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Importance of compatibility and stability in parenteral nutrition (PN)

Many people in the US require PN to help them meet their nutritional needs. In fact, more than 33,000 hospitalized patients receive PN while an estimated 25,000 patients require PN at home.1,2 Some patients may even receive PN in long-term care (LTC) facilities.

While PN is considered a valued clinical intervention for those who need it, it is complex, and clinicians must follow safety-focused policies, procedures, and practices—no matter the clinical setting.3

The Institute for Safe Medication Practices classifies PN as a high-alert medication in acute care and LTC settings, meaning that significant patient harm can occur if PN is used in error.4,5 Errors can occur at any step of the PN process, including review and verification of the order by a pharmacist.6 This step is critical for evaluating the compatibility and stability of the PN admixture before it goes out the door.3,6 Understanding compatibility and stability are important considerations for ensuring a patient receives PN that is safe and effective.

“The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription.”3

There are various components used when compounding PN. These may include lipid emulsions, amino acids, and electrolytes, and each component has unique physicochemical properties that can affect the compatibility and stability of the final admixture.3

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Compatibility simply means that two or more components may be combined without resulting in unfavorable physical or chemical reactions over time.3 However, if the components are incompatible, adverse reactions may occur or the therapeutic efficacy of one or more of the components may be decreased.3

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Stability means an ingredient or a dosage form is able to maintain its chemical and physical properties throughout its shelf life and storage.3 Temperature, light, oxygen, solvents, reactants, and pH can all cause instability, resulting in decomposition or degradation of the ingredient or dosage form that cannot be reversed.3

When it comes to PN, a pharmacist must be knowledgeable in pharmaceutics and understand how to apply known data on the physical and chemical properties of each component to best determine compatibility and stability.3 Altering just one component can impact the final admixture, no matter if the PN is customized for a patient’s specific nutritional needs or if a standardized commercially available PN product is used.3

“When you talk about stability, you have to look at the macronutrients that you’re compounding the PN with, number one. And number two, you have to look at the final concentration of each macronutrient.”

Reid Nishikawa, PharmD, BCNSP, FASPEN, FCSHP

As the US market leader in lipid injectable emulsions (ILEs),7 we recognize that compatibility—and particularly, stability—can pose a challenge when considering the use of ILEs. That’s why we worked tirelessly on obtaining the necessary research to generate compatibility and stability data for PN admixtures involving two of our alternative ILEs. To view our Compatibility Tool and Stability Data Reference Guides, please visit: www.freseniuskabinutrition.com/resources/#products

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References: 1. John J, Seifi A. Total parenteral nutrition usage trends in the United States. J Crit Care. 2017;40:312-313. 2. Mundi MS, Pattinson A, McMahon MT, Davidson J, Hurt RT. Prevalence of Home Parenteral and Enteral Nutrition in the United States. Nutr Clin Pract. 2017;32(6):799-805. 3. Boullata JI, Mirtallo JM, Sacks GS, et al. Parenteral nutrition compatibility and stability: A comprehensive review. JPEN J Parenter Enteral Nutr. 2022;46(2):273-299. 4. ISMP List of High-Alert Medications in Acute Care Settings. ISMP website. 2018. Accessed January 9, 2024. https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf 5. High-Alert Medications in Long-Term Care (LTC) Settings. ISMP website. 2021. Accessed January 9, 2024. https://www.ismp.org/system/files/resources/2021-05/HighAlertMedications_LTC-2021.pdf 6. Mirtallo JM, Ayers P. Parenteral Nutrition Safety. Pharmacy Practice News website. September 7, 2021. Accessed January 9, 2024. https://www.pharmacypracticenews.com/Review-Articles/Article/09-21/Parenteral-Nutrition-Safety/64518 7. Data on File; 1/1/24; calculation includes: all ILEs approved in the US.