title: Finding new solutions in pediatric parenteral admixtures: how to improve quality and to deal with shortages.
abstract: BACKGROUND
  Pediatric parenteral nutrition enables normal growth even of preterm infants. Those children require, however, tailored parenteral nutrition and the creation of such can be challenging due to the risk of instability and shortages.
  
  
  OBJECTIVE
  Prototypical parenteral admixtures were created using different calcium salts (organic and inorganic) and different lipid emulsions and tested for stability. 36 of parenteral admixtures containing two types of calcium salts: chloride or gluconolactobionate and different lipid emulsions (SMOFlipid® or Lipofundin MCT/LCT®) were under investigation.
  
  
  METHODS
  Preliminary admixtures were prepared in two-chamber bags whereas lipid emulsions were placed separately in the second chamber. Pre-admixtures were stored for up to 21 days at +4ºC. Contents of the two chambers were combined at t = 0 or after 21 days of storage. Physical analysis of completed admixtures (visual inspection, microscopic observation, pH measurement and determination of the size distribution of oily droplets) was carried out after 21 days of the storage. Stability of lipid, commercial emulsions stored in ethylene vinyl acetate (EVA) bags for 42 days was also studied.
  
  
  RESULTS
  Irrespectively of the time of storage of preadmixtures and type of calcium salt and different lipid emulsions among 36 total parenteral admixtures only one showed signs of destabilization after preparation and one was unstable when stored for longer than 14 days. All other formulations were qualified to be stable during the study. All investigated commercial lipid emulsions were physically stable in EVA bags even when stored at room temperature.
  
  
  CONCLUSIONS
  The study proved that it was possible to store pre-admixture in EVA bags for 21 days at 4°C as well as that CAN (critical aggregation number) and CaxP (the products of multiplication of calcium and phosphate ions concentration) should not be used as reliable indicators of admixture physical stability. No influence of the type of calcium salts on stability of admixtures was observed.
authors.affiliation: Department of Pharmaceutical Technology. Medical University of Gdansk. Poland.. dwatro@gumed.edu.pl.
authors.forename: Dorota
authors.initials: D
authors.lastname: Watrobska-Swietlikowska
authors.affiliation: Department of Pharmaceutical Technology. Medical University of Gdansk. Poland.. dwatro@gumed.edu.pl.
authors.forename: Anna
authors.initials: A
authors.lastname: Kwidzynska
authors.affiliation: Department of Pediatrics. Pediatric Gastroenterology, Hepatology and Nutrition. Medical University of Gdansk. Poland.. dwatro@gumed.edu.pl.
authors.forename: Agnieszka
authors.initials: A
authors.lastname: Szlagatys-Sidorkiewicz
authors.affiliation: Department of Pharmaceutical Technology. Medical University of Gdansk. Poland.. dwatro@gumed.edu.pl.
authors.forename: Malgorzata
authors.initials: M
authors.lastname: Sznitowska
authors.affiliation: Stanley Dudrick's Memorial Hospital. General Surgery and Oncology Unit. Skawina. Poland.. dwatro@gumed.edu.pl.
authors.forename: Stanislaw
authors.initials: S
authors.lastname: Klek
mesh_terms: D002648:Child; D005217:Fat Emulsions, Intravenous / Q000032:analysis / Q000600:supply & distribution; D006801:Humans; D010288:Parenteral Nutrition / Q000592:standards*; D057947:Parenteral Nutrition Solutions / Q000032:analysis / Q000600:supply & distribution*; D058996:Quality Improvement
chemical_list: D005217:Fat Emulsions, Intravenous; D057947:Parenteral Nutrition Solutions