:412-421. [PMID: 29276265 DOI: 10.1177/0018578717720313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Purpose: To assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2016 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the paper was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 103 articles were identified; 10 from the primary literature were voted by the group to be of high importance. An additional 11 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists, engaged in nutrition support therapy, be familiar with the majority of these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | | | - Anne M Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Todd W Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
With advancements in the care of preterm infants, the goals in nutritional care have expanded from survival and mimicking fetal growth to optimizing neurodevelopmental outcomes. Inadequate nutritional support may be a risk factor for major complications of prematurity; conversely, higher disease burden is a risk for growth restriction. Early complete parenteral nutrition support, including intravenous lipid emulsion, should be adopted, and the next challenge that should be addressed is parenteral nutrition customized to fit the specific needs and metabolism of the extremely preterm infant. Standardized feeding protocols should be adopted.
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Affiliation(s)
- Kera McNelis
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Ting Ting Fu
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Brenda Poindexter
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA.
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13
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Huston RK, Kaempf JW, Wang M, Wang L, Grunkemeier GL, Cohen HS. Calcium chloride in neonatal parenteral nutrition: A 15 year experience. J Neonatal Perinatal Med 2017; 10:33-38. [PMID: 28304321 DOI: 10.3233/npm-1646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The objective of this study was to determine if outcomes at our neonatal intensive care units (NICUs) since we began using calcium chloride (CaCl2) as our preferred calcium additive in order to reduce aluminum (Al) exposure are within expected outcome ranges for NICUs in the U.S. where calcium gluconate in glass vials (CaGlu-Gl) has been the preferred additive. STUDY DESIGN A retrospective study of very low birth weight infants born between January 1, 2000 and December 31, 2014. Outcomes in two intensive care units (NICUs) using CaCl2 were compared to all U.S. NICUs in the Vermont Oxford Network. Primary outcomes were chronic lung disease (CLD), percent requiring supplemental oxygen at 28 days, and mortality excluding early deaths (MEED). The incidence of IV infiltrates of all admissions to the study NICUs in 2013-2014 was compared to the literature. RESULTS The incidence of CLD and those requiring oxygen at 28 days were 24.0% vs 28.6% and 46.2% vs 51.8% for the study NICUs compared to all U.S. NICUs, respectively (both p < 0.0001). The MEED was 8.7% vs 10.3% (p < 0.002). All major morbidities were lower at the study NICUs. The incidence of infiltrates was lower than that in the literature. CONCLUSION The use of CaCl2 was not associated with any detectable adverse effects. Calcium chloride appears to be a safe alternative to the use of CaGlu-Gl based upon studies of clinical outcomes.
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Affiliation(s)
- R K Huston
- Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA
| | - J W Kaempf
- Women's and Children's Program, Providence St. Vincent Medical Center, Portland, OR, USA
| | - M Wang
- Medical Data Research Center, Providence Health and Services, Portland, OR, USA
| | - L Wang
- Medical Data Research Center, Providence Health and Services, Portland, OR, USA
| | - G L Grunkemeier
- Medical Data Research Center, Providence Health and Services, Portland, OR, USA
| | - H S Cohen
- Northwest Newborn Specialists, PC and Pediatrix Medical Group, Portland, OR, USA
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Huston RK, Heisel CF, Vermillion BR, Christensen JM, Minc L. Aluminum Content of Neonatal Parenteral Nutrition Solutions. Nutr Clin Pract 2016; 32:266-270. [PMID: 27679526 DOI: 10.1177/0884533616668789] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Calcium chloride (CaCl2) has been the only calcium additive available in the United States that has a low aluminum (Al) content. Calcium gluconate in glass vials (CaGluc-Gl) has a high Al content while calcium gluconate in plastic vials (CaGluc-Pl) has a low Al content. The purpose of this study was to measure Al concentrations in neonatal parenteral nutrition (PN) solutions prepared using various calcium additives. METHODS Samples of solutions compounded with CaCl2 or CaGluc-Gl and sodium phosphate (NaPhos) as well as CaGluc-Pl and sodium glycerophosphate (NaGP) with and without cysteine were analyzed for Al content. Samples of the cysteine and calcium gluconate additives were also sent for analysis. RESULTS Solutions containing CaCl2 and CaGlu-Pl had mean Al concentrations of 1.2-2.3 mcg/dL, while those with CaGlu-Gl had mean concentrations of 14.6-15.1 mcg/dL. Solutions made with NaGP were low in Al content. The measured Al content of 2 lots of the cysteine additive were 168 ± 23 mcg/L and 126 ± 5 mcg/L. The Al concentration equalled 2730 ± 20 mcg/L for the CaGlu-Gl additive and 310 ± 80 mcg/L for the CaGlu-Pl additive. CONCLUSION The study indicates that solutions containing CaCl2 or CaGluc-Pl and NaPhos or NaGP are low in Al content. Using these options for calcium and phosphate additives can limit aluminum intake from neonatal PN to levels within the Food and Drug Administration guideline of ≤5 mcg/kg/d.
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Affiliation(s)
- Robert K Huston
- 1 Northwest Newborn Specialists, PC, and Pediatrix Medical Group, Portland, Oregon, USA
| | - Carl F Heisel
- 2 Neonatal Pharmacy, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
| | - Benjamin R Vermillion
- 2 Neonatal Pharmacy, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
| | - J Mark Christensen
- 3 Department of Pharmaceutical Sciences, Oregon State University, Corvallis, Oregon, USA
| | - Leah Minc
- 4 Radiation Center, Oregon State University, Corvallis, Oregon, USA
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Anderson C, MacKay M. Physical Compatibility of Calcium Chloride and Sodium Glycerophosphate in Pediatric Parenteral Nutrition Solutions. JPEN J Parenter Enteral Nutr 2016; 40:1166-1169. [DOI: 10.1177/0148607115592673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/01/2015] [Indexed: 01/15/2023]
Affiliation(s)
| | - Mark MacKay
- Primary Children’s Hospital, Salt Lake City, Utah
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Plogsted S, Adams SC, Allen K, Breen HB, Cober MP, Greaves J, Mogensen KM, Ralph A, Ward C, Ybarra J, Holcombe B. Parenteral Nutrition Electrolyte and Mineral Product Shortage Considerations. Nutr Clin Pract 2015; 31:132-4. [DOI: 10.1177/0884533615621550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Stephen C. Adams
- Vitaline Infusion Pharmacy Services, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Karen Allen
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - June Greaves
- Coram/CVS Specialty Infusion Services, Woonsocket, Rhode Island, USA
| | - Kris M. Mogensen
- Department of Nutrition, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Amy Ralph
- Yale–New Haven Hospital, New Haven, Connecticut, USA
| | | | - Joe Ybarra
- The Medical Center of McKinney, McKinney, Texas, 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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18
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Lima-Rogel V, Romano-Moreno S, de Jesús López-López E, de Jesús Escalante-Padrón F, Hurtado-Torres GF. Aluminum Contamination in Parenteral Nutrition Admixtures for Low-Birth-Weight Preterm Infants in Mexico. JPEN J Parenter Enteral Nutr 2014; 40:1014-20. [DOI: 10.1177/0148607114550001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 08/11/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Victoria Lima-Rogel
- Neonatology Unit, Hospital Central Dr Ignacio Morones Prieto and Faculty of Medicine, University of San Luis Potosí, México
| | | | | | | | - Gilberto Fabian Hurtado-Torres
- Internal Medicine and Clinical Nutrition Department, Hospital Central Dr Ignacio Morones Prieto and Faculty of Medicine, University of San Luis Potosi, México
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Huston RK, Christensen JM, Karnpracha C, Rosa JE, Clark SM, Migaki EA, Wu Y. Calcium chloride in neonatal parenteral nutrition: compatibility studies using laser methodology. PLoS One 2014; 9:e106825. [PMID: 25192060 PMCID: PMC4156409 DOI: 10.1371/journal.pone.0106825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/07/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction We have previously reported results of precipitation studies for neonatal parenteral nutrition solutions containing calcium chloride and sodium phosphate using visual methods to determine compatibility. The purpose of this study was to do further testing of compatibility for solutions containing calcium chloride using more sensitive methods. Methods Solutions of Trophamine (Braun Medical Inc, Irvine, CA) and Premasol (Baxter Pharmaceuticals, Deerfield, IL) were compounded with calcium chloride and potassium phosphate. Controls contained no calcium or phosphate. After incubation at 37° for 24 hours solutions without visual precipitation were analyzed to determine mean particle size using dynamic light scattering from a laser light source. Results Particle sizes were similar for control solutions and those without visual precipitation and a mean particle size <1000 nm. Compatible solutions were defined as those with added calcium and phosphate with no visual evidence of precipitation and mean particle size <1000 nm. In solutions containing 2.5–3% amino acids and 10 mmol/L of calcium chloride the maximum amount of potassium phosphate that was compatible was 7.5 mmol/L. Conclusion Maximum amounts of phosphate that could be added to parenteral nutrition solutions containing Trophamine and calcium chloride were about 7.5–10 mmol/L less for a given concentration of calcium based upon laser methodology compared to visual techniques to determine compatibility. There were minor differences in compatibility when adding calcium chloride and potassium phosphate to Premasol versus Trophamine.
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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
| | - Chanida Karnpracha
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, OR, United States of America
| | - Jill E. Rosa
- Pharmacy Department, Denver Veterans Affairs Medical Center, Denver CO, United States of America
| | - Sara M. Clark
- Neonatal Pharmacy, Providence St. Vincent Medical Center, Portland, OR, United States of America
| | - Evelyn A. Migaki
- Neonatal Pharmacy, Providence St. Vincent Medical Center, Portland, OR, United States of America
| | - YingXing Wu
- Medical Data Research Center, Providence Health and Services, Portland, OR, United States of America
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Abrams SA, Hawthorne KM, Placencia JL, Dinh KL. Micronutrient requirements of high-risk infants. Clin Perinatol 2014; 41:347-61. [PMID: 24873837 DOI: 10.1016/j.clp.2014.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Micronutrient requirements are well-established for healthy full-term infants. However, few such recommendations exist for high-risk infants, including full-term infants with a variety of medical disorders or very preterm infants. Key micronutrients considered in this review are calcium, phosphorus, magnesium, iron, and zinc. The ongoing unresolved shortages, especially of intravenous forms of these minerals, remain a major problem. Considered are some aspects of how the nutrient shortages may be managed, recognizing the complexity and changing nature of the supply.
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Affiliation(s)
- Steven A Abrams
- US Department of Agriculture/Agriculture Research Service, Department of Pediatrics, Children's Nutrition Research Center, Texas Children's Hospital, Baylor College of Medicine, 1100 Bates Street, #7074, Houston, TX 77030, USA.
| | - Keli M Hawthorne
- US Department of Agriculture/Agriculture Research Service, Department of Pediatrics, Children's Nutrition Research Center, Texas Children's Hospital, Baylor College of Medicine, 1100 Bates Street, #7074, Houston, TX 77030, USA
| | - Jennifer L Placencia
- US Department of Agriculture/Agriculture Research Service, Department of Pediatrics, Children's Nutrition Research Center, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street WB1120, Houston, TX 77030, USA
| | - Kimberly L Dinh
- US Department of Agriculture/Agriculture Research Service, Department of Pediatrics, Children's Nutrition Research Center, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street WB1120, Houston, TX 77030, USA
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Courtney-Martin G, Kosar C, Campbell A, Avitzur Y, Wales PW, Steinberg K, Harrison D, Chambers K. Plasma Aluminum Concentrations in Pediatric Patients Receiving Long-Term Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2014; 39:578-85. [PMID: 24743391 DOI: 10.1177/0148607114531046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/17/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients receiving long-term parenteral nutrition (PN) are at increased risk of aluminium (Al) toxicity because of bypass of the gastrointestinal tract during PN infusion. Complications of Al toxicity include metabolic bone disease (MBD), Al-associated encephalopathy in adults, and impaired neurological development in preterm infants. Unlike the United States, there are no regulations regarding Al content of large- and small-volume parenterals in Canada. We, therefore, aimed to present our data on plasma Al concentration and Al intake from our cohort of pediatric patients receiving long-term PN. METHODS Plasma Al concentration was retrospectively gathered from the patient charts of all 27 patients with intestinal failure (IF) receiving long-term PN at The Hospital for Sick Children, Toronto, Canada, and compared with age- and sex-matched controls recruited for comparison. In addition, Al concentration was measured in PN samples collected from 10 randomly selected patients with IF and used to determine their Al intake. RESULTS The plasma Al concentration of patients with IF receiving long-term PN was significantly higher than that of control participants (1195 ± 710 vs 142 ± 63 nmol/L; P < .0001). In the subgroup of 10 patients for whom Al intake from their PN solution was determined, mean ± SD Al intake from PN was 15.4 ± 15 µg/kg, 3 times the Food and Drug Administration upper recommended intake level, and Al intake was significantly related to plasma Al concentration (P = .02, r (2) = 0.52). CONCLUSION Pediatric patients receiving long-term PN for IF in Canada are at risk for Al toxicity.
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Affiliation(s)
- Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Christina Kosar
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Alison Campbell
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada The Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada The Department of Surgery, University of Toronto, Toronto, Canada
| | - Karen Steinberg
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Kathryn Chambers
- Research Institute, The Hospital for Sick Children, Toronto, Canada Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
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Boullata JI, Gilbert K, Sacks G, Labossiere RJ, Crill C, Goday P, Kumpf VJ, Mattox TW, Plogsted S, Holcombe B. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr 2014; 38:334-77. [PMID: 24531708 DOI: 10.1177/0148607114521833] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND 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. METHOD A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?
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Viswanathan S, Khasawneh W, McNelis K, Dykstra C, Amstadt R, Super DM, Groh-Wargo S, Kumar D. Metabolic bone disease: a continued challenge in extremely low birth weight infants. JPEN J Parenter Enteral Nutr 2013; 38:982-90. [PMID: 23963689 DOI: 10.1177/0148607113499590] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Metabolic bone disease (MBD) is an important prematurity-related morbidity, but remains inadequately investigated in extremely low birth weight (ELBW) infants, the group most at risk. The objective was to describe the incidence and associated risk factors of MBD in ELBW infants. METHODS Retrospective analysis of all ELBW infants admitted between January 2005 and December 2010 who survived > 8 weeks. MBD was defined as the presence of osteopenia or rickets in radiographs. RESULTS Of the 230 infants included in the study, 71 (30.9%) developed radiological evidence of MBD (cases) of which 24/71 (33.8%) developed spontaneous fractures. MBD and fractures were noted at mean postnatal ages of 58.2 ± 28 and 100.0 ± 61 days, respectively. Compared with controls, cases were smaller at birth (664.6 ± 146 g vs 798.1 ± 129 g), more premature (25.0 ± 1.8 vs 26.4 ± 1.9 weeks), more frequently associated with mechanical ventilation, chronic lung disease, parenteral nutrition days, cholestasis, furosemide, postnatal steroids, and antibiotics use (all P < .01). Cases had lower average weekly intake of calcium, phosphorous, vitamin D, protein, and calories during the first 8 weeks of life compared with controls. Cases with MBD, compared with controls, had higher mortality (14.1 vs 4.4%) and longer hospital stay (140.2 ± 51 vs 101.0 ± 42 days; P < .01). CONCLUSIONS MBD remains an important morbidity in ELBW infants despite advances in neonatal nutrition. Further research is needed to optimize the management of chronic lung disease and early nutrition in ELBW infants.
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Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, University Hospitals, Cleveland, OH, USA
| | - Wasim Khasawneh
- Division of Neonatology, Department of Pediatrics, Cleveland Clinic, Cleveland, OH, USA
| | - Kera McNelis
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Carly Dykstra
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Randi Amstadt
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Dennis M Super
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sharon Groh-Wargo
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Deepak Kumar
- Division of Critical Care, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Gonyon T, Carter PW, Phillips G, Owen H, Patel D, Kotha P, Green JBD. Probability-based compatibility curves for calcium and phosphates in parenteral nutrition formulations. JPEN J Parenter Enteral Nutr 2013; 38:717-27. [PMID: 23894169 DOI: 10.1177/0148607113495415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/04/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The information content of the calcium phosphate compatibility curves for adult parenteral nutrition (PN) solutions may benefit from a more sophisticated statistical treatment. Binary logistic regression analyses were evaluated as part of an alternate method for generating formulation compatibility curves. MATERIALS AND METHODS A commercial PN solution was challenged with a systematic array of calcium and phosphate concentrations. These formulations were then characterized for particulates by visual inspection, light obscuration, and filtration followed by optical microscopy. Logistic regression analyses of the data were compared with traditional treatments for generating compatibility curves. RESULTS Assay-dependent differences were observed in the compatibility curves and associated probability contours; the microscopic method of precipitate detection generated the most robust results. Calcium and phosphate compatibility data generated from small-volume glass containers reasonably predicted the observed compatibility of clinically relevant flexible containers. CONCLUSIONS The published methods for creating calcium and phosphate compatibility curves via connecting the highest passing or lowest failing calcium concentrations should be augmented or replaced by probability contours of the entire experimental design to determine zones of formulation incompatibilities. We recommend researchers evaluate their data with logistic regression analysis to help build a more comprehensive probabilistic database of compatibility information.
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Huston RK, Markell AM, McCulley EA, Marcus MJ, Cohen HS. Computer Programming. Nutr Clin Pract 2013; 28:515-21. [DOI: 10.1177/0884533613490741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robert K. Huston
- Randall Children’s Hospital at Legacy Emanuel, Portland, Oregon
- Northwest Newborn Specialists, PC, Portland, Oregon
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Driscoll DF, Newton DW, Bistrian BR. Potential Hazards of Precipitation Associated With Calcium Chloride in Parenteral Nutrition Admixtures. JPEN J Parenter Enteral Nutr 2012; 36:497-8; author reply 498-500. [DOI: 10.1177/0148607112455064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Huston RK, Migaki EA. Issues Concerning the Safety of Calcium Chloride in Neonatal Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2012. [DOI: 10.1177/0148607112456297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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