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Aminosyn II in Dextrose Injection

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Aminosyn II in Dextrose

INDICATIONS

Aminosyn II in Dextrose Injection is indicated for intravenous infusion to prevent nitrogen loss and negative nitrogen balance in cases where (a) the gastrointestinal tract by the oral, gastrostomy or jejunostomy route cannot or should not be used, (b) gastrointestinal absorption of nutrients is impaired or (c) metabolic requirements for protein and calories are substantially increased as with extensive burns and (d) morbidity and mortality may be reduced by replacing amino acids lost from tissue breakdown, thereby preserving tissue reserves, as in acute renal failure. In such patients intravenous feeding for more than a few days would be expected.

The addition of supplemental electrolytes, multivitamins, and trace metal additives will be required in accordance with the prescription of the attending physician.

DOSAGE AND ADMINISTRATION

The total daily dose of Aminosyn II in Dextrose (amino acid injection in dextrose injection) Injection to be infused depends on daily protein and caloric requirements and on the patient's metabolic and clinical response. Aminosyn II in Dextrose (amino acid injection in dextrose injection) Injection is administered intravenously. It may be administered by peripheral or central vein, depending upon the dextrose concentration. Peripheral vein administration of Aminosyn II 3.5% in 5% Dextrose Injection (with electrolytes added per the physician's prescription) is appropriate. However, simultaneous administration with intravenous fat emulsion is recommended, both to reduce the final admixture osmolarity, and to provide additional calories.

Peripheral vein administration of Aminosyn II 4.25% in 10% Dextrose Injection (with electrolytes added) is not recommended unless fat emulsion is delivered simultaneously. The high solution osmolarity (894 mOsmol/L) will likely provoke vein irritation if the solution is administered without fat emulsion.

Solutions of Aminosyn II in 20% or 25% Dextrose Injection are intended only for central venous administration. In adults, hypertonic mixtures of amino acids and dextrose may be safely administered by continuous infusion through a central venous catheter with the tip located in the vena cava. In many patients, provision of adequate calories in the form of hypertonic dextrose may require the administration of exogenous insulin to prevent hyperglycemia and glycosuria. To prevent rebound hypoglycemia, a solution containing 5% dextrose should be administered when hypertonic dextrose infusions are abruptly discontinued.

As reported in the literature, the dosage and constant infusion rate of intravenous dextrose must be selected with caution in pediatric patients, particularly neonates and low birth weight infants, because of the increased risk of hyperglycemia/ hypoglycemia.

As with all intravenous fluid therapy, the parenteral administration of a solution of amino acids and dextrose requires an accurate estimate of the total fluid, electrolyte and acid-base needs to compensate for the patient's measurable urinary and other (i.e., nasogastric suction, fistula drainage, diarrhea) daily losses. After estimating the total daily fluid (water) requirements, the appropriate volume to be infused to meet the daily protein requirement of the patient, can be determined. The daily determination of nitrogen balance and accurate body weights, corrected for fluid balance, are probably the best means of assessing individual protein requirements. The balance of fluid needed beyond the volume of the amino acid/dextrose solution can be provided by other solutions suitable for intravenous infusion. Vitamins and trace minerals may be added to the amino acid/dextrose solution as needed.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Adult Patients

The daily nutrient requirements of an average adult patient, not hypermetabolic, in an acceptable weight range and with restricted physical activity, are about 30 kcal/kg of body weight, 12 to 18 grams of nitrogen (or 1.0 to 1.5 g amino acid/kg/day) and between 2500 and 3000 mL of fluids. In depleted and severely traumatized patients such as burned patients or patients who have received major surgery with complications, the requirements for nutrients and fluids may be significantly higher. In such cases, 4000 calories and 25 grams of nitrogen or more may be required daily to achieve nitrogen balance. The fluid losses through drainages and wound surface must be taken into account in calculating the fluid requirements of these patients.

Nutritional admixtures with a final dextrose concentration greater than 10% must be administered by central vein. Peripheral vein administration of Aminosyn II 3.5% in 5% Dextrose Injection or Aminosyn II 4.25% in 10% Dextrose Injection is possible, but simultaneous administration of lipid emulsion is recommended to reduce the osmolarity of the admixture, and to increase the nonprotein energy intake.

Fat emulsion administration should be considered when prolonged parenteral nutrition is required in order to prevent essential fatty acid deficiency (EFAD). Serum lipids should be monitored for evidence of EFAD in patients maintained on fat-free TPN.

Each gram of dextrose provides approximately 3.4 calories. The infusion rate of Aminosyn II in 20% or 25% Dextrose Injection should be 2 mL/min initially and may be gradually increased to deliver the required amounts of amino acids and calories. If nutrient administration falls behind schedule, under no circumstances should an attempt to “catch up” to planned intake be made. The rate of nutrient infusion is governed by the protein requirements and by the patient's glucose tolerance estimated by glucose levels in plasma and urine. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg/hour; at a rate of 0.8 g/kg/hour, about 95% of the infused dextrose is retained. Administration of exogenous insulin may be required in order to control hyperglycemia and glycosuria which may occur upon infusion of concentrated glucose solutions. When concentrated dextrose infusion is abruptly interrupted rebound hypoglycemia may occur, which can be prevented by the administration of 5% or 10% dextrose solutions. Part of the caloric requirement may be met by the infusion of I.V. fat emulsion.

SERUM ELECTROLYTES SHOULD BE MONITORED AS INDICATED. Electrolytes should be added to the nutrient solution as indicated by the patient's clinical condition and laboratory determinations of plasma values. Major electrolytes are sodium, chloride, potassium, phosphate, magnesium and calcium. Adding 20 mL of TPN Electrolytes (multiple electrolyte additive, List 5779) to each 500 mL of the amino acid solution and 4 to 5 mL of Potassium Phosphate (List 7296) to each 500 mL of 40 to 50% dextrose solution will result in final admixture concentrations appropriate for central vein administration. Alternate electrolyte additives may be used at the clinician's discretion.

Vitamins, including folic acid and vitamin K are required additives. Vitamin K1 (Phytonadione Injection, USP) is given intramuscularly or added to the solution as desired. The trace element supplements should be given when long-term parenteral nutrition is undertaken. Iron is added to the solution or given intramuscularly in depot form as indicated.

Calcium and phosphate are added to the solution as indicated. The usual dose of phosphate added to a liter of TPN solution (containing 25% dextrose) is 12 to 15 mM. This requirement is related to the carbohydrate calories delivered. If the final admixture contains only 5% or 10% dextrose, then a proportionate reduction in the amount of additive phosphate is recommended. An inorganic phosphate supplement is recommended to facilitate synthesis of high energy phosphate during dextrose metabolism.

Calcium and phosphate additives are potentially incompatible when added to the TPN admixture. However, if one additive is added to the amino acid solution, and the other to the concentrated dextrose solution, and if the contents of both chambers are mixed before they are combined, then the likelihood of physical incompatibility is reduced.

In patients with hyperchloremic or other metabolic acidosis, sodium and potassium may be added as the acetate or lactate salts to provide bicarbonate alternates.

Pediatric Patients

Pediatric requirements for parenteral nutrition are constrained by the greater relative fluid requirements of the child and greater caloric requirements per kilogram. These solutions are too concentrated for use in pediatric patients less than 1 year old, who generally receive a 2.5% amino acid solution. However, older pediatric patients can tolerate amino acids in concentrations of up to 5%. Dosage of amino acids is usually prescribed on a g/kg body weight/day basis, with adjustments for patient age as follows: ages 1 to 3 years, 2 to 2.5 g/kg/day; ages 4 to 12 years, 2 g/kg/day; ages 13 to 15 years, 1.7 g/kg/day; ages 16 and above, 1.5 g/kg/day. Energy requirements for children between 1 and 7 years of age are approximately 75 to 90 kcal/kg/day; for children 7 to 12 years of age, 60 to 75 kcal/kg/day; and for ages 12 to 18 years, 30 to 60 kcal/kg/day. Energy intake may be supplemented with intravenous fat emulsion. In cases of malnutrition or stress, these requirements may be increased.

Supplemental electrolytes and vitamin additives should be administered as deemed necessary by careful monitoring of blood chemistries and nutritional status. Iron supplementation is more critical in the child than the adult because of the increasing red cell mass required by the growing child. Serum lipids should be monitored for evidence of essential fatty acid deficiency in patients maintained on fat-free TPN. Bicarbonate should not be administered during infusion of the nutritional solution unless deemed absolutely necessary.

To ensure the precise delivery of the small volumes of fluid necessary for total parenteral nutrition in children, accurately calibrated and reliable infusion systems should be used.

Instructions for Use

DO NOT USE IF AMINOSYN II IS DISCOLORED OR IF CLAMP IS OPEN OR MISSING. COLOR VARIATION IN THE DEXTROSE INJECTION FROM PALE YELLOW TO YELLOW IS NORMAL AND DOES NOT ALTER EFFICACY.

To Open

Tear outer wrap at notch and remove solution container. Check the container for minute leaks by squeezing firmly. If leaks are found, discard the solution, as sterility may be impaired. If supplemental medication is desired, follow directions below before preparing for administration.

To Add Medication

(Use Aseptic Technique)

Additives may be incompatible. See DOSAGE AND ADMINISTRATION.

  1. Open clamp between the two chambers. Completely drain all the solution and air into the lower chamber. To achieve this, stretch the side wall of the emptied top chamber. Close clamp after draining.
  2. Agitate container to assure adequate mixing.
  3. Prepare lower chamber additive port.
  4. Using aseptic technique, puncture the reseal additive port at the target area through inner diaphragm with an 18, 19, or 20 gauge additive delivery needle of appropriate length. Inject additive medication.
  5. Repeat as necessary. Mix container contents thoroughly after each additive.
  6. After use, protect additive ports by covering with additive caps.

Preparation for Administration

(Use Aseptic Technique)

  1. If you have not already done so in step 1 above, open clamp between the two chambers. Completely drain all the solution and air into the lower chamber. To achieve this, stretch the side wall of the emptied top chamber.
  2. Close flow control clamp of administration set.
  3. Remove cover from outlet port at bottom of container.
  4. Insert piercing pin of administration set into port with a twisting motion until the set is firmly seated. NOTE: When using a vented administration set, replace bacterial retentive air filter with piercing pin cover. Insert piercing pin with twisting motion until shoulder of air filter housing rests against outlet port flange.
  5. Suspend from hanger at top of container.
  6. Squeeze and release drip chamber to establish proper fluid level in chamber.
  7. Open flow control clamp to expel air from set. Close flow control clamp.
  8. Connect to central or peripheral infusion catheter.
  9. Regulate rate of administration with an electronic flow-control device.

WARNING: Do not use flexible container in series connections.

HOW SUPPLIED

The Nutrimix® dual-chamber flexible container provides 500 mL of Aminosyn® II in the upper chamber and 500 mL of Dextrose Injection, USP in the lower chamber. Concentrations provided in the separate chambers and in the combined 1000 mL volume after release of the clamp and mixing are shown below.

List No. Concentrations Prior to Admixture Concentrations Following Admixture Total Admixture Volume
Aminosyn II Dextrose Aminosyn II Dextrose
Central Vein Formulations
7752 8.5% 40% 4.25% 20% 1000 mL
Peripheral Vein Formulations
7751* 8.5% 20% 4.25% 10% 1000 mL
*Administered by peripheral vein only if lipid emulsion is administered simultaneously.

Exposure of pharmaceutical products to heat should be minimized. Avoid excessive heat. Protect from freezing. It is recommended that the product be stored at room temperature (25°C); however, brief exposure up to 40°C does not adversely affect the product.

Avoid exposure to light.

To prevent breakage, handle cold or refrigerated (2°C to 8°C) co-polyester (CR3) containers with care.

Hospira, Inc., Lake Forest, IL 60045 USA. Revised: May, 2004. FDA revision date: 2/19/2003

Last reviewed on RxList: 1/14/2009
This monograph has been modified to include the generic and brand name in many instances.

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