Alternative to chlorides in parental nutrition solutions: Clinical relevance and feasability
Hôpitaux Universitaires Paris Centre, 75014 PARIS
In preterm infants, the risk of metabolic acidosis (MA) without anion gap (AG) is high. This study focuses on MA without AG and hyperchloremia linked to exogenous intakes of chlorides (Cl-) provided by Parenteral Nutrition Solutions (PNS). In order to reduce these disorders, an alternative to Cl- is evaluated.
- Assessment of clinical relevance: retrospective cohort study including infants <28 weeks’gestation admitted to the neonatal intensive care unit, fed with PNS from birth until day 10 and having cumulative total exogenous Cl-≥ 45 mmol/kg at day 10,
- Identification of salt providing the majority of Cl- and its alternative,
- Research of ways for a reliable supply,
- Implementation in the daily practices of prescription/production.
36 infants were included. MA were diagnosed in 24 infants: 11 were explained by exogenous intakes of Cl-; 5 by high intake of NaCl to correct extracellular dehydration; 8 by hemodynamic disorders. 10 premature infants had a hyperchloremia.
NaCl 7.5% provided 52% of the final amount of Cl versus 41% for KCl 7.4% and 7% for MgCl2 10%. The salt to substitute was NaCl. Sodium acetate was the alternative chosen for its acceptor role of H+ and its buffer capacity.
Industrial sterile injectable solution of sodium acetate was no longer available. Therefore, 2 options were possible: local production (formulation of 2mmol/ml solution and sterilisation by sterile filtration) or subcontracting. 2 hospitals agreed to sign a contract: Geneva CHU (2 mmol/ml solution in vials of 50 ml) and E. Herriot Hospital-Lyon (3 mmol/ml solution in vials of 125 ml), both of which sterilized by terminal sterilization.
Before integration into the daily practices of prescription/production, a stability study of PNS containing sodium acetate and the validation of processes must be performed.
The sodium acetate is a relevant and feasible alternative to NaCl. At first, subcontracting with Geneva CHU is the solution retained, as concentration and volume would better fit our needs.