Three-in-one parenteral nutrition: a safe and economical method of nutritional support for infants

Three-in-one parenteral nutrition in neonates and pediatric patients: risks and benefits

Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.

Assessment of the physicochemical stability of all-in-one parenteral emulsions for neonates according to USP specifications

BACKGROUND

The purpose of this study was to describe the methodology to assess the stability of all-in-one (AIO) parenteral nutrition admixtures, containing glucose, proteins, and lipids, to the standards of U.S. Pharmacopoeia (USP <729>). The influence of calcium and commercially available lipid emulsions and amino acid solutions were also examined.

METHODS

Four batches of 5 AIO admixtures containing calcium were compounded with commercially available lipid emulsions and amino acid solutions. Two of them contained calcium. Their stability was tested under conditions simulating clinical use. All the admixtures were assessed for criteria set by the USP <729>: (1) mean droplet diameter (MDD) and (2) percentage of volume weighted particles with diameter > 5 μm (PFAT5).

RESULTS

All admixtures were within the specifications set by the USP with respect to the MDD at 0, 24, and 48 hours, but only those batches lacking calcium met the benchmarks set by the pharmacopoeia, with respect to PFAT5, on the day of preparation.

CONCLUSIONS

The presence of calcium destabilized the admixtures, while the use of different commercial ingredients altered the admixtures' characteristics. Only 1 batch of the AIO admixtures studied was found to be compliant with USP <729> standards.

Central line occlusion with three-in-one nutrition admixtures administered at home

The use of single-container parenteral nutrition admixtures can be cost effective and can simplify home administration. Three-in-one admixtures (dextrose, amino acids, lipid emulsion, and other additives in a single bag) were in use when a marked increase in catheter occlusions was seen in the pediatric home parenteral nutrition population. Insoluble laminar deposits were found in the removed catheters. In all subsequently placed catheters, separate (SPLIT) infusions of lipid and parenteral nutrition solution were used rather than three-in-one admixtures. This was associated with an obvious decrease in catheter occlusions. Catheter life-span was retrospectively determined for 15 catheters of identical size and style that were used in eight patients who had received either infusions of three-in-one admixtures or SPLIT infusions. Life table survival analysis revealed a median survival time of 70 days for the three-in-one group (n = 8) and 290 days for the SPLIT group (n = 7). Survival distributions for the two groups were significantly different (p = .025). During the period of clustered catheter occlusion, the use of three-in-one admixtures that were stored in the home for up to 7 days was associated with a shortened catheter life-span. Occlusion or deposit development was not seen in catheters used for inpatient parenteral nutrition support when admixtures were prepared and infused within 28 hours. Catheter deposits were implicated as sanctuary sites for pathogenic bacteria in two patients. Failure to retrieve and inspect occluded catheters delayed the identification of the deposits.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous fat emulsions in clinical practice

The use of intravenous fat emulsions has become an integral part of the provision of parenteral nutrition. In the past, this was achieved by the administration of lipids separately from the dextrose-amino acid base solution. More recently, lipids have been admixed along with the dextrose-amino acid formula as a total nutrient admixture (TNA). This article discusses the advantages and disadvantages of TNAs, the factors that affect the stability of emulsions, the potential for microbial growth in TNAs, and guidelines for the compounding of TNAs.