Stability and compatibility of parenteral nutrition solutions; a review of influencing factors

Select micronutrients for the preterm neonate

“…18 However, if there was availability in the United States of the more soluble organic sodium glycerophosphate salt, compatibility would be adequate with even the calcium chloride salt, allowing a decreased aluminum provision within neonatal PN admixtures. 7,24,25 The recommended intake of enteral calcium ranges from 120 to 220 mg/kg/day, with phosphorus intake ranging from 70 to 120 mg/kg/day (Table 2). 4 The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommends 120-200 mg/kg/day as the goal intake of calcium and 70-115 mg/kg/day for phosphorus.…”

“…An adequate provision of calcium and phosphorus in a neonatal PN admixture is a challenge in times in which calcium gluconate is in short supply because of ongoing drug shortages and calcium chloride is utilized instead 18 . However, if there was availability in the United States of the more soluble organic sodium glycerophosphate salt, compatibility would be adequate with even the calcium chloride salt, allowing a decreased aluminum provision within neonatal PN admixtures 7,24,25 …”

Safety in parenteral nutrition compounding

“…Solubility of calcium and phosphate within a PN admixture is dependent on various factors, including the amino acid product used, the type of calcium and phosphate salts used, the final amino acid and dextrose concentrations, the pH of the admixture, presence of ILE in a TNA, addition of cysteine hydrochloride, final concentration of calcium and phosphate, and order of mixing to compound the PN admixture. 35 The influence of each of these factors is further described in Table 2. In the United States, inorganic sodium or potassium phosphate is used for PN compounding.…”

“…However, outside the United States, the use of the organic sodium phosphate salt, which is currently not approved by the FDA, dramatically improves the calcium:phosphate solubility within a given PN admixture. 22,35,36 Although many institutions use various calculations to determine calcium:phosphate solubility within a given PN admixture, the most accurate method for predicting the risk of calcium phosphate precipitation is by experimentation that generates calcium:phosphate solubility curves. 22 It is important to note that these curves are specific to a given PN admixture and the ingredients used to compound the given formulation.…”

“…Incorporation of nonnutrient medications within a PN admixture increases the risk of instability and incompatibility of a PN admixture. 35 ASPEN recommends the addition of nonnutrient medications within a PN admixture only when evidence supports the physicochemical compatibility and stability of the medication and PN admixture, as well as confirmation of the therapeutic actions of the medication when included in a PN admixture. 18 Because the PN admixture will be administered either over a period during the day (eg, cyclic) or as a continuous infusion, the nonnutrient medication should be therapeutically active throughout the administrative T A B L E 2 Factors impacting calcium:phosphate solubility in PN admixtures.…”