In an ASHP Midyear 2022 Clinical Meeting & Exhibition session titled “Parenteral Nutrition—Focus on Compounding,” Kristen Kruszewski, PharmD, BCSCP, assistant director, integrated pharmacy supply chain Management, UNC Health and Erinn Rowe, PharmD, MS, clinical manager, UNC Health, offered insight into overcoming clinical- and technology-related medication safety challenges. These included strategies to solve issues posed by calcium phosphate solubility and component shortages, among other hurdles.

Drs. Kruszewski and Rowe provided an evaluation of the current state of parenteral nutrition (PN), focusing on the medication-use process elements of transcription, compounding, dispensing, and administration. They also evaluated best practices for minimizing work arounds in parenteral nutrition transcription processes to solve common clinical challenges faced while compounding and dispensing PN and design a plan for administering PN that encompasses a variety of locations (e.g., inpatient, home infusion).

The complexity of compounding, the presenters stressed, requires competent staff and specialized policies and procedures to ensure sterility and accuracy of PN products. For example, they said calcium-phosphate precipitation is a potentially serious problem associated with PN preparation, and staff should be mindful of both the calculated and physical risks. To this end, the speakers recommended agitating the mixture after each ingredient is added. In addition, they said that phosphate should be injected early, and calcium gluconate should be injected as the ultimate or penultimate component added. The final calcium and phosphate concentration, they also pointed out, must be below solubility curve and include all sources of calcium and phosphate.

The presenters emphasized the need to consider USP<797> parameters, recognizing that PN is “one of the most complicated forms of sterile compounding.” For example, they said, PN compounding is classified as medium-risk sterile compounding stratification due to multiple components. For this reason, the direct compounding area must meet ISO Class 5 standards (or better), including but not limited to requirements for particle counts. Extra care, they stressed, is needed to ensure that space, equipment, and staff are in compliance with USP chapter <797> standards.

To help ensure accuracy and safety, the presenters highlighted benefits of PN compounding automation, including a reduction of human error since little human intervention is needed, and barcode scanning, which affords greater accuracy. Moreover, they said, automation is more labor intensive and results in increased throughput compared with manual compounding.

Combatting the current shortages of drugs and supplies needed for PN compounding, they said, “can create challenges and a need for innovative solutions.” Drs. Kruszewski and Rowe recommended several strategies, including centralizing services at a single hospital in the health system; ensuring all components are available when switching brands; administering calcium chloride as a separate infusion; and using a premixed IV magnesium for supplementation outside of PN, among other tactics. They also suggested finding alternative sources of sodium and switching other IVs to normal saline, if compatible.

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