Effect of addiivet selection on calculated aluminum content of parenteral nutrient solutions

Smith, Brian S.; Kothari, Hema; Hayes, Bryan D.; Tataronis, Gary; Hudlin, Margaret; Doole, John E.; Hartman, Christian

doi:10.2146/ajhp060163

Cited by 32 publications

(23 citation statements)

References 12 publications

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“…Statistically significant differences in aluminum content of PN solutions before and after its minimization were also seen. 97,98 The trace elements chromium and zinc are the most frequently measured as contaminants in a number of PN components. 90,91,95,[99][100][101][102] This may necessitate the use of individual rather than fixeddose multi-trace element products to allow dosing flexibility for patient PN regimens when contaminants are of concern.…”

Section: Questionmentioning

confidence: 99%

A.S.P.E.N. Clinical Guidelines

Boullata

Gilbert

Sacks

et al. 2014

J Parenter Enteral Nutr

253

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Background: Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation. Method: A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calciumphosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na-or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE? (JPEN J Parenter Enteral Nutr. 2014;38:334-377)

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Section: Questionmentioning

confidence: 99%

A.S.P.E.N. Clinical Guidelines

Boullata

Gilbert

Sacks

et al. 2014

J Parenter Enteral Nutr

253

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“…3 Although CaGlu has been consistently found to have significantly higher levels of Al contamination compared with CaCl, [4][5][6] CaGlu has been used in neonatal PN solutions by many centers to provide increased Ca intake instead of solutions containing CaCl. Currently, the FDA recommends limiting the Al intake from contamination of PN for preterm infants to ≤0.19 µmol/ kg/d (≤5 µg/kg/d).…”

Section: Infantsmentioning

confidence: 99%

Neonatal Parenteral Nutrition Containing Calcium Chloride and Sodium Phosphate

Huston¹,

McCulley

Markell

et al. 2012

ICAN: Infant, Child, & Adolescent Nutrition

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Objective. The authors' objectives were to determine mineral as well as Al intakes for ≤1000 g birth weight (ELBW) infants supported with parenteral nutrition (PN) solutions containing calcium chloride (CaCl) and sodium phosphate (NaPhos). Study design. This study was a prospective cohort study of 32 ELBW infants. Nutrient and Al intakes were recorded based on actual fluid intakes and concentrations of nutrients and Al in PN solutions. Growth velocities and peak alkaline phosphatase (AP) levels during the hospital stay were recorded. Result. Mean (±standard deviation) weight, length, and head circumference gains and AP were 13.7 ± 1.8 g/kg/d, 1.0 ± 0.2 cm/wk, 0.7 ± 0.1 cm/wk, and 636 ± 227 U/L, respectively. Al intake was 0.27 ± 0.07 µmol/kg/d (7.2 ± 1.8 µg/ kg/d) in infants receiving PN with low Al content. This study documented average parenteral Ca and P intakes of 1.15 to 1.20 and 1.19 to 1.29 mmol/ kg/d, (46-48 and 37-40 mg/kg/d), respectively, with PN fluid intakes of 90 to 100 mL/kg/d. Conclusion. AP and growth in ELBW infants receiving PN solutions containing CaCl are comparable to those reported in the literature for ELBW infants. Ca and P intakes approaching those reported for preterm infants receiving PN containing calcium gluconate can be provided with PN solutions containing CaCl. Fluid restriction is a significant factor limiting mineral intakes. Al intake can be limited to near FDA recommended intakes in PN solutions containing CaCl.

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“…At the concentrations of calcium and phosphorus used in PN solutions to support neonatal patients the risk of precipitation is increased [5]. However, CaGlu has been consistently identified as the calcium (Ca) additive with the highest level of Al contamination in PN [6]–[8] while PN solutions made with CaCl 2 and sodium phosphate (NaPhos) contain significantly less Al compared to those made with CaGlu and potassium phosphate (KPhos) [1], [9]. Currently, the FDA recommends limiting the Al intake from contamination of PN for preterm infants to ≤0.19 µmol/kg/day (≤5 µg/kg/day) [10].…”

Section: Introductionmentioning

confidence: 99%

Calcium Chloride in Neonatal Parenteral Nutrition: Compatibility Studies Using Laser Methodology

et al. 2014

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IntroductionWe have previously reported results of precipitation studies for neonatal parenteral nutrition solutions containing calcium chloride and sodium phosphate using visual methods to determine compatibility. The purpose of this study was to do further testing of compatibility for solutions containing calcium chloride using more sensitive methods.MethodsSolutions of Trophamine (Braun Medical Inc, Irvine, CA) and Premasol (Baxter Pharmaceuticals, Deerfield, IL) were compounded with calcium chloride and potassium phosphate. Controls contained no calcium or phosphate. After incubation at 37° for 24 hours solutions without visual precipitation were analyzed to determine mean particle size using dynamic light scattering from a laser light source.ResultsParticle sizes were similar for control solutions and those without visual precipitation and a mean particle size <1000 nm. Compatible solutions were defined as those with added calcium and phosphate with no visual evidence of precipitation and mean particle size <1000 nm. In solutions containing 2.5–3% amino acids and 10 mmol/L of calcium chloride the maximum amount of potassium phosphate that was compatible was 7.5 mmol/L.ConclusionMaximum amounts of phosphate that could be added to parenteral nutrition solutions containing Trophamine and calcium chloride were about 7.5–10 mmol/L less for a given concentration of calcium based upon laser methodology compared to visual techniques to determine compatibility. There were minor differences in compatibility when adding calcium chloride and potassium phosphate to Premasol versus Trophamine.

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Effect of addiivet selection on calculated aluminum content of parenteral nutrient solutions

Abstract: There is wide variability in the aluminum concentration of injectable products used in the compounding of PN solutions. Selecting products with low aluminum concentration may substantially reduce the amount of the element administered to patients.

Cited by 32 publications

References 12 publications

A.S.P.E.N. Clinical Guidelines

A.S.P.E.N. Clinical Guidelines

Neonatal Parenteral Nutrition Containing Calcium Chloride and Sodium Phosphate

Calcium Chloride in Neonatal Parenteral Nutrition: Compatibility Studies Using Laser Methodology

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