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De Pourcq JT, Riera A, Gras L, Garin N, Busquets MA, Cardenete J, Cardona D, Riera P. Physicochemical Compatibility of Ceftolozane-Tazobactam with Parenteral Nutrition. Pharmaceuticals (Basel) 2024; 17:896. [PMID: 39065746 PMCID: PMC11279994 DOI: 10.3390/ph17070896] [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: 06/10/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Ceftolozane-tazobactam (CT) is used for the treatment of complicated infections and for multidrug-resistant strains of Pseudomonas aeruginosa and extended-spectrum beta-lactamase-producing enterobacteria. In certain cases, simultaneous administration of CT and parenteral nutrition (PN) may be required, but compatibility of Y-site co-administration is unknown. The aim of this study was to analyse the physicochemical compatibility of CT Y-site administered with PN. We evaluated a protocolized PN approach for critical patients in our center. We studied both bolus infusion (2 g ceftolozane/1 g tazobactam in 1 h) and continuous infusion (CI) (6 g ceftolozane/3 g tazobactam) strategies. Samples were visually observed against light, microscopically inspected, and pH was analysed using a pH meter. The mean lipid droplet diameter (MDD) was determined via dynamic light scattering. CT concentration was quantified using HPLC-HRMS. No alterations were observed through visual or microscopic inspection. Changes in pH were ≤0.2, and changes in osmolarity were less than 5%. MDD remained below 500 nm (284.5 ± 2.1 for bolus CT and 286.8 ± 7.5 for CI CT). CT concentrations at t = 0 h and t = 24 h remained within prespecified parameters in both infusion strategies. CT is physiochemically compatible with PN during simulated Y-site administration at the tested concentration and infusion rates.
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Affiliation(s)
- Jan Thomas De Pourcq
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), 08041 Barcelona, Spain
| | - Adria Riera
- Department of Pharmacy, Hospital de Sant Pau i Santa Tecla, 43003 Tarragona, Spain
| | - Laura Gras
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), 08041 Barcelona, Spain
| | - Noe Garin
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- School of Health Science Blanquerna, Universitat Ramon Llull, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 28007 Madrid, Spain
| | - Maria Antònia Busquets
- Institute of Nanoscience and Nanotechnology (IN2UB), University of Barcelona, 08028 Barcelona, Spain;
- Department of Pharmacy and Pharmaceutical Technology and Physical-Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
| | - Joana Cardenete
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), 08041 Barcelona, Spain
| | - Daniel Cardona
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
| | - Pau Riera
- Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), 08041 Barcelona, Spain
- CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Escuder-Vieco D, Gomis Muñoz P, Hernández Ramos JA, Bruni Montero MÁ, Bergón Sendín E, de la Cruz Bértolo J, Bustos Lozano G. Stability of individualized neonatal parenteral nutrition admixtures with fish oil and high calcium content. NUTR HOSP 2024; 41:547-553. [PMID: 38328971 DOI: 10.20960/nh.04931] [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] [Indexed: 02/09/2024] Open
Abstract
Introduction Introduction: the stability of total parenteral nutrition admixtures for neonates (TPNAn) has been questioned in relation to the interaction between calcium and fish oil emulsions. Aim: the aim of this study was to check the stability (particle size < 1 µm) of different individualized TPNAn prepared with fish-oil emulsion and containing calcium at concentrations ranging from 10 to 20 mmol/L. Methods: admixtures analyzed: twelve different formulations with SMOFlipid® 20 % (conserved for 24 h and for 96 h), three formulations with Lipoplus® 20 % (conserved for 96 h) and three formulations with SMOFlipid® 20 % with Multi-12K1® Pediatric (conserved for 96 h). Two bags were compounded for each formulation and conservation period. Measurements on each admixture bag: particle standardized diameter by laser diffraction technique and pH by a calibrated pH-meter. Data analysis with mixed linear regression models. Results: maximum particle size was < 0.8 µm for all investigated admixtures. Lipid concentration of 5 g/L and sodium and potassium concentration of 100 mmol/L slightly increased the proportion of particles > 0.6 µm. Ninety six hours storage also increased the percentage of particles > 0.6 µm (+0.143 ± 0.07; p = 0.038) but did not influence other parameters. No association with calcium composition was observed. Amino acid content was inversely correlated with pH (-0.83; p < 0.0001). Conclusions: the studied individualized parenteral nutrition admixtures for newborns that contain fish oil emulsions and meet cation requirements are stable for at least 96 hours.
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Senarathna SMDKG, Strunk T, Petrovski M, Woodland S, Martinez J, Chuang VTG, Batty KT. Physical compatibility of lipid emulsions and intravenous medications used in neonatal intensive care settings. Eur J Hosp Pharm 2023:ejhpharm-2023-003870. [PMID: 37875283 DOI: 10.1136/ejhpharm-2023-003870] [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: 06/08/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the physical compatibility of intravenous lipid emulsions with parenteral medications used in neonatal intensive care. METHODS Lipid emulsion and drug solutions were combined 1:1 in glass vials, inspected for physical incompatibility at 0, 1 and 2 hours, and assessed on the basis of lipid droplet size at 0 and 2 hours after mixing. Intravenous fluid controls (Water for Injection, sodium chloride 0.9% w/v, glucose 5% w/v), positive controls (gentamicin, albumin), negative controls (metronidazole, paracetamol, vancomycin) and 21 previously untested drug combinations were evaluated. RESULTS No phase separation, change in colour, gas production or other visible anomaly was observed. The between-run mean droplet diameter (MDD) for SMOFlipid20% alone (0.301±0.008 µm) was comparable to the lipid emulsion/intravenous fluid and lipid emulsion/drug solution combinations. In addition to gentamicin and albumin, caffeine citrate (20 mg/mL) was shown to be incompatible with the lipid emulsion. All other lipid:drug combinations were compatible, based on the MDD data. CONCLUSION Intravenous lipid emulsions were found to be compatible with 20 parenteral medications, including antimicrobial agents, inotropes, anti-inflammatory drugs and caffeine base, in simulated Y-site conditions. The lipid emulsion was incompatible with caffeine citrate injection.
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Affiliation(s)
| | - Tobias Strunk
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
- Neonatal Directorate, Child and Adolescent Health Service, Subiaco, Western Australia, Australia
| | - Michael Petrovski
- Pharmacy Department, Women and Newborn Health Service, Subiaco, Western Australia, Australia
| | - Sarah Woodland
- Pharmacy Department, Women and Newborn Health Service, Subiaco, Western Australia, Australia
| | - Jorge Martinez
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Victor T G Chuang
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Kevin T Batty
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia, Australia
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4
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Brito-de la Fuente E, Muñiz-Becerá S, Ascanio G. Lipid emulsions in clinical nutrition: Enteral and parenteral nutrition. ADVANCES IN FOOD AND NUTRITION RESEARCH 2023; 105:301-342. [PMID: 37516466 DOI: 10.1016/bs.afnr.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Clinical nutrition emulsions are important products that can be life-saving for many patients suffering from gastrointestinal tract disorders, swallowing impairment, cancer, liver diseases, and many other clinical conditions. The transfer of lipids to the human body can be either intravenously (Parenteral Nutrition, PN) or through the gastrointestinal tract (Enteral Nutrition, EN). PN emulsions are considered pharmaceuticals and thus regulated accordingly. On the other hand, EN emulsions are classified as Food for Specific Medical Purposes (FSMP) and do not follow pharmaceutical regulations. Regarding product design, PN emulsions must follow theoretical emulsion formulation and production aspects, but special requirements regarding droplet size distribution must be followed to comply with national pharmacopeia monographs. Furthermore, a full clinical program on clinical evidence to prove safety and efficacy must be provided for marketing approval. On the contrary, EN emulsions require limited clinical evidence to substantiate health or clinical benefits. A short introduction to clinical nutrition with a focus on lipid emulsions is presented in this chapter. Furthermore, a general overview of the composition and main ingredients of clinical nutrition lipid emulsions is reviewed. Main clinical aspects are also mentioned here, highlighting the difficulties of clinically proving the efficacy of these products. The manufacturing and control of clinical nutrition emulsions are also reviewed, focusing on PN products and the main regulatory requirements related to the safety of these intravenous emulsions. Finally, stability and physicochemical properties are reviewed, and examples of commercially available products are used to illustrate these properties linked to the stability of these products. Lipids in clinical nutrition is a moving field and we do hope this chapter may remain a valuable source to understand newly emerging research on this topic.
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Affiliation(s)
- Edmundo Brito-de la Fuente
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico.
| | - Sahylin Muñiz-Becerá
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico
| | - Gabriel Ascanio
- Instituto de Ciencias Aplicadas y Tecnología, Universidad Nacional Autónoma de México, Circuito Exterior S/N, Ciudad Universitaria, Mexico City, Mexico
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5
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Giorgia Z, Barzan D, Marzaro G, Pigozzo S, Valenti A. One-chamber and two-chamber parenteral nutrition admixtures for pediatric and adult patients: An evaluation of physico-chemical stability at room and cold temperature. Nutrition 2023; 106:111891. [PMID: 36459846 DOI: 10.1016/j.nut.2022.111891] [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: 08/01/2022] [Revised: 10/05/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the physico-chemical stability of compounded total parenteral nutrition admixtures through peroxidation assay and ultraviolet-visible spectroscopy, high-performance liquid chromatography analysis, nuclear magnetic resonance spectrometry, pH meter, and dynamic light scattering. METHODS The present study considered parenteral nutrition (PN) admixtures for pediatric and adult patients. The admixtures were characterized by a high content of vitamins and trace elements. They were prepared in one- or two-chamber bags in the hospital pharmacy using an automatic compounding system in a sterile room with laminar airflow at different temperature conditions and light exposure. The experiment setup comprised fat emulsions, lipid-free PN solutions, and single-chamber bags before and after adding vitamins and trace elements. The stability at room temperature (+25°C) and cold temperature (+2-8°C) was assessed by various means. RESULTS Two-compartment admixtures, single-chamber bags, and all-in-one PN supplemented with vitamins and trace elements are stable up until 35, 9, and 7 d, respectively, when protected from light and stored at +2 to 8°C. Also, the supplemented single-chamber PN was found to be stable up to 48 h when stored at +25°C with light exposure. CONCLUSIONS The results obtained will help improve PN management at the compounding center and in hospital wards, because they allow for the extension of the validity time frame provided so far by the different formulations and, therefore, therapy scheduling over several days.
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Affiliation(s)
- Zorzetto Giorgia
- Veneto Oncology Institute, Scientific Hospitalization and Care Institutes, University of Padua, Padua, Italy.
| | | | - Giovanni Marzaro
- Department of Pharmaceutical Sciences, University of Padua, Padua, Italy
| | - Sara Pigozzo
- Hospital Pharmacy Service, Mirano, Venice, Italy
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6
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Berlana D. Parenteral Nutrition Overview. Nutrients 2022; 14:4480. [PMID: 36364743 PMCID: PMC9659055 DOI: 10.3390/nu14214480] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 09/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall 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
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7
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A New Control Strategy for High-Pressure Homogenization to Improve the Safety of Injectable Lipid Emulsions. Pharmaceutics 2022; 14:pharmaceutics14081603. [PMID: 36015229 PMCID: PMC9412542 DOI: 10.3390/pharmaceutics14081603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023] Open
Abstract
Intravenous lipid emulsions are biocompatible formulations used as clinical nutrition products and lipid-based delivery systems for sparingly soluble drugs. However, the particle-size distribution is associated with risks of embolism. Accordingly, the mean particle diameter (MPD) and particle-distribution tailing (characterized as the pFAT5 value) are critical quality attributes that ensure patient safety. Compliance with the limits stated in the United States Pharmacopoeia is ensured by high-pressure homogenization, the final step of the manufacturing process. The US Food and Drug Administration’s Quality-by-Design approach requires a control strategy based on deep process understanding to ensure that products have a consistent and predefined quality. Here we investigated the process parameters of a jet-valve high-pressure homogenizer, specifically their effect on the MPD, pFAT5 value and droplet count (determined by microscopy) during the production of a Lipofundin MCT/LCT 20% formulation. We provide deep insight into droplet breakup and coalescence behavior when varying the process pressure, emulsion temperature and number of homogenization cycles. We found that high shear forces are not required to reduce the pFAT5 value of the particle distribution. Finally, we derived a control strategy for a rapid and cost-efficient two-cycle process that ensures patient safety over a large control space.
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8
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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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9
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Cober MP, Gura KM, Mirtallo JM, Ayers P, Boullata J, Anderson CR, Plogsted S. ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations. Nutr Clin Pract 2021; 36:1106-1125. [PMID: 34705289 DOI: 10.1002/ncp.10778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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Affiliation(s)
- M Petrea Cober
- Neonatal Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA.,College of Pharmacy, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kathleen M Gura
- Pharmacy Clinical Research Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA.,College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, Mississippi, USA
| | - Joseph Boullata
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Otero-Millán L, Lago Rivero N, Blanco Rodicio A, García Beloso N, Legido Soto JL, Piñeiro-Corrales G. Stability of lipid emulsion in total parenteral nutrition: An overview of literature. Clin Nutr ESPEN 2021; 45:19-25. [PMID: 34620316 DOI: 10.1016/j.clnesp.2021.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGOUND AND AIMS Total parenteral nutrition (TPN) is an extremely complex mixture. The multitude of chemical compounds involved can give rise to numerous reactions that condition its stability. We set out to review the existing literature on different issues related to stability, and which are still of concern in the hospital environment; such as the stability of the lipid emulsion. In addition, we analyse other related factors and parameters that allow us to predict the stability of TPN based on the composition. MATERIAL AND METHODS we searched PubMed and Google Scholar, over the date range 1995-2019 for relevant studies about TPN stability. We included experimental studies where the physical stability of the lipid emulsion in TPN had been analysed. We applied specific exclusion criteria. RESULTS we included 20 papers in this review of TPN stability. The studies combined different analytical techniques to assess the stability. In all the studies, the mean droplet diameter (MDD) is measured and the stability analysis is completed with other measurements. Temperature and components concentration are also considered. CONCLUSIONS studies on the stability of TPN used differing components with different chemical characteristics and their results can be difficult to extrapolate. There is no clear consensus about the composition of the mixtures and there is also great variety in the analytical techniques that were used to analyse stability. It is necessary to conduct new studies to update information on TPN stability.
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Affiliation(s)
- Luis Otero-Millán
- Complexo Hospitalario Universitario de Vigo, Pharmacy Department, Vigo, Spain.
| | | | | | - Nerea García Beloso
- Complexo Hospitalario Universitario de Vigo, Pharmacy Department, Vigo, Spain.
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11
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Boullata JI, Berlana D, Pietka M, Klek S, Martindale R. Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S74-S81. [PMID: 32049398 DOI: 10.1002/jpen.1737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/15/2019] [Indexed: 12/13/2022]
Abstract
A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.
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Affiliation(s)
- Joseph I Boullata
- Department of Nutrition Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Berlana
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,Department of Nutrition, University of Barcelona, Barcelona, Spain
| | | | - Stanislaw Klek
- General Surgery and Oncology Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Robert Martindale
- and the Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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12
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Ross EL, Salinas A, Petty K, Her C, Carpenter JF. Compatibility of medications with intravenous lipid emulsions: Effects of simulated Y-site mixing. Am J Health Syst Pharm 2020; 77:1980-1985. [DOI: 10.1093/ajhp/zxaa299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Purpose
To determine the physical intravenous Y-site compatibility of 19 commonly used medications at pediatric concentrations with 3 different types of lipid emulsion.
Methods
Medications at commonly used pediatric concentrations were mixed in a 1:1 ratio with lipid emulsions (Intralipid, Nutrilipid, and Smoflipid) and incubated at room temperature for 4 hours to simulate Y-site administration. Each sample was then diluted with particle-free water and analyzed using the analytical technique of light obscuration recommended in United States Pharmacopeia (USP) general information chapter 729 (USP <729>). Physical compatibility was determined by measuring the percentage of fat residing in globules larger than 5 µm (PFAT5) per USP <729> recommendations.
Results
Most combinations tested were physically compatible based on USP <729> regulations. Incompatibilities differed for the different brands of lipid emulsion. The two combinations that met USP <729> criteria for physical incompatibility were cisatracurium 2 mg/mL with Intralipid and gentamicin 2 mg/mL with Smoflipid.
Conclusion
Three different lipid emulsions were physically compatible at the Y site with the majority of medications tested. Data regarding Y-site compatibility for one lipid emulsion product cannot be safely extrapolated to another without additional testing.
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Affiliation(s)
- Emma L Ross
- Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO
| | - Allison Salinas
- Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO
| | - Kirsten Petty
- Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO
| | - Cheng Her
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Science, Aurora, CO
| | - John F Carpenter
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Science, Aurora, CO
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13
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Zhao B, Gao R, Jiao L, Zhang F, Wang B, Mei D. Physical Stability of Medium-Chain Triglyceride/Long-Chain Triglyceride Emulsion Injections From 5 Manufacturers in High-Concentration Electrolyte-Based Total Nutrient Admixtures. JPEN J Parenter Enteral Nutr 2020; 45:1275-1284. [PMID: 32860630 DOI: 10.1002/jpen.2009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/09/2020] [Accepted: 08/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Lipid emulsion injections for parenteral nutrition are an important source of energy and essential fatty acids. Yet stability and compounding challenges remain. We compared the physicochemical stability of 5 commercial medium-chain triglyceride/long-chain triglyceride (MCT/LCT)-based lipid emulsions compounded in total nutrient admixtures (TNAs). METHODS Stability of the MCT/LCT-based TNAs was assessed when compounded with high concentrations of electrolytes. We measured mean droplet diameter (MDD), percentage of fat residing in globules ≥5 μm (PFAT5), pH, and osmolality immediately after compounding (time 0) and 6, 12, 18, 24, 36, 48, 60, and 72 hours later. Repeated-measures analyses of variance were used to evaluate changes in stability over time, and post hoc tests were used to assess group differences. RESULTS Over 72 hours, MDD of TNAs ranged from 0.206 to 0.713 μm, PFAT5 from 0.58% × 10-3 to 43.18% × 10-3 , pH from 5.769 to 5.879, and osmolality from 1304 to 1357 mOsm/kg. MDDs and PFAT5s showed a tendency to increase gradually over the first 24 hours and then decrease or remained stable after that. We identified some significant differences in MDDs and PFAT5s among the 5 MCT/LCT-based TNAs, although all met the United States Pharmacopeia <729> standards. CONCLUSIONS The stability of some commercial MCT/LCT-based TNAs under high concentrations of electrolytes exhibits differences over the 72 hours after compounding. Clinicians should pay attention, therefore, to possible performance differences of injectable lipid emulsions produced by different manufacturers when compounded in TNAs under high electrolyte concentrations.
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Affiliation(s)
- Bin Zhao
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ruichen Gao
- Department of Pharmacy, The Central Hospital of Jia Mu Si City, Jiamusi, People's Republic of China
| | - Lei Jiao
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Fan Zhang
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Biao Wang
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Dan Mei
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Improving plasma stability and antitumor effect of gemcitabine via PEGylated liposome prepared by active drug loading. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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15
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Stawny M, Gostyńska A, Nadolna M, Jelińska A. Safe Practice of Y-Site Drug Administration: The Case of Colistin and Parenteral Nutrition. Pharmaceutics 2020; 12:E292. [PMID: 32213881 PMCID: PMC7151260 DOI: 10.3390/pharmaceutics12030292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 11/29/2022] Open
Abstract
A serious problem in everyday clinical practice is the co-administration of drugs using the same infusion line. Potential complications of co-administration of incompatible drugs include precipitation in the infusion line or central venous catheter leading to its occlusion. Administration of precipitate and large lipid droplets into the venous system may lead to the embolization of capillaries and local or systemic inflammatory reactions, with the consequences of venous thrombosis, chronic venous insufficiency, and even pulmonary embolism. The co-administration of drugs must always be confirmed and clearly defined. The study aimed to determine the interaction between colistin (COL) in the dose used during intermittent hemodialysis and five different ready-to-use PN admixtures (PN) (Kabiven, Smofkabiven, Olimel N9E, Nutriflex Lipid Special, and Nutriflex Omega Special). COL-PN compatibilities were tested by comparing physicochemical properties (pH, zeta potential, lipid emulsion particle size) of COL and PN at three time points: immediately after sample preparation, after ten minutes, and after four hours. No changes in the visual inspection were observed. Both PN without COL and COL-PN samples remained white, homogeneous oil-in-water emulsions with no signs of phase separation, precipitation, or color change. There were no significant changes in pH, and the mean droplet diameter remained below the acceptance limit of 500 nm. The zeta potential and osmolality of COL-PN samples ranged from -21.4 to -7.22 mV and from 567 to 1304 mOsm/kg, respectively. The COL does not influence the physical stability of studied PN admixtures. The co-infusion of COL with Kabiven, Nutriflex Lipid Special, Olimel N9E, Nutriflex Omega Special, and Smofkabiven is possible in the dose used during intermittent hemodialysis.
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Affiliation(s)
- Maciej Stawny
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland; (A.G.); (M.N.); (A.J.)
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Deng Y, Zhong G, Wang Y, Wang N, Yu Q, Yu X. Quality by design approach for the preparation of fat-soluble vitamins lipid injectable emulsion. Int J Pharm 2019; 571:118717. [DOI: 10.1016/j.ijpharm.2019.118717] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/03/2019] [Accepted: 09/19/2019] [Indexed: 12/16/2022]
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Nilsson N, Nezvalova-Henriksen K, Tho I. Emulsion Stability of Different Intravenous Propofol Formulations in Simulated Co-Administration with Remifentanil Hydrochloride. PHARMACEUTICAL TECHNOLOGY IN HOSPITAL PHARMACY 2019. [DOI: 10.1515/pthp-2019-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Propofol and remifentanil often need to be co-administered via the same intravenous catheter line, which predisposes to potential compatibility issues. Our aim was to determine and compare the emulsion stability of three propofol formulations, two with medium chain triglycerides and one with long chain triglycerides, when administered together with remifentanil hydrochloride.
Methods
Remifentanil hydrochloride (Ultiva
®
) 50 µg/mL was mixed with two concentrations (10 and 20 mg/mL) of each propofol formulation in mixing ratios 10+1, 20+1, 1+1 and 1+20. Emulsion stability was assessed immediately after mixing and 4 hours later by measurements of pH, mean droplet diameter, polydispersity index, and calculating percentage of fat residing in globules>5 µm (PFAT5).
Results
High PFAT5 values were observed in certain mixing ratios. The correlation between elevated PFAT5 and high propofol concentration (20 mg/mL), when remifentanil was in abundance and for long contact time indicated that these factors influenced the stability of the propofol emulsions.
Conclusions
Stability differences between the propofol formulations were identified under extreme test conditions. Co-administration of remifentanil and propofol in the same i.v. line is safe when propofol is in abundance. Caution is advised when remifentanil is present in equal parts or in abundance when co-administered with propofol 20 mg/mL.
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Affiliation(s)
- Niklas Nilsson
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences , University of Oslo , P.O.Box 1068 Blindern , Oslo 0371 , Norway; Oslo Hospital Pharmacy, Rikshospitalet, Norway
| | | | - Ingunn Tho
- Department of Pharmacy , Faculty of Mathematics and Natural Sciences, University of Oslo, P.O.Box 1068 Blindern , Oslo 0371 , Norway
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Effect of Lipid Emulsion on Stability of Ampicillin in Total Parenteral Nutrition. Nutrients 2019; 11:nu11030559. [PMID: 30845675 PMCID: PMC6470911 DOI: 10.3390/nu11030559] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Ampicillin (AMP) is frequently administered parenterally in critically ill patients with meningitis or endocarditis. Many of them require parallel infusion of total parenteral nutrition (TPN) admixtures. The aim of the study was to determine the physicochemical stability of AMP in TPN admixtures. Methods: AMP was added to two formulations of TPN admixtures differing in the lipid emulsion (Lipofundin® MCT/LCT 20% or LIPIDem®). Samples were stored at 4 ± 1 °C with light protection, and at 25 ± 1 °C with and without light protection to assess the impact of temperature and light on formulation stability. Every 24 h the pH, zeta potential, mean droplet diameter (MDD) of a lipid emulsion, and AMP concentration using HPLC method were determined. The assessment of stability and compatibility of TPN admixtures with vitamins and trace elements was carried out immediately after preparation and after 24 h of storage. Results: The addition of AMP as well as vitamins and trace elements to the TPN admixtures did not affect their physical stability. An increase in the pH value of approx. 0.6 and reduction of zeta potential were observed. The MDD of the lipid emulsions was below the limit of 500 nm (dynamic light scattering (DLS) method) and no fat droplets greater than 525 nm were observed (light diffraction (LD) method). The content of AMP after the first 24 h was within the acceptable limit of 90% for TPN admixtures stored at 4 ± 1 °C and 25 ± 1 °C with light protection. Conclusions: The results showed that co-administration of AMP in the same bag with TPN admixture at the tested dose is possible when used ex tempore and with light protection.
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Missing evidence for toxicity of high PFAT5 levels in mixtures of lipids. CLINICAL NUTRITION EXPERIMENTAL 2016. [DOI: 10.1016/j.yclnex.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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