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Tomczak S, Kaszuba K, Szkudlarek J, Piwowarczyk L, Jelińska A. Potential Use of Common Administration of Emulsion for Parenteral Nutrition and Vinpocetine: Compatibility Study and Prospect. Metabolites 2024; 14:439. [PMID: 39195535 DOI: 10.3390/metabo14080439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 08/29/2024] Open
Abstract
Vinpocetine (VP) is distributed after oral and intravenous administration, and its uptake in the thalamus, basal ganglia, and visual cortex. Due to poor bioavailability (~7%) and marked first-pass effect (~75%), including a short half-life (2-3 h), oral administration of VP is limited. It requires frequent administration of the drug to obtain a therapeutic effect. Attempts to overcome these difficulties include the use of new drug delivery systems and/or alternative routes of drug administration. One possibility is the common administration of lipid emulsion and drug using the same catheter. However, this procedure is not recommended due to potential interaction and lack of safety data. For this purpose, we checked the compatibility of VP solutions with eight commercially available parenteral nutrition admixtures, i.e., Lipoflex special, Omegaflex special, Lipoflex peri, Omegaflex peri, Kabiven, SmofKabiven, Kabiven Peripheral, and Olimel Peri N4E. Coadministration is only possible if the stability of the drug and the lipid emulsion is confirmed. The available data are scarce and only concern the incompatibility of VP with ibuprofen. Compatibility tests were carried out in simulated administration through a Y-site connector using clinical flow rates. The stability of the drug and lipid emulsion was assessed by visual inspection and measurement of pH, osmolality, particle size as mean droplet diameter (MDD) and percentage of lipids residing in globules larger than 5 µm (PFAT5), zeta potential, polydispersity index, and lipid-free parenteral nutrition admixture(PNA) turbidity. The results of the compatibility of VP with eight commercial PN admixtures showed that all lipid emulsions show different signs of destabilization. In the studied samples, particles larger than 1000 nm, a significant increase in MDD, zeta potential, and loss of homogeneity visible as an increase in the polydispersity index were observed. Most of the samples had PFAT5 above the USP limit (0.05%). Taking into account the obtained data, VP should not be administered with the studied lipid emulsions for parenteral nutrition.
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Affiliation(s)
- Szymon Tomczak
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 3 Rokietnicka, 60-806 Poznań, Poland
| | - Kornelia Kaszuba
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 3 Rokietnicka, 60-806 Poznań, Poland
| | - Jagoda Szkudlarek
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 3 Rokietnicka, 60-806 Poznań, Poland
| | - Ludwika Piwowarczyk
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 3 Rokietnicka, 60-806 Poznań, Poland
| | - Anna Jelińska
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 3 Rokietnicka, 60-806 Poznań, Poland
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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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Tomczak S, Chmielewski M, Szkudlarek J, Jelińska A. Antiemetic Drugs Compatibility Evaluation with Paediatric Parenteral Nutrition Admixtures. Pharmaceutics 2023; 15:2143. [PMID: 37631357 PMCID: PMC10459602 DOI: 10.3390/pharmaceutics15082143] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/24/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Chemotherapy-induced nausea and vomiting are defined as the most common of side effects of treatment and, at the same time, are very difficult to accept for patients', frequently causing changes in the therapy regimen, significantly reducing its effectiveness. Thus, an antiemetic prophylactic is essential to the provision of such a therapy for the patient. Pharmacotherapy often includes various drugs, including antiemetics, with the administration of such drugs by injection through two separate catheters being the preferred method. However, the co-administration of drugs and parenteral nutrition admixtures (PNAs) requires the consideration of compatibility, stability and potential negative interactions. To meet the purposes of clinical pharmacy, a compatibility test of ondansetron, dexamethasone and hydrocortisone with paediatric PNAs was conducted. PNAs differ in the composition of amino acid source (Primene® or Aminoplasmal Paed® 10%) and the type of injectable lipid emulsion (Lipidem® 200 mg/mL, Clinoleic® 20%, SMOFlipid® 200 mg/mL, Intralipid® 20%). An in vitro evaluation was performed in a static way as a simulated co-administration through a Y-site. The drug PNA ratios were determined based on the extreme infusion rates contained in the characteristics of medicinal products. All calculations were performed for a hypothetical patient aged 7 years weighing 24 kg. As a result of this study, it can be concluded that all tested PNAs showed the required stability in the range of parameters such as pH, osmolality, turbidity, zeta potential, MDD and homogeneity. The co-administration of antiemetic drugs does not adversely affect lipid emulsion stability. This combination was consistently compatible during the evaluation period.
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Affiliation(s)
- Szymon Tomczak
- Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland
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Nilsson N, Nezvalova-Henriksen K, Bøtker JP, Højmark Andersen N, Strøm Larsen B, Rantanen J, Tho I, Brustugun J. Co-administration of Intravenous Drugs: Rapidly Troubleshooting the Solid Form Composition of a Precipitate in a Multi-drug Mixture Using On-Site Raman Spectroscopy. Mol Pharm 2023. [PMID: 37167030 DOI: 10.1021/acs.molpharmaceut.2c00983] [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: 05/13/2023]
Abstract
Intravenous drugs are often co-administrated in the same intravenous catheter line due to which compatibility issues, such as complex precipitation processes in the catheter line, may occur. A well-known example that led to several neonatal deaths is the precipitation due to co-administration of ceftriaxone- and calcium-containing solutions. The current study is exploring the applicability of Raman spectroscopy for testing intravenous drug compatibility in hospital settings. The precipitation of ceftriaxone calcium was used as a model system and explored in several multi-drug mixtures containing both structurally similar and clinically relevant drugs for co-infusion. Equal molar concentrations of solutions containing ceftriaxone and calcium chloride dihydrate were mixed with solutions of cefotaxime, ampicillin, paracetamol, and metoclopramide. The precipitate formed was collected as an "unknown" material, dried, and analyzed. Several solid-state analytical methods, including X-ray powder diffraction, Raman spectroscopy, and thermogravimetric analysis, were used to characterize the precipitate. Raman microscopy was used to investigate the identity of single sub-visual particles precipitated from a mixture of ceftriaxone, cefotaxime, and calcium chloride. X-ray powder diffraction suggested that the precipitate was partially crystalline; however, the identity of the solid form of the precipitate could not be confirmed with this standard method. Raman spectroscopy combined with multi-variate analyses (principal component analysis and soft independent modelling class analogy) enabled the correct detection and identification of the precipitate as ceftriaxone calcium. Raman microscopy enabled the identification of ceftriaxone calcium single particles of sub-visual size (around 25 μm), which is in the size range that may occlude capillaries. This study indicates that Raman spectroscopy is a promising approach for supporting clinical decisions and especially for compatibility assessments of drug infusions in hospital settings.
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Affiliation(s)
- Niklas Nilsson
- Department of Pharmacy, University of Oslo, Oslo 0316, Norway
- Oslo University Hospital and Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo 0372, Norway
| | - Katerina Nezvalova-Henriksen
- Department of Pharmacy, University of Oslo, Oslo 0316, Norway
- Oslo University Hospital and Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo 0372, Norway
| | - Johan P Bøtker
- Department of Pharmacy, University of Copenhagen, Copenhagen 2100, Denmark
| | | | | | - Jukka Rantanen
- Department of Pharmacy, University of Copenhagen, Copenhagen 2100, Denmark
| | - Ingunn Tho
- Department of Pharmacy, University of Oslo, Oslo 0316, Norway
| | - Jørgen Brustugun
- Oslo University Hospital and Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South-Eastern Norway, Oslo 0372, Norway
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Fresan D, Luque S, Benítez-Cano A, Sorlí L, Milagro Montero M, De-Antonio M, Prim N, Vega V, Horcajada JP, Grau S. Pharmacokinetics/pharmacodynamics and therapeutic drug monitoring of ceftazidime/avibactam administered by continuous infusion in patients with MDR Gram-negative bacterial infections. J Antimicrob Chemother 2023; 78:678-683. [PMID: 36626402 DOI: 10.1093/jac/dkac439] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/07/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of β-lactams in critically ill patients has been correlated with better clinical outcomes. Evidence on TDM of newer β-lactams such as ceftazidime/avibactam administered by continuous infusion (CI) is very limited. OBJECTIVES To describe our experience with TDM of ceftazidime/avibactam and pharmacokinetic/pharmacodynamic (PK/PD) target attainment in patients with MDR bacterial infections. Clinical outcomes of ceftazidime/avibactam administered by CI were also assessed. METHODS Patients treated with ceftazidime/avibactam administered by CI and undergoing TDM of ceftazidime plasma concentrations were included. Blood samples were obtained as part of the TDM program. The PK/PD therapeutic target of ceftazidime/avibactam was defined as 100%fT > 4 × MIC of the causative pathogen, and 100%fT > 10 × MIC was considered overexposure. Dose changes were made according to the TDM results. RESULTS Thirty-one patients were included. Ceftazidime/avibactam total daily doses ranged from 1 g/0.25 g to 6 g/1.5 g. Twenty-six patients (83.9%) achieved a 100%fT > 4 × MIC, 15 (48.4%) of which were overexposed (100%fT > 10 × MIC). Dose reduction was suggested in 16/28 (57.1%) patients and dose maintenance in 12/28 (42.9%). Overall clinical cure was observed in 21 (67.7%) patients, and 18 of these (85.7%) achieved a 100%fT > 4 × MIC. CONCLUSIONS Administering ceftazidime/avibactam by CI enabled the desired PK/PD target to be achieved in a large proportion of patients, even at lower doses than those recommended for a 2 h extended infusion. We suggest that the use of CI with TDM may be a useful tool for reducing initial doses, which could help to reduce antimicrobial-related adverse effects and treatment costs.
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Affiliation(s)
- D Fresan
- Pharmacy Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - S Luque
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
| | - A Benítez-Cano
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - L Sorlí
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain.,Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - M Milagro Montero
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain.,Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - M De-Antonio
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - N Prim
- Microbiology Department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - V Vega
- Analytical Department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - J P Horcajada
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain.,Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - S Grau
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.,Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain.,CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain.,Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Nunez-Nunez M, Murillo-Izquierdo M, Moya-Martin M, Hoxha M, Quesada Pérez MT, Oltra-Hostalet F, Alonso-Ramos H, Cordero-Ramos J, Barrera-Cabeza J, Retamar-Gentil P, Fernández-Del-Castillo SS. Compatibility of prolonged infusion antibiotics during Y-site administration. Nurs Crit Care 2022; 27:849-858. [PMID: 35088491 DOI: 10.1111/nicc.12754] [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: 10/14/2020] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial resistance is a threat to global public health. The use of prolonged infusions in the hospital setting for certain antimicrobials is widely increasing in order to improve their efficacy and safety, including resistance development. Due to limited vascular access, it is important to clarify whether they can be infused through the same line with other drugs during Y-site administration. AIM The aim of this review is to update and summarize the evidence on Y-site compatibility of antibacterial agents administered as prolonged infusions in intensive care units (ICUs). STUDY DESIGN A literature review of PubMed, EMBASE and Trissel's Handbook on Injectable Drugs databases was conducted on the compatibility of selected antimicrobials administered simultaneously at a Y-site connection with parenteral nutrition and other widely used drugs in ICUs. All articles published up to October 30, 2021, in English or Spanish were included, regardless of the type of publication (original articles, case reports, letters, etc.). Eligible antimicrobials were those that can be administered as prolonged infusions: ceftazidime, cefepime, piperacillin/tazobactam, meropenem, ceftolozane/tazobactam, ceftaroline, cloxacillin, ceftobiprole, vancomycin and fosfomycin. RESULTS A total of 1302 drug-to-drug potential combinations were explored, 196 (15.05%) were found to be incompatible, and in 541 (41.55%), data were not available. The results were presented in a simple 2-dimensional consultation chart as a quick reference for health care professionals. CONCLUSIONS This review provides useful and reliable information on the compatibility of antimicrobials administered as Y-site infusion with other drugs commonly used in the critical setting. This review contributes to patient safety in nursing practice. RELEVANCE TO CLINICAL PRACTICE To our knowledge, this is the first review on Y-site compatibility of antimicrobials used as prolonged infusions with other commonly used drugs, including anti-emetics, analgesics and anti-epileptic and parenteral nutrition. The results of the current review need to be addressed to promote the knowledge sharing between health professionals and improve the quality and safety of patients. We believe that this review may serve as a simple and effective 2-dimensional updated drug-to-drug compatibility reference chart for critical care nurses.
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Affiliation(s)
- María Nunez-Nunez
- Pharmacy Department, University Hospital Clínico San Cecilio, Granada, Spain
- Biomedical Research Institute of Granada (Ibs.Granada), Granada, Spain
| | | | - Marisa Moya-Martin
- Pharmacy Department, University Hospital Virgen Macarena, Seville, Spain
| | - Malvina Hoxha
- Department of Chemical-Toxicological and Pharmacological Evaluations of Drugs, Catholic University Our Lady of Good Counsel, Tirane, Albania
| | | | | | - Hector Alonso-Ramos
- Pharmacy Department, University Hospital Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Jose Barrera-Cabeza
- Pharmacy Department, University Hospital Clínico San Cecilio, Granada, Spain
| | - Pilar Retamar-Gentil
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University of Seville/University Hospital Virgen Macarena, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Seville, Spain
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Piwowarczyk L, Tomczak S, Antkowiak P, Jelińska A, Stawny M. Sodium Valproate Incompatibility with Parenteral Nutrition Admixtures—A Risk to Patient Safety: An In Vitro Evaluation Study. Pharmaceutics 2022; 14:pharmaceutics14020371. [PMID: 35214103 PMCID: PMC8876349 DOI: 10.3390/pharmaceutics14020371] [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: 01/01/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is defined as a group of concerning problems related to the nervous system; its defining feature is a predisposition to epileptic seizures. The frequency of seizures in intensive care units (ICU) ranges from 3.3% to 34%, and ICU antiepileptic treatment is routine practice. The administration of drugs through the same infusion line is not recommended but is common clinical practice, especially in ICU. Incompatibilities between parenteral drugs and between drugs and parenteral nutrition admixtures (PNAs) are common medical errors and pose risks to patient safety. The co-administration of drugs must always be confirmed and clearly defined. The simultaneous infusion of sodium valproate (VPA, drug used to treat seizures and epilepsy) with parenteral PNAs has not yet been studied. During the experiment reported in this study, a visual control, pH, osmolality, zeta potential, particle size, polydispersity index, and turbidity were measured. The conducted research shows that the lipid emulsion composition has a significant influence on drug–PN (drug–parenteral nutrition) compatibility. The acceptance criteria were met only for PNs containing omega-3-acid-triglycerides (Omegaflex special and peri). The second fraction of particles above 1000 nm was observed for most of the tested PNAs (Lipoflex special, Lipoflex peri, Kabiven, SmofKabiven, Kabiven Peripheral, and Olimel Peri N4E), which disqualifies their simultaneous administration with VPA.
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