There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution,
solution for injection, liquid
Effervescent tablet
CAUTIONARY AND ADVISORY LABELS 13, 21
▶Solvazinc (Galen Ltd)
Zinc sulfate monohydrate 125 mg Solvazinc 125mg effervescent
tablets sugar-free | 90 tablet p £17.20 DT = £17.20
Nutrition (intravenous)
Intravenous nutrition
Overview
When adequate feeding through the alimentary tract is not
possible, nutrients may be given by intravenous infusion.
This may be in addition to ordinary oral or tube feeding—
supplemental parenteral nutrition, or may be the sole
source of nutrition— total parenteral nutrition (TPN).
Indications for this method include preparation of
undernourished patients for surgery, chemotherapy, or
radiation therapy; severe or prolonged disorders of the
gastro-intestinal tract; major surgery, trauma, or burns;
prolonged coma or refusal to eat; and some patients with
renal or hepatic failure. The composition of proprietary
preparations available is given under Proprietary Infusion
Fluids for Parenteral Feeding p. 1134.
Parenteral nutrition requires the use of a solution
containing amino acids, glucose, fat, electrolytes, trace
elements, and vitamins. This is now commonly provided by
the pharmacy in the form of a 3-litre bag. A single dose of
vitamin B12, as hydroxocobalamin p. 1085, is given by
intramuscular injection; regular vitamin B12 injections are
not usually required unless total parenteral nutrition
continues for many months. Folic acid p. 1084 is given in a
dose of 15 mg once or twice each week, usually in the
nutrition solution. Other vitamins are usually given daily;
they are generally introduced in the parenteral nutrition
solution. Alternatively, if the patient is able to take small
amounts by mouth, vitamins may be given orally.
The nutrition solution is infused through a central venous
catheter inserted under full surgical precautions.
Alternatively, infusion through a peripheral vein may be
used for supplementary as well as total parenteral nutrition
for periods of up to a month, depending on the availability of
peripheral veins; factors prolonging cannula life and
preventing thrombophlebitis include the use of soft
polyurethane paediatric cannulas and use of feeds of low
osmolality and neutral pH. Only nutritional fluids should be
given by the dedicated intravenous line.
Before starting, the patient should be well oxygenated
with a near normal circulating blood volume and attention
should be given to renal function and acid-base status.
Proprietary Infusion Fluids for Parenteral Feeding
1,2Energy
Nitrogen
K+
Preparation
g/litre
kJ/litre
Aminoven 25 (Fresenius Kabi Ltd)
25.7
–
Net price 500 ml = £19.72
Clinimix N9G20E (Baxter Healthcare Ltd)
4.6
30.0
Net price (dual compartment bag of
amino acids with electrolytes 1000 mL
and glucose 20% with calcium 1000 mL)
2 litre: no price available
ClinOleic 20% (Baxter Healthcare Ltd)
–
Net price 100 ml: no price available; Net
Blood and nutrition
price 500 ml: no price available
Intralipid 10% (Fresenius Kabi Ltd)
–
Net price 100 ml = £4.12; Net price
500 ml = £9.01
Intralipid 20% (Fresenius Kabi Ltd)
–
Net price 100 ml = £6.21; Net price
250 ml = £10.16; Net price 500 ml =
£13.52
5.3
23.0
Kabiven (Fresenius Kabi Ltd)
Net price 1.54 litre = £44.09; Net price
2.053 litre = £57.42; Net price 2.566 litre
= £59.92
3.75
17.0
Kabiven peripheral (Fresenius Kabi Ltd)
Net price (triple compartment bag of
amino acids and electrolytes 300 mL,
400 mL, or 500 mL; glucose 885 mL,
1180 mL, or 1475 mL; lipid emulsion
255 mL, 340 mL, or 425 mL) 1.44 litre =
£30.77; Net price 1.92 litre = £44.09; Net
price 2.4 litre = £55.72
–
Lipidem (B.Braun Medical Ltd)
Net price 100 ml = £19.11; Net price
250 ml = £31.85; Net price 500 ml =
£40.34
Lipofundin MCT/LCT 10% (B.Braun
–
Medical Ltd)
Net price 500 ml = £13.69
Lipofundin MCT/LCT 20% (B.Braun
–
Medical Ltd)
Net price 100 ml = £13.28; Net price
500 ml = £20.36
4.6
30.0
Nutriflex basal (B.Braun Medical Ltd)
Net price 2 litre = £29.20
5.7
15.0
Nutriflex peri (B.Braun Medical Ltd)
Net price 2 litre = £30.47
6.8
25.0
Nutriflex plus (B.Braun Medical Ltd)
Net price (dual compartment bag of
amino acids 400 mL or 800 mL; glucose
600 mL or 1200 mL) 1 litre: no price
available; Net price 2 litre = £33.02
10.0
25.7
Nutriflex special (B.Braun Medical Ltd)
Net price (dual compartment bag of
amino acids 500 mL or 750 mL; glucose
500 mL or 750 mL) 1 litre: no price
available; Net price 1.5 litre = £27.60
1 1000 kcal = 4200kJ; 1000 kJ = 238.8 kcal. All entries are Prescription-only medicines.
2 Excludes protein- or amino acid-derived energy
Electrolytes mmol/litre
Mg2+
Na+
Acet–
Cl–
Other components/litre
–
–
–
–
–
40.0 Ca2+ 2.3 mmol, phosphate
2.5
35.0
50.0
15 mmol, anhydrous glucose
100 g
purified olive and soya oil 200 g,
–
–
–
–
–
glycerol 22.5 g, egg
phosphatides 12 g
soya oil 100 g, glycerol 22 g,
–
–
–
–
–
purified egg phospholipids 12 g,
phosphate 15 mmol
soya oil 200 g, glycerol 22 g,
–
–
–
–
–
purified egg phospholipids 12 g,
phosphate 15 mmol
45.0 Ca2+ 2 mmol, phosphate
4.0
31.0
38.0
9.7 mmol, anhydrous glucose
97 g, soya oil 39 g
33.0 Ca2+ 1.4 mmol, phosphate
2.8
22.0
27.0
7.5 mmol, anhydrous glucose
67.5 g, soya oil 35.4 g
omega-3-acid triglycerides 20 g,
–
–
–
–
–
soya oil 80 g, medium chain
triglycerides 100 g
soya oil 50 g, medium-chain
–
–
–
–
–
triglycerides 50 g
soya oil 100 g, medium-chain
–
–
–
–
–
triglycerides 100 g
50.0 Ca2+ 3.6 mmol, acid phosphate
5.7
49.9
35.0
12.8 mmol, anhydrous glucose
125 g
31.6 Ca2+ 2.5 mmol, acid phosphate
4.0
27.0
19.5
5.7 mmol, anhydrous glucose
80 g
35.5 Ca2+ 3.6 mmol, acid phosphate
5.7
37.2
22.9
20 mmol, anhydrous glucose
150 g
49.5 Ca2+ 4.1 mmol, acid phosphate
5.0
40.5
22.0
14.7 mmol, anhydrous glucose
240 g
1,2Energy
Nitrogen
K+
Preparation
g/litre
kJ/litre
4.56
24.0
NuTRIflex Lipid peri (B.Braun Medical
Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 20% 250 mL, 375 mL or
500 mL) 1.25 litre = £42.83; Net price
1.875 litre = £54.37; Net price 2.5 litre =
£64.22
5.44
28.0
NuTRIflex Lipid plus (B.Braun Medical
Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 20% 250 mL, 375 mL or
500 mL) 1.25 litre = £46.56; Net price
1.875 litre = £59.46; Net price 2.5 litre =
£68.39
5.44
–
NuTRIflex Lipid plus without Electrolytes
(B.Braun Medical Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 20% 250 mL, 375 mL or
500 mL) 1.25 litre = £46.56; Net price
1.875 litre = £59.45; Net price 2.5 litre =
£84.64
8.0
37.6
NuTRIflex Lipid special (B.Braun Medical
Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 20% 250 mL, 375 mL or
500 mL) 1.25 litre = £56.95; Net price
1.875 litre = £74.62
8.0
–
NuTRIflex Lipid special without
Electrolytes (B.Braun Medical Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 20% 250 mL, 375 mL or
500 mL) 1.25 litre = £56.95; Net price
1.875 litre = £74.62
5.4
28.0
NuTRIflex Omega plus (B.Braun Medical
Ltd)
Net price (triple compartment bag of
amino acids 500 mL, 750 mL or 1000 mL;
glucose 500 mL, 750 mL or 1000 mL;
lipid emulsion 250 mL, 375 mL or
500 mL) 1.25 litre = £47.43; Net price
1.875 litre = £60.57; Net price 2.5 litre =
£69.66
8.0
37.6
NuTRIflex Omega special (B.Braun
Medical Ltd)
Net price (triple compartment bag of
amino acids 250 mL, 500 mL, 750 mL or
1000 mL; glucose 250 mL, 500 mL,
750 mL or 1000 mL; lipid emulsion
125 mL, 250 mL, 375 mL or 500 mL)
625 ml = £43.62; Net price 1.25 litre =
£58.01; Net price 1.875 litre = £76.01;
Net price 2.5 litre = £89.71
1 1000 kcal = 4200kJ; 1000 kJ = 238.8 kcal. All entries are Prescription-only medicines.
2 Excludes protein- or amino acid-derived energy
Electrolytes mmol/litre
Mg2+
Na+
Acet–
Cl–
Other components/litre
38.4 Ca2+ 2.4 mmol, Zn2+
2.4
40.0
32.0
24 micromol, phosphate 6 mmol,
anhydrous glucose 64 g, soya oil
20 g, medium-chain triglycerides
20 g
36.0 Ca2+ 3.2 mmol, Zn2+
3.2
40.0
36.0
24 micromol, phosphate
Blood and nutrition
12 mmol, anhydrous glucose
120 g, soya oil 20 g, medium-
chain triglycerides 20 g
anhydrous glucose 120 g, soya
–
–
–
–
oil 20 g, medium-chain
triglycerides 20 g
48.0 Ca2+ 4.24 mmol, Zn2+
4.24
53.6
48.0
32 micromol, phosphate
16 mmol, anhydrous glucose
144 g, soya oil 20 g, medium-
chain triglycerides 20 g
anhydrous glucose 144 g, soya
–
–
–
–
oil 20 g, medium-chain
triglycerides 20 g
36.0 Ca2+ 3.2 mmol, Zn2+
3.2
40.0
36.0
24 micromol, phosphate
12 mmol, anhydrous glucose
120 g, refined soya oil 16 g,
medium-chain triglycerides 20 g,
omega-3-acid triglycerides 4 g
48.0 Ca2+ 4.24 mmol, Zn2+
4.24
53.6
48.0
30 micromol, phosphate
16 mmol, anhydrous glucose
144 g, refined soya oil 16 g,
medium-chain triglycerides 20 g,
omega-3-acid triglycerides 4 g
1,2Energy
Nitrogen
K+
Preparation
g/litre
kJ/litre
Plasma-Lyte 148 (water) (Baxter
–
–
Healthcare Ltd)
Net price 1 litre: no price available
Plasma-Lyte 148 (dextrose 5%) (Baxter
–
Healthcare Ltd)
Net price 1 litre: no price available
–
SMOFlipid (Fresenius Kabi Ltd)
Net price 500 ml = £174.30
Synthamin 9 (Baxter Healthcare Ltd)
9.1
60.0
–
Net price 500 ml: no price available
Blood and nutrition
Synthamin 9 EF (electrolyte-free) (Baxter
9.1
–
Healthcare Ltd)
Net price 500 ml: no price available; Net
price 1 litre: no price available
Synthamin 14 (Baxter Healthcare Ltd)
14.0
60.0
–
Net price 500 ml: no price available; Net
price 1 litre: no price available
Synthamin 14 EF (electrolyte-free)
14.0
–
(Baxter Healthcare Ltd)
Net price 500 ml: no price available; Net
price 1 litre: no price available
Synthamin 17 (Baxter Healthcare Ltd)
16.5
60.0
–
Net price 500 ml: no price available
Synthamin 17 EF (electrolyte-free)
16.5
–
(Baxter Healthcare Ltd)
Net price 500 ml: no price available; Net
price 3 litre: no price available
Vamin 14 (Fresenius Kabi Ltd)
13.5
50.0
–
Net price 1 litre = £16.02
Vamin 14 (electrolyte-free) (Fresenius
13.5
–
Kabi Ltd)
Net price 500 ml = £9.48; Net price 1 litre
= £16.02
Vamin 18 (electrolyte-free) (Fresenius
18.0
–
Kabi Ltd)
Net price 500 ml = £11.99; Net price
1 litre = £23.38
1 1000 kcal = 4200kJ; 1000 kJ = 238.8 kcal. All entries are Prescription-only medicines.
2 Excludes protein- or amino acid-derived energy
Appropriate biochemical tests should have been carried out
beforehand and serious deficits corrected. Nutritional and
electrolyte status must be monitored throughout treatment.
Complications of long-term parenteral nutrition include
gall bladder sludging, gall stones, cholestasis and abnormal
liver function tests. For details of the prevention and
management of parenteral nutrition complications,
specialist literature should be consulted.
Protein is given as mixtures of essential and non-essential
synthetic L-amino acids. Ideally, all essential amino acids
should be included with a wide variety of nonessential ones
to provide sufficient nitrogen together with electrolytes.
Solutions vary in their composition of amino acids; they
often contain an energy source (usually glucose p. 1102) and
electrolytes.
Energy is provided in a ratio of 0.6 to 1.1 megajoules
(150–250 kcals) per gram of protein nitrogen. Energy
requirements must be met if amino acids are to be utilised
for tissue maintenance. A mixture of carbohydrate and fat
energy sources (usually 30–50% as fat) gives better
utilisation of amino acids than glucose alone.
Glucose is the preferred source of carbohydrate, but if
more than 180 g is given per day frequent monitoring of
blood glucose is required, and insulin may be necessary.
Electrolytes mmol/litre
Mg2+
Na+
Acet–
Cl–
Other components/litre
5.0
1.5
140.0
27.0
98.0 gluconate 23 mmol
5.0
1.5
140.0
27.0
98.0 gluconate 23 mmol, anhydrous
glucose 50 g
fish oil 30 g, olive oil 50 g, soya
–
–
–
–
–
oil 60 g, medium-chain
triglycerides 60 g
70.0 acid phosphate 30 mmol
5.0
70.0
100.0
44.0
22.0
–
–
–
5.0
70.0
140.0
70.0 acid phosphate 30 mmol
68.0
34.0
–
–
–
5.0
70.0
150.0
70.0 acid phosphate 30 mmol
82.0
40.0
–
–
–
100.0 Ca2+ 5 mmol, SO4
2– 8 mmol
8.0
100.0
135.0
90.0
–
–
–
–
110.0
–
–
–
–
Glucose in various strengths from 10 to 50% must be infused
through a central venous catheter to avoid thrombosis.
In parenteral nutrition regimens, it is necessary to provide
adequate phosphate in order to allow phosphorylation of
glucose and to prevent hypophosphataemia; between 20 and
30 mmol of phosphate is required daily.
Fructose and sorbitol have been used in an attempt to
avoid the problem of hyperosmolar hyperglycaemic non-
ketotic acidosis but other metabolic problems may occur, as
with xylitol and ethanol which are now rarely used.
Fat emulsions have the advantages of a high energy to
fluid volume ratio, neutral pH, and iso-osmolarity with
plasma, and provide essential fatty acids. Several days of
adaptation may be required to attain maximal utilisation.
Reactions include occasional febrile episodes (usually only
with 20% emulsions) and rare anaphylactic responses.
Interference with biochemical measurements such as those
for blood gases and calcium may occur if samples are taken
before fat has been cleared. Daily checks are necessary to
ensure complete clearance from the plasma in conditions
where fat metabolism may be disturbed. Additives should
not be mixed with fat emulsions unless compatibility is
known.
Administration
Because of the complex requirements relating to parenteral
nutrition full details relating to administration have been
omitted. In all cases product literature and other specialist
literature should be consulted.
NUTRIENTS › PARENTERAL NUTRITION
PDF pages 1155, 1156, 1157, 1158, 1159
