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Multi-chamber bag parenteral nutrition is not without risk

Problem: An increase in the number of errors and workarounds related to the shortage of parenteral nutrition (PN) components have been reported to ISMP. To conserve resources, organizations have been forced in some instances to reduce the number of days they provide PN to patients. For example, rather than daily nutrition, an organization reported they had to reduce the administration of PN to three times per week. In other cases, organizations may elect to utilize alternative products, such as multi-chamber bag parenteral nutrition (MCB-PN) for select patients instead of patient-specific compounded PN.

MCB-PN products are commercially available in various standardized compositions. They are available in two- or three-chamber bags. CLINIMIX and CLINIMIX E, manufactured by Baxter, are available with two chambers. Clinimix comes with one chamber containing amino acids and the other containing dextrose, and Clinimix E comes with one chamber containing dextrose with calcium and the other containing amino acids with electrolytes. KABIVEN and PERIKABIVEN, both manufactured by Fresenius Kabi, are available with three chambers holding dextrose, amino acids/electrolytes, and lipids. For all MCB-PN products, the seal(s) that separates the chambers must be broken and the chamber contents must be mixed to ensure complete activation prior to administration. While these products require fewer compounding steps, additives may still need to be added to these products in a sterile environment.

Some of the error reports submitted to ISMP involved mix-ups between MCB-PN bags. For example, during a shortage of PN compounding ingredients, one organization purchased Clinimix E 4.25/10 (dextrose with calcium and amino acids with electrolytes) as well as Clinimix 4.25/10 (dextrose and amino acids without electrolytes). The organization reported multiple errors in which the wrong formulation was dispensed, which was attributed to similar-looking packaging as well as staff unfamiliarity with these products. Other events were related to the failure to activate the MCB-PN bags. This resulted in the omission of certain components of the PN, such as dextrose and calcium. We have previously shared similar errors and actions to take to ensure the proper preparation of MCB-PN bags (March 10, 2011October 21, 2010).

Safe Practice Recommendations: If your organization has purchased or is thinking about purchasing MCB-PN, consider the following risk-reduction strategies:

Conduct an FMEA. Conduct a proactive risk evaluation, such as a failure mode and effects analysis (FMEA), prior to use. During the analysis, be sure to review the labeling and packaging of products and how mix-ups will be prevented, how MCB-PN bags will be ordered in your electronic health record (EHR) system and displayed on your medication administration records (MARs), and the method that will be used to remind practitioners to activate the bag.

Gather stability data. Require the pharmacy to reach out to product manufacturers to review stability data for any pharmacy additives, and make this information readily available to prescribers, pharmacists, and nurses. Establish a maximum timeframe in which MCB-PN should be administered (hang time).

Store safely. Store MCB-PN separately in the pharmacy, away from similar-looking bags. Avoid storing MCB-PN in an automated dispensing cabinet (ADC), as nurses may not be familiar with the need to activate all chambers.

Require pharmacy activation and compounding. Require the pharmacy to activate all MCB-PN bags (mixing the chambers) and add any prescribed additives, such as multivitamins and trace elements, in a sterile environment. Then dispense the activated PN (with additives, if required) to patient care units.

Apply auxiliary labels. Consider applying auxiliary labels to the overwrap of MCB-PN bags upon procurement in the pharmacy to differentiate the products with and without electrolytes. After pharmacy activation, consider applying auxiliary labels directly on MCB-PN bags for nurses to confirm that the product has been activated prior to administration.

Employ barcode technology. Use barcode scanning technology prior to dispensing, compounding, and administration to ensure the correct MCB-PN product is being used.

Convert PN orders. During transitions of care, work with home infusion pharmacies to determine if orders need to be converted from MCB-PN to patient-specific compounded PN. Require an independent double check of all calculations to verify accuracy.

Educate practitioners. Educate practitioners about how to calculate the amount of macronutrients, electrolytes, and additives patients will be provided from a MCB-PN bag, based on the ordered rate of infusion. Also let pharmacy staff know how to activate the bag, and educate nurses to confirm that the product has been activated prior to administration. Since MCB-PN products are commercially standardized, alert nurses to the likely waste of excess PN volume since each bag may contain more than required for a particular patient (e.g., patient may receive only 1,500 mL from a 2,000 mL bag).

Suggested citation:

Institute for Safe Medication Practices (ISMP). Multi-chamber bag parenteral nutrition is not without risk. ISMP Medication Safety Alert! Acute Care. 2022;27(15):3-4.