The European Journal of Hospital Pharmacy Science Volume 12 2006 Issue 2 P. 35 - 40 2006 The European Association of Hospital Pharmacists.

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Calcium and phosphate compatibility and stability studies in different neonatal parenteral nutrition mixtures
Sonia Driss Chaieb, PhD1,2,5, Jean-Claude Chaumeil, PhD2, Sami Jebnoun, MD3, Naima Khrouf, MD3, Abderrazek Hedhili, PhD4, and Souad Sfar, PhD5 ABSTRACT Study objectives: In vitro calcium-phosphate compatibility was evaluated in different parenteral nutrition formulae after the addition of various concentrations of K2HPO4 or glucose-1-phosphate and calcium gluconate, and using Primene as source of amino acids. Methods: Six series of experiments for each calcium and phosphate couple were carried out with varying amino acid concentrations (1%, 2% and 3.5%) and glucose concentration (8% and 14%). Samples were stored for 18 hours at 37 1C. Evaluation was performed by visual inspection, light microscopy, pH measurement, determination of calcium concentration before and after micro-filtration and particle size determination. Results: The precipitation of calcium-phosphate was immediately visually detected for K2HPO4 with both organic and inorganic calcium, with a limit of solubility observed at 9 mmol/L of K2HPO4 and 30 mmol/L of calcium gluconate. However, organic glucose-1-phosphate with calcium gluconate precipitates were not visually detected nor quantified by sophisticated laser light analysis, but were observed by optical microscopy and estimated by micro-filtration. Conclusion: Our data indicated that the use of glucose-1-phosphate as the phosphate source in parenteral nutrition solutions greatly improves solubility but the risk of calcium-phosphate precipitation remains and appropriate measures should be developed for the detection of particles in parenteral solutions. KEY WORDS Parenteral nutrition, stability, compatibility, calcium, phosphate

INTRODUCTION The administration of parenteral nutrition (PN) is an essential part of the therapy given to infants in the neonatal intensive care unit. However, the addition of high concentrations of calcium (Ca) and phosphate (P) to ensure an optimal delivery of calcium for a restricted fluid volume and to reduce metabolic bone disease remains an important pharmaceutical concern [1-9]. Clinical complications and deaths due to calcium
Contact for correspondence: Sonia Driss Chaieb, PhD Major Hospital Pharmacist Department of Pharmacy Service CHU La Rabta Bab Saadoun Service de la Pharmacie 1007 Jebbary, Tunisia Tel/Fax: +216 71 57 88 43 chaieb_sonia@yahoo.fr
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gluconate and potassium phosphate interaction have been reported [10], and the US Food and Drug Administration (FDA) published a Safety Alert report in 1994 [11]. Numerous studies have attempted to determine the maximum concentrations of various combinations of calcium and phosphorus that can be mixed safely, but the results obtained cannot be universally applied because of the differences in the study conditions and the variety of compounding products used [1-9, 12]. Several factors can affect the solubility of these two electrolytes [12-15] including the concentration of calcium and phosphate ions, salt of calcium used, composition and concentration of amino acid solutions, temperature and pH of solutions, presence of other electrolytes and additives, order of mixing, infusion rates and length of storage. The dibasic calcium phosphate salt is 60 times less soluble than the monobasic form in aqueous medium [13] and its solubility is highly pH-dependent [12]. If the solubility product for a particular calcium phosphate salt is exceeded, then precipitation will occur [16]; the generally accepted maximum range of compatibility in a litre of PN solution without the formation of precipitate is 15 mEq of calcium ion and 30 mEq of phosphate ion [17]. However, the use of organic phosphates in the form of sodium glucose-1-phosphate, sodium glycerophosphate [6] or sodium d-fructose1, 6-Diphosphate [18] considerably increases the Ca-P compatibility. Crystallisation of Ca-P is more likely to occur at lower concentrations when the solution is warmed to body temperature in the central venous catheter [19] or in incubators used for neonates because calcium solubility is endothermic [7]. Thus, visual inspection can sometimes be

La Rabta University Hospital, Bab Saadoun, 1007 Jebbary Tunis, Tunisia Laboratoire de pharmacie galnique, Facult des Sciences pharmaceutiques et Biologiques, Universit Ren-Descartes et AGEPS, 4, avenue de lObservatoire, 75270 Paris cedex 06, France 3 Neonatology department, Maternity Centre of Tunis, Tunis, Tunisia 4 Emergency and Anti poison Centre (CAMU), Tunis, Tunisia 5 Laboratoire de Pharmacie Galnique, Facult de Pharmacie de Monastir, Tunisia
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Received: 17 August 2005; Revised manuscript received: 23 January 2006, Accepted: 24 January 2006

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Calcium and Phosphate compatibility and stability in neonatal parenteral nutrition Sonia Driss Chaieb et al The European Journal of Hospital Pharmacy Science

ineffective in preventing infusion of the precipitate [20]. Furthermore, organic calcium additives (Ca-gluconate or glucoheptonate) have a lower degree of dissociation compared to inorganic calcium chloride. But calcium gluconate injections can be contaminated with aluminium (>5 g) which has been associated with neurotoxicity and abnormal bone development in neonates and small children [21,22]. The maximum concentration needed to meet the recommended daily intakes for premature infants is approximately 30 mmol/L of Ca and 20 mmol/L of P, assuming a liquid requirement of 120 ml/day [18]. Given the potential risk of precipitation related to the use of high concentrations of calcium in neonatal PN solutions, this study investigated the complexities of Ca and P solubility when using inorganic or organic phosphate and Primene as amino acid source under simulated clinical conditions. METHODS The study was based on the neonatal PN mixtures named N1, N2 and N3 currently used (except for the formula N1) at the Maternity Hospital. Standard PN solutions were compounded and mixed in a 1000 mL ethylene vinyl acetate (Nutripoche EVA M) PN bag (Baxter, France) using aseptic techniques in a vertical laminar air flow hood. The composition of the six tested formulae are presented in Table 1; these were named N1, N1Mg, N2, N2Mg, N3, N3Mg. Table 1: Composition of TPN solutions
Solutions N1 N1+ Mg Glucose (g/100mL) 8 8 (Siphat, Tunisia) Primene 10%(g/100mL) 1 1 (Clintec Parenteral SA, Baxter France) AA:10g/100mL ; Cl-:15.6mmol/L ; Na+ 5mmol/L NaCl10% (mEq) 3 3 (Unimed, Tunisia) 1mL =100mg =1.7meq NaCl K Cl 7.46% (mEq) 2 2 (Unimed, Tunisia) 1 mL =74.6 mg = 1meq KCl Mg Sulfate 15% (mEq) 0.4 (Aguettant, France) 1mL=14.8mg=0.6mmol=1.22meq Water for injection qsp 500 mL N2 N2 + Mg N3 N3 + Mg 8 8 14 14 2 3 2 2 3 2 0.4 3.5 3 2 3.5 3 2 0.4

containing 0.33 mmol/mL of phosphorus (Aguettant, France). Calcium gluconate at 10% (Glucalcium Renaudin, France) was used as an organic calcium source, whereas calcium chloride (CaCl2) solutions were prepared in the laboratory. General procedure Appropriate volumes of the standard solutions were withdrawn from each of the PN solutions and transferred to universal 20 mL glass test tubes using 0.22 m filters (Sterifix Luer Lock, Braun, France). K2HPO4 or glucose-1-phosphate (G1P) solutions from 5 mmol/L (15.1 mg/dL) to 40 mmol/L (120 mg/dL) were added to each sample, the blank tube did not contain phosphorus. The tubes were shaken then calcium as calcium gluconate (CaGlu) was added at concentrations from 5 mmol/L (20 mg/dL) to 50 mmol/L (200 mg/dL). The samples were capped and vigorously shaken to mix and eliminate local concentrations of both calcium and phosphate. The order of addition was made according to the FDA recommendations [11]. All samples were allowed to stand undisturbed at 37 1C for 18 hours. Immediately after the addition of P and Ca and at the end of the storage period, the samples were visually inspected using good illumination conditions and against dark background for evidence of precipitation or crystallization following a method close to that of the European Pharmacopoeia. The clear samples were checked microscopically using a Zeiss Axioskop microscope (Germany) connected to a digital camera (Canon, France) with polarizer at power 400X, for evidence of micro crystallisation. The pH of each solution was measured with Hanna (USA) instruments pH-meter after the time storage. The pH-meter was calibrated before each series of measurement at pH 4 and 7. Samples were tested in triplicate. The Ca concentrations were determined by atomic absorption spectroscopy (Perkin-Elmer 305 B, USA) before and after micro-filtration (0.22 m). The linearity of the method was performed from 1 mg/L to 10 mg/L by using a 0.1% Lanthanum oxide solution, in order to eliminate interferences with other metals during the dosage of calcium. The samples were diluted to 1/200 and 1/300 before analysis. Particle size was assessed on a Nanosizer ZS (Malvern Instruments, UK) at 25C without dilution to detect particles from 0.6 nm to 6 m, and by a Mastersizer (Malvern Instrument, UK). In this case the sample was diluted automatically in deionised water for the detection of particles greater than 6 m. Statistical analysis was performed by using non parametric ANOVA (Kruskal Wallis test) for comparison of multiple means, Mann-Whitney test for comparison of two independent means and Wilcoxon paired test for comparison of two related means. Differences were considered as significant when p<0.05. We used a non parametric test because sample sizes were reduced (n = 14) and the data were not normally distributed. RESULTS Visual appearance The results revealed that the solutions containing G1P remained clear after 18 hours of storage at 37 1C at all concentrations studied,

Duplicate samples of each solution were prepared. The standard preparations were stored at -40C. Samples were removed from the freezer and stored at room temperature 4 hours prior to commencing the experiments. Preliminary studies showed no alteration of the physico-chemical stability of these standard solutions. To exclude bacterial growth as a cause of turbidity, sterility of the solutions was checked, following the European Pharmacopoeia method. Inorganic phosphate (as dibasic potassium phosphate: K2HPO4) was prepared at a concentration of 0.57 mmol/mL by dissolving 100 g of K2HPO4 powder (Merck) in 1000 mL of distilled water. An organic source of phosphorus was provided by Phocytan (glucose-1-phosphate)

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while immediate milky-like precipitation appeared with solutions containing high concentrations of K2HPO4 and CaGlu, as presented in Table 2. Small white crystals were found adhering to the wall around Table 2: Visual appearance of parenteral nutrition solutions containing various concentrations of phosphate (K2HPO4 ) and calcium gluconates
Std. Sol N 1 2 3 4 5 6 7 8 9 10 11 12 13 14 P (K2HPO4) mmol/L mg/dL 40 120 120 26 13 78 78 39 39 Ca (calcium gluconate) mmol/L mg/dL 30 120 24.5 98 11.25 45 5 20 30 120 24.5 98 15.5 63 5 20 30 120 11.25 45 6.75 27 5 20 50 200 50 200 Results at T0

even at high calcium concentrations (Ca up to 50mmol/L). On the other hand, at Ca: 5 mmol/L the solution remained clear only at lower phosphate concentrations (P<13mmol/L). Microscopic assessment The microscopic investigations of the samples containing G1P and Ca, after 18 hours storage at 37 1C and using polarized light, showed the presence of crystals with different shapes and sizes (Figure 2). The sizes varied from 2 m to 60 m. However, it was very difficult to count the number of particles of >5 m even by using the counting cell, because it was not easy to immobilise the crystals on the cell due to the Brownian movements. Figure 2: a) Different crystal granules found in TPN solutions containing calcium gluconate and Phocytan ( at various concentrations ) after 18 hours of storage at 371C + 24 hours at ambient temperature (Sizes varied from 2 m to 50 m )

9 5

27.2 15.1

immediate precipitate immediate precipitate cloudy appearance cloudy appearance immediate precipitate immediate precipitate cloudy appearance cloudy appearance cloudy appearance mild turbidity clear solution clear solution clear solution at any Ca concentrations up to 200mg/dL clear solution at any Ca concentrations up to 200mg/dL

b) Particles observed at calcium gluconate ( 60 mmol/L ) and Phocytan ( 80 mmol/L ) after 24hours at 371C ( Sizes varied from 25 m to 60 m )

Figure 1: White crystals adhering to the wall of the glass tube containing P: 13mmol/l as K2HPO4 and Ca: 6.75mmol/l as calcium gluconate after 24 hours of standing at room temperature.

the base of the glass tube (Figure 1) for the solution containing P: 13 mmol/L and Ca: 6.75 mmol/L, after standing for 24 hours at room temperature. The limit of Ca-P solubility was found to be 9 mmol/L for P and 5 mmol/L for Ca when using either organic calcium gluconate or inorganic CaCl2. At P: 9 mmol/L the solution remained clear

pH study The pH values of the standard solutions (without calcium and phosphate) were maintained without significant changes (pH = 5.01 0.05) despite the variation in their composition. When adding calcium and phosphate to these standard solutions, the pH was raised to 6.75 0.16, 6.55 0.12 and 6.15 0.16, respectively for N1, N2 and N3 formulae. This increase in pH was probably due to the buffer effect of the glucose-1-phosphate. The mean pH corresponding to N1Mg, N2Mg and N3Mg (Table 3) with various Ca-P concentrations, were found to be significantly different (p<10-3).Variation of the pH (Figure 3) in the final solutions (N1Mg, N2Mg and N3Mg with various Ca-P concentrations), is principally influenced by the concentration of the Primene and to a lesser degree by the glucose concentrations in the mixture. The presence or absence of magnesium sulphate did not affect the pH. The pH of the solutions was considerably decreased at phosphate concentration of 13 mmol/L for the N3Mg mixture (pH = 5.82 0.15). This situation indicates that the buffering effect of phosphates and Primene is limited at high glucose concentrations, and the solution becomes more acidic. Calcium determination by atomic absorption spectrophotometer The results illustrated in Table 4 show a significant (p=0.005) decrease of Ca concentration after filtration in all solutions stored for

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Table 3: pH of the parenteral nutrition solutions studied with various Ca-P concentrations and corresponding means S.D. (N=16)
Samples Std Sol 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Phocytan (P: mg/dL) (Calcium Ca: mg/dL) _ _ P:120mg/dl 200 120 120 98 45 27 P:96mg/dl 200 120 96 98 45 27 P:78mg/dl 200 120 78 98 45 P: 39mg/dl 120 39 98 Mean pH Arithmetic Mean S.D N1Mg 5.03 6.89 6.90 6.89 6.88 6.87 6.78 6.82 6.81 6.79 6.80 6.72 6.71 6.70 6.70 6.46 6.36 6.76 6.75 0.167 6.74 1.023 pH N2Mg 5.04 6.69 6.68 6.67 6.66 6.65 6.57 6.60 6.58 6.58 6.57 6.54 6.53 6.55 6.51 6.33 6.24 6.56 6.55 0.125 0.001 6.54 1.018 <10-3 N3Mg 5.01 6.31 6.28 6.30 6.29 6.30 6.23 6.25 6.23 6.21 6.19 6.11 6.13 6.12 6.12 5.88 5.75 6.17 6.15 0.161 6.13 1.025

Figure 3: Comparison between the pH of N1, N2, N3 (with magnesium) TPN solutions containing various calcium and phosphate concentrations N=14 (95% confidence intervals)

pH

GROUP

Table 5: Paired t test of mean Ca concentrations S.D. in N3 and N3Mg formulas containing P: 40 mmol/L as Phocytan or K2HPO4 and Ca: 30mmol/L before and after filtration (n=6)
Group 1: Phocytan (P: 40mmol/L) + Ca: 30 mmol/L p mean S.D. Ca (mmol/L) 33.9 0.97 0.027 0.027 27.9 1.31 34.75 1.57 0.024 30.83 1.43 Group 2 : Comparison K2HPO4 (P: 40mmol/L) Group 1vs 2 + Ca: 30 mmol/L mean S.D. p p Ca (mmol/L) 19.1 1.37 0.027 0.004 0.027 15.8 1.33 0.004 16.8 0.6 0.027 0.004 0.024 0.004

p Geometric mean S.D p

Samples N3 before filtration N3 filtered N3Mg before filtration N3Mg filtered

18 hours at 37 1C plus 24 hours at ambient temperature (25C), when G1P is present in the mixture, compared to the blank samples without P. The decrease in Ca concentration was 26% before filtration and 39% after filtration for N1Mg solutions, 8% before filtration and 18% after filtration for both N2Mg and N3Mg solutions with various Ca-P concentrations, compared to the blank samples without phosphate. The calcium concentration decreased about 17.5%, 13.5% and 14.8% after filtration for respectively N1Mg, N2Mg and N3Mg solutions with various Ca-P concentrations, compared to the same solutions before filtration. Whereas, the decrease of calcium after filtration represents less than 5% in the mixtures without phosphate. These results indicated that Ca-P precipitation occurred in all formulae tested but it was more pronounced for the N1Mg admixture containing the lowest concentration of amino acids and higher pH value.

0.024 15.2 0.3

By evaluating G1P versus K2HPO4, we noted a significant greater decrease of Ca content (p=0.004) as the inorganic dibasic phosphate is used (Table 5) when compared to the organic phosphate. The decrease in Ca was estimated as about 48 3.5 % with K2HPO4 and 16 4.5 % when G1P is used, compared to the blank samples without P. Particle size determination The correct operation of the instrument Nanosizer ZS was controlled using a standard latex (3060A+NaCl) of diameter (65 nm 5%).

Table 4: Comparison between calcium concentrations (in mmol/L) before and after filtration (0.22) of N1Mg, N2Mg and N3Mg solutions containing G1P (40mmol/L) and various concentrations (N=3) of Ca gluconate after 18 hours storage at 371C + 24 hours at ambient temperature
N1Mg Phosphate P: 0mmol/L P:40mmol/L P:40mmol/L Calcium 30 mmol/L 30 mmol/L 24.5 mmol/L 15.75 mmol/L Ca before 36.25 1.77 29.00 1.41 21.75 2.47 15.50 0.71 Ca after 34.87 1.59 23.75 0.35 16.50 0.71 13.25 1.06 Ca before 34.37 0.88 32.25 0.35 24.50 0.71 17.75 0.35 N2Mg Ca after 33.25 1.06 27.25 0.35 20.00 1.41 15.50 0.71 Ca before 35.50 0.71 33.62 1.59 24.25 0.35 18.75 1.06 N3Mg Ca after 33.75 0.35 29.12 2.30 20.25 1.77 16.25 0.35

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Table 6: Size distribution report of N1Mg, N2Mg and N3Mg solutions with various calcium and phosphate concentrations by intensity
Sample Name Mean (S.D.) Z-Average (nm) Mean (S.D.) PDI (poly-dispersive index) Mean (S.D.) Peak 1* Mean Intensity Mean (S.D.) Peak 2* Mean Intensity Mean (S.D.) Peak 1 Area Intensity (%) Mean (S.D.) Peak 2 Area Intensity (%) N1Mg 309(249.3) 0.42 (0.25) 1.305(0.11) 244.9 (130.13) 80.75 (12.35) 18.27 (12.35) N2Mg N3Mg 422.08(309.82) 174.15(61.59) 0.44 (0.16) 0.93 (0.57) 0.27 (0.13) 1.51 (0.13)

principal peak had a mean intensity (1.298 0.2 nm) which represented more than 80% of the total area intensity for N1Mg and N3Mg samples and about 40% for N2Mg samples, the second peak has a widely variable mean intensity which is not dependant on the Ca-P concentration. Comparison of the means Z-averages (N = 14) presented in Table 7 shows non significant differences between the three formulas N1Mg, N2Mg, N1Mg. Whereas paired test shows a significant difference between formulas N2Mg and N3Mg. The particle diameter was then checked by a Mastersizer to detect particles greater than 6 m, but the sensitivity of the apparatus was not appropriate for the detection of a very small number of detectable particles. No conclusive results were obtained using this method. DISCUSSION The precipitation of calcium and phosphate is always the most likely precipitate of chemical origin to be taken into consideration in the manufacturing of TPN solutions. The precipitation of Ca-P was determined by visual inspection performed immediately after the addition of different concentrations of calcium gluconate (CaGlu) to the standard solutions containing various concentrations of K2HPO4. The technique of using diffuse light against a dark background is suited to detect large (>50 m) particles like calcium-phosphate precipitates [23]. The limit of solubility found was 9 mmol/L of P with 30 mmol/L of Ca, and for Ca concentrations of 5 mmol/L the concentration of P must not exceed 13 mmol/L. In previous studies on Ca and P solubility [4], the crystals formed with CaGlu and inorganic mono- or di-basic potassium phosphates, were described as white translucent needles i.e. white opaque flakes and white translucent granules, ranging from 20 m to 1500 m in length. The use of organic phosphates greatly improved solubility and is recommended for use in neonatal regimens requiring high calcium and phosphorus concentrations. When using organic phosphate G1P, the solutions remained clear after the addition of CaGlu. Microscopic observation of the solutions after storage at 37 1C, using polarized light, revealed the presence of crystals that resulted from the precipitation of CaGlu with the organic phosphate G1P. These crystals have different sizes and shapes (Figure 2). The decrease in the Ca concentration before and after filtration was probably due to its precipitation with phosphate and this phenomenon was more pronounced with N1Mg samples in which pH was slightly more elevated than other mixtures (pH near 7). The decrease before filtration confirmed previous studies that there was probably soluble precipitation of Ca phosphate [8], and the more pronounced decrease of Ca concentration after filtration indicate the presence of large particles in these precipitates. The largest particles observed by light microscopy (>5 m) were not detected by the sophisticated methods using laser scattering; the principal reason could be the irregular shape of the precipitates and the very

701.79 (691.9) 405.02 (187.04) 39.5 (32) 59.75 (32.5) 87.9 (8.6) 11.0 (8.47)

* see peak 1 and peak 2 in Figure 4

Figure 4: Sample of the particle size distribution report of TPN solution (after 18 h at 37C)
Peak 1 Intensity (%) Size Distribution by Inensity

Peak 2

Diameter (nm) Record 99: N1Mg1

Table 7: Statistical analysis of the mean (S.D.) Z-Averages (nm) of N1Mg, N2Mg and N3Mg solutions
Samples Arithmetic mean S.D. p Paired Test Geometric mean S.D. p Paired Test Particles size < 800 nm N1Mg (1) N2Mg (2) N3Mg (3) 319.4 210.8 353.5 178.7 179.9 55.1 0.032 (1) vs. (3): 0.301 (1) vs. (2): 0.321 (2) vs. (3): 0.003 251.18 4.46 338.84 1.58 177.82 1.34 0.047 (1) vs. (3): 0.895 (1) vs. (2): 0.109 (2) vs. (3): 0.008

The results of the particle sizing measurements of the N1Mg, N2Mg and N3Mg solutions with various Ca-P concentrations are summarized in Table 6. This table shows the Z-average diameters (the mean diameter based upon the intensity of scattered light) and the polydispersity index (an estimate of the width of the distribution). The Z-average diameter values are the means of three repeat measurements for each Ca-P concentration. With regard to particle diameter and distribution of samples, where the mean intensity of scattered light exhibited two peaks (figure 4), analysis of results did not point out particles diameters larger than 1 m (except for some samples). The

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Calcium and Phosphate compatibility and stability in neonatal parenteral nutrition Sonia Driss Chaieb et al The European Journal of Hospital Pharmacy Science

low number of large particles. Particle counting with laser light extinction method will only detect precipitation if the particles are suspended in the mixture and this may not be the case with time mediated precipitate formation in which some solid material might adhere to the container surfaces. Different techniques have been described for the particle size analysis [15,23], dispersion processes and the shape of the materials makes particle size analysis a more complex matter than it appears [24]. Microscopy has been described as an excellent technique as it allows to directly look at the particles, to measure the mean diameter, to compare different shapes, furthermore this method is relatively cheap and for some microscopes it is possible to use image analysis. Nevertheless, the problem with this method is that relatively too few particles are examined, which creates the risk of unrepresentative sampling. In addition, the sample preparation is time consuming and it is an arduous technique [23]. In 1994, the US Food and Drug Administration (FDA) [11] reported a number of clinical incidents attributed to Ca and P precipitations in patients receiving a PN solution. In all these cases, the precipitates were identified although appropriate levels of Ca and P had been used [25]. This suggests that the reaction can occur spontaneously at any concentration, and challenges the accepted maximum levels at which the two electrolytes can be mixed [14]. Precipitates that could not be visible to the human eye can act as a seeding point for the formation of a larger precipitate particle. The FDA alert recommends the use of filters when infusing TPN solutions through central or peripheral intravenous line. The benefits listed for in-line filters in TPN solutions include removal of particulate matter, prevention of phlebitis, prevention of air embolism and sepsis. A 0.22 m filter can be considered a sterilizing filter because it removes all particulates and all known bacteria [26]. Further investigations by sophisticated methods REFERENCES
1. Eggert LD, Rusho WJ, MacKay MW, Chan GM. Calcium and phosphorus compatibility in parenteral nutrition solutions for neonates. Am J Hosp Pharm 1982; 39: 49-53. 2. Venkataraman PS, Brissie EO, Tsang RC. Stability of calcium and phosphorus in neonatal parenteral nutrition solutions. Journal of Pediatric Gastroenterology and Nutrition 1983; 2: 640-643 3. Allwood MC. The compatibility of calcium phosphate in pediatric TPN infusions. J Clin Pharm Ther 1987; 12 : 293. 4. Fitzgerald KA, MacKay MW . Calcium and phosphate solubility in neonatal parenteral nutrient solutions containing Aminosyn-PF. Am J Hosp Pharm 1987; 44: 1396-1400. 5. Lenz GT, Mikrut BA. Calcium and phosphate solubility in neonatal parenteral nutrient solutions containing Aminosyn PF or TrophAmine. Am J Hosp Pharm 1988; 45: 2367-71. 6. Raupp P, Kries RV Pfahl H-G., Manz F. Glycero- vs glucose-phosphate in parenteral nutrition of premature infants : a comparative in vitro evaluation of calcium/phosphorus compatibility. J Parenter Enter Nutr. 1991 ;15: 469-473. 7. Dunham B., Marcuard S., Khazanie P. G., Meade G., Craft T. Nichols K. The solubility of calcium and phosphorus in neonatal total parenteral nutrition solutions. J. P. E. N 1991; 15: 608611 8. Levadoux E., Sautou-Miranda V., Arvouet A., Corny-Peccoux S., Chopineau J. Stabilit des mlanges binaires de nutrition parentrale pdiatriques, contenant calcium et phosphates. Journal de Pharmacie Clinique 1996 ; 15: 28-33 9. Periera-da-Silva L., Nurmamodo A, V. Amaral J.M., Rosa M.L., Almeida M.C., Ribeiro M.L. Compatibility of calcium and phosphate in four P.N. solutions for preterm neonates. Am J Health-Syst Pharm. 2003; 60: 1041-1044 10. Knowles JB; Cusson G, Smith M, Sitrin MD. Pulmonary deposition of calcium phosphate crystals as a complication of home parenteral nutrition. J.P.E.N. 1989; 13; 209 11. Food and Drug Administration. Safety alert : hazards of precipitation associated with parenteral nutrition. Am. J. Hosp. Pharm. 1994; 51 : 1427-1428 12. Niemiec PW and Vanderveen TW. Compatibility considerations in parenteral nutrient solutions. Am. J. Hosp. Pharm. 1984; 41: 893-911 13. Driscoll DF, Newton DW , Bistrian BR. Precipitation of calcium phosphate from parenter-

like electron microscopy and energy disperse spectroscopy are needed for particle identification [27]. Chemical and biochemical precipitations of calcium-phosphate minerals are common in natural systems, although the elucidation of the mechanisms of formation, initiation of growth and transformations between crystal forms of the minerals, remain a major challenge. CONCLUSION The results obtained confirmed that the use of glucose phosphate highly improves Ca-P solubility compared to inorganic potassium phosphate. The limits of solubility found were 5 mmol/L and 30 mmol/L of Ca with respectively 13 mmol/L and 9 mmol/L of inorganic P. Furthermore, the precipitation of Ca-P could occur even when organic P is used at the daily recommended dose. The risk of precipitation is higher for solutions containing 1% of Primene with 8% glucose and lower for solutions containing 2% and 3.5% of Primene with 14% glucose. Our results illustrate that the organic Ca-P precipitation cannot be detected with a laser diffraction method, but can be assessed by the determination of Ca concentration before and after microfiltration and by microscopy. Further investigations with appropriate methods are needed for a quantitative evaluation of the organic Ca-P precipitations. ACKNOWLEDGEMENTS We acknowledge the technical assistance of the medical staff of the neonatology department of the Maternity Centre of Tunis. We are also grateful to Dr N Gharbi, Laboratoire d'analyses l'Institut de Neurologie, Tunis; to Dr A Boubaker, Immunology Department of Pasteur Institute, Tunis; to Ms R Touati, Emergency and Anti-poison Centre (CAMU), Tunis; to the Opalia Pharmaceutical Laboratory; to Professor B Zouari, Facult de mdecine de Tunis and to Ms N Ennaifer, Chief Pharmacist of the Pharmacy Department CHU La Rabta, Tunis.

al nutrient fluids. Am J Hosp Phar 1994; 51; 28-34 14. Maswoswe J J, Okpara A.U., Hilliard MA. An old nemesis: Calcium and phosphate interaction in TPN admixtures. Hosp Pharm 1995; 30(7): 579-586 15. Allwood M.C., Kearney M.C.J. Compatibility and Stability of additives in Parenteral Nutrition Admixtures. Nutrition 1998;14 (9):697-706. 16. Barnett MI, Cosslett AG, Duffield JR, Evans DA, Hall SB, Williams DR. Parenteral Nutrition : Pharmaceutical problems of compatibility and stability. Drug Safety 1990; 5(suppl 1) : 101106 17. Trissel LA. Handbook on injectable drugs. 11th edition. American Society of Health-System Pharmacists, Bethesda, Maryland, USA , 2001 18.Prinzivalli M, Ceccarelli S. Sodium d-fructose-1,6-diphosphate vs. Sodium mono-hydrogen phosphate in total parenteral nutrition : a comparative in vitro assessment of calcium phosphate compatibility. J Parenter Enter Nutr. 1999; 23(6) : 326-32 19. Robinson LA, Wright BT. Central venous catheter occlusion caused by body-heat-mediated calcium phosphate precipitation. Am J Hosp Pharm 1982; 39 : 120-1 20. Hasegawa GR. Caring about stability and compatibility. Am J Hosp Pharm 1994; 51 ;1533 1534. 21. Canada T, Albercht J. Parenteral calcium gluconate supplementation: efficacious or potentially disastrous? J Am Col Nutr 1998; 17(4); 401-403 22. Micard S, Durand JL, Daoud P, Maison C. Nutrition parentrale du premature et apport en aluminium. J Pharm Clin 1998 ; 17 : 249-52 23. Minton A.R., Barnett MI, Cosslett AG. Detection of Particulate Material in Parenteral Nutrition Admixtures. Nutrition 1998;14 :251-252 24. Rawele A. Basic principles of particulate size analysis. Technical paper, Malvern Instruments, 2004. www. Malvern.co.uk 25. Hill S.E., Heldman L. S., Goo E. D. H.,Whippo P. E. Fatal microvascular pulmonary emboli from precipitation of total nutrient admixture solution. J.P.E.N. 1996; 20 :81-8 26. Buthune K., Allwood M., Grainger C., Wormleighton C. Use of filters during the preparation and administration of parenteral nutrition. Nutrition 2001, 17 (5): 403-408 27. Ball PA, Bethune KM, Fox JC, Ledger R and Barnett MI. Particulate contamination in parenteral nutrition solutions, still cause of concern. Clin Nutr 1999; 18(S1):14

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