J. zyxwvutsrqponm Paediatr. ChildHealth (1991) zyxwvutsrq 27, 180-183 Delivery of Vitamin A from parenteral nutrition solutions in neonates D. G. THOMAS,’ S. L. JAMES,’ A. FUDGE? zyxwvu C. ODGERS,3 J. TEUBNER2 and K. SIMMER’ Departments of Paediatrics, *Biochemistry and 3Pharmacy. Flinders Medical Centre, Bedford Park, South Australia, Australia Abstract The delivery of Vitamin A from parenteral nutrition may be suboptimal. To investigate this sample solutions were prepared and Vitamins A and E concentrations from the solution bags and the efflux from the lines were measured over a 24 h period. The results show that mean Vitamin A levels in the solution bags declined from a range of 57-66% to 17% of expected over 24 h and at the efflux of the lines from a range of 13-29% to 4% of expected, giving a calculated delivery of 10% of expected. There is no improvement with light protection or an ethylene vinyl acetate system. Mixing the vitamin preparation in lipid showed less decline (from 92 to 70% of expected over 24 h), but the delivery was variable. When vitamins were added to a lipid-dextrose-amino acid solution, there was minimal loss from the solution bag and line with a calculated delivery of 94% of expected. The delivery of Vitamin E from all systems was constant with a mean calculated delivery of 74% of expected. It was concluded that the mixing of multivitamins in dextrose-amino acid-electrolyte solutions results in poor delivery of Vitamin A and this is improved by mixing in lipid solution. This is important in preterm infants who are prone to become Vitamin A deficient. Key words: neonates; parenteral nutrition; Vitamin A. Parenteral nutrition is essential in the care of many patient groups. A deficiency of many nutrients will occur if supple- mentation is not given. This applies to Vitamin A which is necessary for the photochemical process of vision and the maintenance and differentiation of epithelial tissues. There is concern that Vitamin A delivery from parenteral nutrition is suboptimal due to losses from plastic adsorption or photo- degradation.’ -5 This is of particular relevance to preterm infants who often require parenteral nutrition for prolonged periods because of respiratory or gastrointestinal immaturity or disease. To investigate this, an in vitro study was established using solutions identical to those used in the care of very low birth- weight (VLBW) infants in our nursery. The aim of the study was to demonstrate the Vitamin A delivery from our parenteral nutri- tion delivery systems and to investigate methods of improvement. MATERIALS AND METHODS Parenteral nutrition solutions were prepared under normal sterile pharmacy conditions using 50% dextrose, Synthamin 17 (Baxter Healthcare, NSW) and lntralipid 20% (KabiVitrum, Stockholm, Sweden) as the carbohydrate, protein and fat sources respec- tively. The vitamin source used was MVI Pediatric (Armour Correspondence: Dr D. G. Thomas, Department of Paediatrics, Flinders Medical Centre, Bedford Park, SA 5042, Australia. D. G. Thomas, MB. BS. Senior Paediatric Registrar. S. L. James, MB, ChB. FRACP, Senior Specialist in Paediatrics. A. Fudge, BSc, Hospital Scientist. C. Odgers. BPharm, FSHP. Acting Chief Pharmacist. J. K. Teubner, BSc, PhD, Senior Biochemist. K. Simmer, MB, BS. PhD. MRCP, FRACP, Staff Specialist in Paediatrics. Accepted for publication 20 February 1991. Pharmaceutical, Illinois, USA), a multivitamin preparation in which the oil-soluble vitamins are solubilized in water with polysorbate. This provides 0.5 pmol (140 pg) of retinol (Vitamin A) and 3.3 pmol (1.4 mg) of a-tocopherol acetate (Vitamin E) per millilitre. A standard solution of 120 mL was prepared containing the following: 1Oohdextrose, 1.5 g amino acids, 2 mmol sodium, 1 mmol potassium, 1 mmol calcium, 0.2 mmol magnesium, 2 mmol chloride, 0.8 mmol phosphate, 5.5. pg chromium, 95 pg copper, 7.7 pg manganese, 5.1 pg iodine and 1 mL of MVI (20% of a vial, giving expected concentrations of 4.1 and 27.1 pmol/L of Vitamins A and E respectively). All solution bags were protected from light with black plastic. The following variables were examined: (i) 0 or 3 g amino acids; (ii) a non-PVC system using ethylene vinyl acetate; (iii) 15% dextrose; (iv) 1 g albumin; (v) light protection of the line using aluminium foil; (vi) doubling the amount of MVI; (vii) 2 g lipid running concurrently; (viii) the addition of MVI to the lipid solution with and without light protection; (ix) lipid added to the dextrose-amino acid-electrolyte solution (‘three in one’). Each variable was analysed once, i.e. a total of 12 solutions. Following preparation, the solutions were connected to an intravenous delivery system comprising Viaflex 500 mL PVC bags, ball valve Buretrol solution infusion set (Baxter Healthcare), Critikon IV extension pump set size C (Johnson & Johnson, Florida), aerodisc DLL disposable filter assembly (Gelman Sciences, Michigan), minimum volume extension line (Healthmed Marketing, SA) and LS connector luer lock (Braun, Penang). In one study, a non-PVC system was used comprising an ethylene vinyl acetate bag (Mirarned, Mirandola, Italy) and IMED 9630 circuset closed system non-PVC fluid pathway (IMED Co., Cali- fornia) connected to the filter, extension line and luer lock, as above. All solutions were run through a 24 gauge lnsyte intra- venous catheter (Deseret Medical, Utah) in the nursery, under