TPN and Medication Compatibilities

DRUG

PPN/TPN 2-IN-1 NO Lipid

PPN/TPN 3-IN-1

COMMENTS

Precipitation of ceftriaxone-calcium can occur when Ceftriaxone for Injection, USP is mixed with calcium-containing solutions in the same intravenous administration line.

Ceftriaxone for Injection must not be administered simultaneously with calcium-containing intravenous solutions, including continuous calcium-containing infusions, such as parenteral nutrition via a Y-site.

However, in patients (age>28 days) other than neonates, Ceftriaxone for Injection, USP and calcium-containing solutions may be administered sequentially of one another if the infusion lines are thoroughly flushed between infusions with compatible fluid (e.g., 0.9% Sodium Chloride Injection or D5W).

Concomitant use of ceftriaxone and intravenous calcium-containing products is contraindicated in neonates (≤28 days of age) because of the risk of ceftriaxone-calcium precipitation.

3-in-1: Cyclosporine was physically incompatible with the peripheral-line and central-line total nutrient admixtures (TNA) due to a small amount of precipitation which appeared immediately upon mixing. However, cyclosporine was physically compatible with the bone marrow transplant TNA exhibiting no particulate formation and no visible emulsion damage within the 4-hour study period.

2-in-1: The drug was physically compatible with the peripheral TPN exhibiting no visible changes and no change in the measured haze level or particulates for the 4-hour study period. However, a small amount of microparticulates appeared after 1 hour but within 4 hours of mixing the cyclosporine with the central-line TPN.

Variable compatibility results have been reported for this combination possibly depending on the drug concentration and the composition of the TPN admixture.

One of the studies showed that 2-in-1 TPN was physically incompatible with undiluted Dexamethasone (4mg/ml). Haze or precipitation was observed.

OK to Y-site: Physically compatible with 2-in-1: No visible haze or particulate formation, color change, or gas evolution.

Not recommended to mix in solution as it is chemically incompatible with PNs: The manufacturer states that foscarnet sodium chelates calcium ions from calcium-containing solutions such as parenteral nutrition admixtures and is, therefore, chemically incompatible with such solutions.

Variable compatibility results have been reported for this drug with 2-in-1 parenteral nutrition admixtures probably due to differences in admixture composition and possibly evaluation techniques. The high-pH of the furosemide contributes to compatibility problems.

Physically compatible with 3-in-1 TPN. No visible change, particulate formation, or color change. Little change in measured pH and electronically measured particle content (including lipid particles) was reported.

3-in-1: Physically incompatible. Initial inspection of an iron dextran-containing total nutrient admixture for clinical administration revealed no incompatibility, but during administration the 1.2-mcm inline filter clogged and a half-inch layer of clear, yellow-brown liquid free oil floated on top the remaining admixture. A repeat test on a non-clinical sample found visible yellow droplets formed about 19 hours after preparation that rose to the top to form a yellow free-oil layer. Analysis of the "oiled out" separated layer found a substantially reduced amount of iron and an increased amount of fat compared to the theoretical content. An identical TNA with no iron present underwent no visible changes in 24 hours.

2-in-1: Physically incompatible. Rust colored precipitate formed in 12 hours.

2-in-1 and 3-in-1: Y-site compatible: Physically compatible. No visible changes and no change in the measured haze level or particulates.

In mixture with 2-in-1 and 3-in-1 PN Solution: uncertain stability showed in Study Period of 48 hours at room temperature and 7 days under refrigeration: analytical results were quite variable, probably indicating lack of control of the analytical method. Drawing meaningful stability conclusions was not possible.

3-in-1: Solution: Physically compatible. No visible precipitation or color change was observed and the fat particle size remained unchanged.

3-in-1: Y-site: 1 mg/mL concentration: Physically incompatible. The fat emulsion component was disrupted immediately upon mixing leading to possible free oil formation. 2 mg/mL concentration: Physically compatible. No visible change, particulate formation, or color change. Little change in measured pH and electronically measured particle content (including lipid particles) was reported.

2-in-1: Solution compatibility: 1000 units/mL concentration: Uncertain compatibility. No visible haze or particulate formation, color change, or gas evolution occurred in 5 of 6 samples tested. However, the sixth sample exhibited an unacceptable increase in micro-particulates within 24 hours.

2-in-1: Solution compatibility: Other Penicillin G Potassium concentrations: Physically compatible. No visible haze or particulate formation, color change, or gas evolution.

3-in-1: Y-site compatibility: Physically incompatible. The fat emulsion component was disrupted immediately upon mixing leading to possible free oil formation.

2-in-1: Y-site compatibility: 48 mg/mL concentration: Physically incompatible. Precipitation appeared upon mixing. 5 mg/mL concentration: Physically compatible. No visible changes and no change in the measured haze level or particulates.

2-in-1: Y-site compatibility: 64mg/mL concentration: Physically incompatible. Precipitation appeared upon mixing. 5 mg/mL concentration: Physically compatible. No visible changes and no change in the measured haze level or particulates.

3-in-1 Y-site compatibility: 5 mg/mL concentration: Physically incompatible. The fat emulsion component was disrupted immediately upon mixing leading to possible free oil formation.

2:1 - Physically incompatible. Yellow discoloration appeared after 12 hours and became more intense after 24 hours.

3:1 - Physically incompatible. Brown discoloration appeared soon after mixing and increased in intensity over time, probably due to pantoprazole decomposition at the acidic pH of the TNA mixture.

3-in-1: Y-site: 3mmol/mL concentration: Physically incompatible. The fat emulsion component was disrupted immediately upon mixing leading to possible free oil formation. 0.12 mmol/mL concentration: Physically compatible. No visible change, particulate formation, or color change. Little change in measured pH and electronically measured particle content (including lipid particles) was reported.

2-in-1: Physically incompatible. A visible increase in turbidity appeared immediately upon mixing.

2-in-1: Y-site: 0.5 mg/mL concentration: Uncertain stability. A propofol loss of 3% and 6% occurred in 5 hours in the TPN admixtures with Aminosyn concentrations of 2.5% and 5%, respectively. In the TPN admixture with an Aminosyn concentration of 1.5%, the reported loss of propofol were 3% in 3 hours at 28% in 5 hours. The anomalous result may indicate a loss of drug or it may indicate an assay problem.

2-in-1: Y-site: 2 mg/mL and 3 mg/mL concentrations: Physically compatible. No visible changes and no substantial change in the measured particle size distribution. Chemically stable. About 4 to 6% propofol loss occurred in 5 hours in all of the TPN admixtures.

Per Voriconazole package label: Voriconazole should not be run through the same line with parenteral nutrition admixtures. May be infused simultaneously with TPN through a separate IV line. If TPN is infused through a multiple lumen catheter, use a different port than used for Voriconazole.