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Otero-Millán L, Bea-Mascato B, Legido Soto JL, Martínez-López-De-Castro N, Lago Rivero N. Electron Microscopy for the Stability Assessment of Parenteral Nutrition Admixtures: Focus on Precipitation. Nutrients 2024; 16:1390. [PMID: 38732636 PMCID: PMC11085670 DOI: 10.3390/nu16091390] [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: 04/08/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background: parenteral nutrition (PN) is indispensable for patients unable to receive oral or enteral feeding. However, the complexity of PN solutions presents challenges regarding stability and compatibility. Precipitation reactions may occur. The most frequent is the formation of calcium phosphate (Ca-P). The different factors influencing these reactions must be considered to ensure patient safety. (2) Methods: eight paediatric PN solutions were prepared, following standard protocols. Samples were stored at room temperature and in a refrigerator. Electron microscopy, coupled with energy dispersive X-ray spectroscopy (EDS), was employed. Precipitates were analysed for composition and morphology. (3) Results: precipitates were observed in all samples, even at day 0. Crystalline structures, predominantly composed of calcium or magnesium, sometimes associated with chlorine or phosphorus, were detected. Additionally, amorphous precipitates, contained heterogeneous compositions, including unexpected elements, were identified. (4) Conclusions: various precipitates, primarily calcium- or magnesium-based, can form in PN solutions, although it is not expected that they can form under the real conditions of use. Calcium oxalate precipitation has been characterised, but the use of organic calcium and phosphate salts appears to mitigate calcium phosphate precipitation. Electron microscopy provides interesting results on NP precipitation, but sample preparation may present technical limitations that affect the interpretation of the results.
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Affiliation(s)
- Luis Otero-Millán
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain;
- NeumoVigo I+i Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, 36312 Vigo, Spain
| | - Brais Bea-Mascato
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, 36312 Vigo, Spain;
| | - Jose Luis Legido Soto
- Applied Physic Department, Faculty of Sciences, University of Vigo, 36310 Vigo, Spain;
| | - Noemi Martínez-López-De-Castro
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain;
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, 36312 Vigo, Spain;
| | - Natividad Lago Rivero
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain;
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur) SERGAS-UVIGO, 36312 Vigo, Spain;
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2
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Otero-Millán L, Bea-Mascato B, Legido Soto JL, Martínez-López-De-Castro N, Lago-Rivero N. Physicochemical Stability of Hospital Parenteral Nutrition Solutions: Effect of Changes in Composition and Storage Protocol. Pharmaceutics 2024; 16:572. [PMID: 38794234 PMCID: PMC11125120 DOI: 10.3390/pharmaceutics16050572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/26/2024] Open
Abstract
(1) Background: Parenteral nutrition (PN) is a technique used for the administration of nutrients to patients for whom traditional routes cannot be used. It is performed using solutions with extremely complex compositions, which can give rise to a large number of interactions. These interactions can impact their stability and put the patient's life at risk. The aim of this study is to determine how changes in composition and storage protocol affect the stability of NP solutions. (2) Methods: Twenty-three samples were prepared according to routine clinical practice, with modifications to the concentration of some components. The samples were stored at room temperature (RT) and refrigerated (4 °C). Measurements of the droplet diameter, pH, density and viscosity were performed for both storage protocols on days 1, 3, 10 and 14. (3) Results: The samples with the lowest concentration of lipids (PN13-17) and proteins (PN18-22) showed a larger droplet diameter than the rest of the samples throughout the experiments. The USP limits were exceeded for some of the measurements of these sample groups. The pH density and viscosity remained relatively constant under the conditions studied. (4) Conclusions: The PN samples were considered stable and safe for administration under real-world conditions, but the samples with the lowest concentrations of lipids and proteins showed a tendency towards emulsion instability.
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Affiliation(s)
- Luis Otero-Millán
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain
- NeumoVigo I+i Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312 Vigo, Spain
| | - Brais Bea-Mascato
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312 Vigo, Spain
| | - Jose Luis Legido Soto
- Applied Physic Department, Faculty of Sciences, University of Vigo, 36310 Vigo, Spain
| | - Noemi Martínez-López-De-Castro
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312 Vigo, Spain
| | - Natividad Lago-Rivero
- Pharmacy Department, University Hospital Complex of Vigo, 36312 Vigo, Spain
- Innovation in Clinical Pharmacy Research Group (i-FARMA-Vigo), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, 36312 Vigo, Spain
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Boullata JI, Mirtallo JM, Sacks GS, Salman G, Gura K, Canada T, Maguire A. Parenteral nutrition compatibility and stability: A comprehensive review. JPEN J Parenter Enteral Nutr 2021; 46:273-299. [PMID: 34788478 DOI: 10.1002/jpen.2306] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Joseph I Boullata
- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jay M Mirtallo
- Clinical Practice Specialist, American Society for Parenteral and Enteral Nutrition, Professor Emeritus, The Ohio State University, College of Pharmacy, Columbus, OH
| | - Gordon S Sacks
- Senior Director, Medical Affairs for PN Market Unit, Fresenius Kabi USA, LLC, Lake Zurich, IL
| | - Genene Salman
- Assistant Professor of Pharmacy Practice, Marshall B. Ketchum University, College of Pharmacy, Department of Pharmacy Practice, Fullerton, CA
| | - Kathleen Gura
- Manager, Pharmacy Clinical research Program/Clinical Specialist GI/Nutrition, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA
| | - Todd Canada
- Clinical Pharmacy Services Manager & Nutrition Support Team Coordinator, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Angela Maguire
- Clinical Pharmacist, BJC HomeCare Infusions, Overland, MO
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- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
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Huston RK, Christensen JM, Mohamed SM, Minc L, Sawyer T, Stout KN, Heisel CF. High particle counts in neonatal parenteral nutrition solutions with added cysteine: Relationship to crystal formation and effect of filtration on cysteine content. JPEN J Parenter Enteral Nutr 2021; 46:583-591. [PMID: 34197649 DOI: 10.1002/jpen.2218] [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: 11/05/2022]
Abstract
BACKGROUND Parenteral nutrition(PN) solutions containing calcium gluconate and cysteine have elevated particle counts when analyzed using laser light obscuration (LO) as recommended by the United States Pharmacopeia. It is unclear whether increased particle formation in these solutions results in decreased availability of cysteine to neonatal patients due to filtration. OBJECTIVE The purpose of this study was to measure cysteine concentrations in neonatal PN solutions before and after filtration as well as analyze precipitates on filters. METHODS Solutions of PN containing amino acids with and without cysteine that were compounded with calcium chloride or calcium gluconate plus potassium phosphate were analyzed using LO. Concentrations of cysteine were measured before and after filtration. The effect on particle formation of magnesium sulfate (MgSO4 ) and D70 was also evaluated. RESULTS Multiple additives including the specific calcium or D70 additive, cysteine, and MgSO4 influenced particle formation of particles detected using LO. There was no significant decrease in cysteine concentration because of filtering and there was no difference in the amount of calcium on filters of various solutions after filtration regardless of LO particle counts. Scanning electron micrographic (SEM) analysis found no significant differences in crystal composition. Light microscopic and SEM examination did not show evidence of high particle counts on filters. CONCLUSION The increased particle counts detected in neonatal PN solutions containing cysteine added at the time of compounding does not appear to result in increased precipitate or crystal formation. It is not associated witha decrease in cysteine delivery to patients.
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Affiliation(s)
- Robert K Huston
- Northwest Newborn Specialists, PC and Pediatrix Medical Group, Portland, Oregon, USA
| | - John Mark Christensen
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, Oregon, USA
| | - Sumeia M Mohamed
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, Oregon, USA
| | - Leah Minc
- Radiation Center, Oregon State University, Corvallis, Oregon, USA
| | - Teresa Sawyer
- OSU Electron Microscopy Facility, Linus Pauling Science Center, Oregon State University, Corvallis, Oregon, USA
| | - Kim N Stout
- Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
| | - Carl F Heisel
- Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
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Staven V, Wang S, Grønlie I, Tho I. Physical stability of an all-in-one parenteral nutrition admixture for preterm infants upon mixing with micronutrients and drugs. Eur J Hosp Pharm 2020; 27:36-42. [PMID: 32064087 PMCID: PMC6992975 DOI: 10.1136/ejhpharm-2018-001562] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/04/2018] [Accepted: 06/14/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives The main objective was to investigate Y-site compatibility of intravenous drugs with one standard total parenteral nutrition (TPN) admixture for preterm infants. Since micro-precipitation was observed in the water phase after addition of trace elements, the concentration effect on micro-precipitation formation developed as a sub-goal. Methods Seven drugs (ampicillin, ceftazidime, fluconazole, fosphenytoin, furosemide, metronidazole and paracetamol) were mixed in three mixing ratios with one preterm TPN admixture. Samples were investigated within 1 hour and again after 4 hours. Precipitation was studied in a lipid-free version called TPNaq by light obscuration, turbidimetry and visual examination. Emulsion stability data were assessed by light obscuration and laser diffraction. pH was measured to assess the theoretical risk of precipitation and emulsion destabilisation. The influence of different concentrations of trace elements on precipitation was investigated by visual examination, turbidimetry and light obscuration. Results Ampicillin, ceftazidime, fosphenytoin and furosemide led to precipitation after mixing with TPNaq. In some samples of TPN and fluconazole, metronidazole and paracetamol, the emulsion droplet size was above the acceptance limit, although this might also be inherent to the TPN admixture. An unexpected formation of micro-precipitate correlating with increasing amounts of added trace elements might be caused by an interaction of cysteine and copper, and complicated the compatibility assessment with drugs. Conclusions The micro-precipitate resulting from the addition of trace elements should be investigated further. This study did not provide sufficient evidence to recommend Y-site infusion of the tested drugs and the preterm admixture; however, it might offer some additional support to other compatibility data.
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Affiliation(s)
- Vigdis Staven
- Hospital Pharmacy of North Norway Trust, Tromsø, Norway
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Siri Wang
- Norwegian Medicines Agency, Oslo, Norway
| | - Ingrid Grønlie
- Norwegian Medicines for Children Network, Bergen, Norway
- Hospital Pharmacy at Haukeland University Hospital, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ingunn Tho
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- School of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
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Influence of the type of amino acids in the formation of precipitates of copper and sulphur in parenteral nutrition. NUTR HOSP 2019; 36:764-768. [DOI: 10.20960/nh.02661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Huston RK, Christensen JM, Alshahrani SM, Mohamed SM, Heisel CF, Stout KN. Calcium Chloride and Calcium Gluconate in Neonatal Parenteral Nutrition Solutions with Added Cysteine: Compatibility Studies Using Laser Light Obscuration Methodology. JPEN J Parenter Enteral Nutr 2018; 43:426-433. [PMID: 30156306 DOI: 10.1002/jpen.1434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/12/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) solutions containing calcium gluconate (CaGlu) and cysteine have elevated particle counts when analyzed using laser light obscuration (LO) as recommended by the United States Pharmacopeia (USP). There are no compatibility studies for solutions compounded with cysteine and containing calcium chloride (CaCl2 ) using LO. The purpose of this study was to conduct compatibility testing for neonatal PN solutions containing CaCl2 and CaGlu with cysteine. METHODS Solutions of amino acids (2.5%), containing either CaCl2 or CaGlu plus potassium phosphate, were compounded with 50 and 100 mg/dL cysteine. Solutions were analyzed for particle counts using LO. Maximum concentrations tested were 20 mmol/L calcium and 15 mmol/L phosphate. Three solutions containing CaCl2 (144 total solutions) and 2 containing CaGlu (96 total solutions) and the same concentration of additives were compounded. If the average particle count of replicates exceeded USP guidelines, the solution was incompatible. RESULTS All solutions containing CaGlu had particle counts that exceeded USP guidelines for particle counts ≥10 μm (range, 86-580 particles/mL). For CaCl2 , 90 of 144 solutions were compatible (range of particle counts for all solutions, 3-121 particles/mL). Maximum compatible concentrations of CaCl2 and potassium phosphate were 15 mmol/L and 12.5 mmol/L, respectively, for solutions containing both 50 and 100 mg/dL cysteine. CONCLUSION This study found that neonatal PN solutions containing CaGlu with added cysteine have significantly higher particle counts, exceeding USP guidelines for compatibility, than those containing CaCl2 .
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Affiliation(s)
- Robert K Huston
- Northwest Newborn Specialists, PC and Pediatrix Medical Group, Portland, Oregon, USA
| | - J Mark Christensen
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, Oregon, USA
| | - Sultan M Alshahrani
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, Oregon, USA.,College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | - Sumeia M Mohamed
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University, Corvallis, Oregon, USA
| | - Carl F Heisel
- Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
| | - Kim N Stout
- Randall Children's Hospital at Legacy Emanuel, Portland, Oregon, USA
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Effectiveness of in-Line Filters to Completely Remove Particulate Contamination During a Pediatric Multidrug Infusion Protocol. Sci Rep 2018; 8:7714. [PMID: 29769547 PMCID: PMC5955886 DOI: 10.1038/s41598-018-25602-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/18/2018] [Indexed: 11/08/2022] Open
Abstract
The large number of drugs administered simultaneously to neonates and children in hospital results in the formation of particles that are potentially infused. We have investigated the ability of IV in-line filters to eliminate particulate matter from multidrug infusion lines and so prevent contamination. The impact on particle occurrence of the internal volume of the IV line below the in-line filter was then evaluated. The multidrug therapy given to children was reproduced with and without in-line filtration. Three combinations with a filter were tested to vary the internal volume (V) between the filter and the catheter egress. The catheter was then connected to a dynamic particle count to evaluate the particulate matter potentially administered to children during infusion. The introduction of in-line filters led to a significant reduction in overall particulate matter, from 416,974 [208,479-880,229] to 7,551 [1,985-11,287] particles (p < 0.001). Larger particles of ≥10 and 25 µm were also significantly reduced. Adding an extension set to the egress of the in-line filter (V = 1.7 mL) caused a significant increase in particulate contamination for both. This study showed that in-line filtration is an effective tool in preventing particle administration to patients. Their position in the infusion in-line is therefore important because of its impact on internal volume and drug particle formation.
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Stability and assessment of amino acids in parenteral nutrition solutions. J Pharm Biomed Anal 2018; 147:125-139. [DOI: 10.1016/j.jpba.2017.07.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 10/19/2022]
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Flamein F, Storme L, Maiguy-Foinard A, Perez M, Décaudin B, Masse M, Genay S, Odou P. Avoid Drug Incompatibilities: Clinical Context in Neonatal Intensive Care Unit (NICU). PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2017. [DOI: 10.1515/pthp-2017-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AbstractThe administration of several intravenous products on the same catheter is a very common situation in neonatology, where the stakes are high and the dangers sometimes unknown to clinicians. A large number of factors are involved in this administration, directly related to the installation of the infusion line. Moreover, the therapeutics used are often limited, and excluding classic “Marketing Authorization”. Some of these products may prove to be incompatible and thus lose their effectiveness, or even generate particles that are likely to be administered to the patient. We must be aware of these risks in order to optimize the prescription and administration of these intravenous products, especially as we treat fragile and immature patients. The aim of this work is to review the literature on the subject for the prescribers of neonatology units.
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Livingstone C. Review of Copper Provision in the Parenteral Nutrition of Adults. Nutr Clin Pract 2016; 32:153-165. [DOI: 10.1177/0884533616673190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Callum Livingstone
- Clinical Biochemistry Department, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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