Y-Site Compatibility of Medications with Parenteral Nutrition

The most discussed change in parenteral nutrition compatibility within the last two years was with ceftriaxone. In the summer of 2007, Roche Laboratories updated their prescribing information for Rocephin^® (ceftriaxone sodium) to include a contraindication for the co-administration of ceftriaxone with calcium-containing intravenous solutions in neonates due to reported fatal cases of pulmonary and renal precipitates in this patient population.1 The additional warnings to avoid a potential interaction are the most controversial. It is now recommended that ceftriaxone and calcium-containing intravenous solutions, such as parenteral nutrition, not be administered within 48 hours of each other regardless of patient age or remote administration sites. Institutions have struggled with the theoretical expansion of this interaction to older children and adults. At this time, no published case reports could be found in the literature.

Obtaining and maintaining venous access in pediatric patients can be complicated. Many patients require multiple treatment modalities to be administered intravenously including medications, fluids, blood products and nutrition. Clinicians must optimize available access to ensure appropriate and timely administration of all products prior to establishing additional access. Separate administration of intravenous products, if feasible, is always preferred, however, many times simultaneous administration of medications and parenteral nutrition will be required making compatibility considerations essential. It is important to recognize that compatibility only reflects the physical interactions such as formation of a precipitate and does not necessarily address stability or pharmacologic activity of the products. Published data may report both compatibility and stability, however most evaluate visual compatibility alone. Currently there are multiple resources to use when answering the question of compatibility with parenteral nutrition. We strove to evaluate and present the available published data as a comprehensive and practical reference. Primary literature regarding y-site compatibility of medications with three different parenteral nutrition formulas, 3-in-1, 2-in-1 and lipids alone was reviewed. When conflicting results were encountered the clinical strength was considered. When published data was not accessible Trissel's Handbook on Injectable Drugs2 was used.

ABBREVIATIONS

C

Compatibility has been demonstrated. When Y-site compatibility was not available, medications compatible in solution for 24 hours were assumed to be Y-site compatible. Medications compatible with 3-in-1 admixtures were assumed to be compatible with lipids alone.2

I

Incompatibility has been demonstrated

—

Compatibility data not available

C/I

Conflicting compatibility has been demonstrated and strength of the evidence supports compatible

I/C

Conflicting compatibility has been demonstrated and strength of the evidence supports incompatible

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