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Stability of total parenteral nutrition supplied as 'all-in-one' for children with chemotherapy-linked hyperhydration
1Department of Pharmacy, Academic Medical Centre, Amsterdam, The Netherlands.
Insights
For children receiving chemotherapy and total parenteral nutrition (TPN), calcium and phosphate concentrations must be carefully managed. TPN mixtures remain stable if calcium is below 16 mmol/l, phosphate below 52 mmol/l, and their product under 250 mmol²/l².
Area of Science:
- Pediatric Nutrition
- Clinical Pharmacy
- Biochemistry
Background:
- Children undergoing chemotherapy often require total parenteral nutrition (TPN), leading to high electrolyte loads in limited volumes.
- The presence of polyvalent electrolytes like calcium and phosphate in TPN can potentially cause precipitation and lipid emulsion instability.
- Assessing the safe limits of calcium and phosphate in pediatric TPN is crucial for patient safety and effective nutrition delivery.
Purpose of the Study:
- To determine the maximal allowable concentrations of calcium and phosphate in pediatric TPN mixtures.
- To investigate the impact of calcium and phosphate levels on the stability of lipid emulsions in TPN.
- To establish safe TPN formulation guidelines for pediatric patients receiving chemotherapy.
Main Methods:
- Investigated calcium (1.5-150 mmol/l) and phosphate (21-300 mmol/l) concentrations in TPN mixtures.
- Assessed TPN mixture stability via microscopy for precipitates after 24 and 48 hours at 22°C and 37°C.
- Evaluated fat emulsion stability visually and measured particle size distribution using flow cytometry.
Main Results:
- TPN mixtures (pH 5.4-5.7) demonstrated stability for 48 hours at 37°C under specific ionic conditions.
- Stability was maintained when calcium concentration remained below 16 mmol/l.
- Phosphate concentration needed to be below 52 mmol/l, and the product of calcium and phosphate concentrations below 250 mmol²/l² for emulsion integrity.
Conclusions:
- Established critical concentration thresholds for calcium and phosphate in pediatric TPN to prevent precipitation.
- Identified specific limits for calcium, phosphate, and their combined product to ensure TPN stability in pediatric patients.
- Provided evidence-based guidelines for formulating safe and stable TPN for children, particularly those on chemotherapy.
Abstract:
The maximal allowable concentrations of calcium and phosphate in total parenteral nutrition mixtures for children from one compartment were investigated. Children treated with both chemotherapy and total parenteral nutrition are supplied with high amounts of electrolytes (besides normal nutritive needs) in a restricted volume. Such nutritive mixtures are suspected of precipitation and disintegration of the lipid emulsion by (polyvalent) electrolytes, such as calcium and phosphate. Calcium (range 1.5-150 mmol/l total parenteral nutrition) and phosphate (range 21-300 mmol/l) were added to a test total parenteral nutrition mixture. After storage (24 and 48 h) at both 22 degrees C and 37 degrees C the mixtures were observed by microscopy for the presence of precipitates. The stability of the fat emulsion was visually assessed and the particle size distribution was measured by flow cytometry. The examined total parenteral nutrition mixtures (pH 5.4-5.7) were stable during 48 h at 37 degrees C if the calcium concentration is below 16 mmol/l, the phosphate concentration is below 52 mmol/l and the product of both concentrations is below 250 mmol2/l2.