title: Fatal microvascular pulmonary emboli from precipitation of a total nutrient admixture solution.
abstract: BACKGROUND
  Paroxysmal respiratory failure and death occurred in two young adult females with pelvic infections. Autopsy revealed an amorphous material containing calcium obstructing the pulmonary microvasculature of each patient. Both patients received an identical total nutrient admixture (TNA) solution before their deaths.
  
  
  METHODS
  Infusion of TNA into an animal model was undertaken in an effort to reproduce the clinical effect. Laboratory investigation was also performed to isolate a precipitate and identify the factors contributing to precipitation.
  
  
  RESULTS
  A nonvisible precipitate containing calcium, phosphorus, and organic material was isolated from the TNA solution. Infusion of the formulation into healthy pigs resulted in sudden death within 4 hours. Alteration of the amino acid component, mix sequence, agitation technique, and mixing container influenced precipitate formation.
  
  
  CONCLUSIONS
  Pulmonary embolization of a precipitate containing calcium phosphate resulted in the death of two patients. The pH of the amino acid component, transient elevation of calcium and phosphorus concentrations during mixing, and the lack of agitation during automated preparation of the formulation were identified as the etiologic factors producing the fatal precipitate.
authors.affiliation: Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: S E
authors.initials: SE
authors.lastname: Hill
authors.forename: L S
authors.initials: LS
authors.lastname: Heldman
authors.forename: E D
authors.initials: ED
authors.lastname: Goo
authors.forename: P E
authors.initials: PE
authors.lastname: Whippo
authors.forename: J C
authors.initials: JC
authors.lastname: Perkinson
mesh_terms: D000328:Adult; D000818:Animals; D001064:Appendicitis / Q000628:therapy; D002118:Calcium / Q000737:chemistry / Q000302:isolation & purification; D002130:Calcium Phosphates / Q000737:chemistry; D011232:Chemical Precipitation; D004195:Disease Models, Animal; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008833:Microcirculation / Q000473:pathology; D009869:Oophoritis / Q000628:therapy; D010289:Parenteral Nutrition, Total / Q000009:adverse effects*; D010758:Phosphorus / Q000737:chemistry / Q000302:isolation & purification; D011655:Pulmonary Embolism / Q000209:etiology* / Q000473:pathology; D012996:Solutions; D013552:Swine
chemical_list: D002130:Calcium Phosphates; D012996:Solutions; D010758:Phosphorus; D002118:Calcium