Amino Acid Injection

• Intravenous Nutritional Therapy

Note: Correct severe fluid, electrolyte, and acid-base disorders prior to administration.

Component of parenteral nutrition: Protein as amino acids: IV:

Maintenance: 0.8 to 1 g/kg/day

Normal/mild stress level: 1 to 1.2 g/kg/day

Moderate stress level: 1.2 to 1.5 g/kg/day

Severe stress level: 1.5 to 2 g/kg/day

Burn patients (severe): Increase protein until significant wound healing achieved

Solid organ transplant: Perioperative: 1.5 to 2 g/kg/day

Renal failure:

Acute (severely malnourished or hypercatabolic): 1.5 to 1.8 g/kg/day

Chronic, with dialysis: 1.2 to 1.8 g/kg/day (maximum: 2.5 g/kg/day)

Chronic, without dialysis: 0.6 to 0.8 g/kg/day

Continuous hemofiltration: ≥1 g/kg/day

Hepatic failure:

Acute management when other treatments have failed:

With encephalopathy: 0.6 to 1 g/kg/day

Without encephalopathy: 1 to 1.5 g/kg/day

Chronic encephalopathy: Use branch chain amino acid enriched diets only if unresponsive to pharmacotherapy

Pregnant women in second or third trimester: Add an additional 10 to 14 g/day

Use with caution in patients with hepatic impairment; dosage adjustments may be necessary. Some products are contraindicated in patients in hepatic coma.

IV: Administered as a component of peripheral parenteral or total parenteral nutrition. Peripheral administration of nutrition is dependent upon osmolality of solution. Total parenteral nutrition must be administered via central venous access. May require use of inline filter (consult specific product labeling and/or individual institutional policies and procedures). Initiation and termination of nutritional fluids must be gradual to permit endogenous insulin release adjustment. Consult specific product labeling for maximum infusion rates.

Vesicant; ensure proper needle or catheter placement prior to and during IV infusion. Avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave needle/cannula in place); gently aspirate extravasated solution (do NOT flush the line); initiate hyaluronidase antidote; remove needle/cannula; apply dry cold compresses (Hurst 2004); elevate extremity.

Hyaluronidase: Intradermal or SubQ: Inject a total of 1 mL (15 units/mL) as five separate 0.2 mL injections (using a 25-gauge needle) into area of extravasation at the leading edge in a clockwise manner (MacCara 1983; Zenk 1981).

Concerns related to adverse effects:

• Hepatic effects: Parenteral nutrition associated liver disease has been reported in patients receiving parenteral nutrition for extended periods of time, especially preterm infants, and can present as cholestasis or steatohepatitis; cholecystitis, cholelithiasis, cholestasis, hepatic steatosis, fibrosis and cirrhosis, and hepatic failure have also been reported. Increase in blood ammonia levels and hyperammonemia may also occur. Consider discontinuation or dose reduction in patients who develop abnormal LFTs.

• Hyperglycemia or hyperosmolar hyperglycemic state: Administration of dextrose at a rate exceeding the patient’s utilization rate may lead to hyperglycemia, coma, and death. Patients with underlying confusion and renal impairment who receive dextrose infusions may be at greater risk of developing hyperosmolar hyperglycemic state. Monitor blood glucose levels.

• Hypersensitivity/infusion reactions: Hypersensitivity/infusion reactions including anaphylaxis have been reported. Stop infusion immediately and treat patient accordingly if any signs or symptoms of a hypersensitivity reaction develop.

• Refeeding syndrome: Refeeding severely undernourished patients may result in refeeding syndrome (eg, intracellular shift of potassium, phosphorus, and magnesium as the patient becomes anabolic); thiamine deficiency and fluid retention may also develop. Carefully monitor severely undernourished patients and slowly increase nutrient intakes, while avoiding overfeeding.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, cardiac insufficiency due to left ventricular systolic dysfunction, heart failure); these patients are susceptible to excessive fluid accumulation; dosage adjustments may be necessary. Consider concentrated total parenteral nutrition formula.

• Diabetes: Use with caution in patients with diabetes mellitus. Monitor blood glucose levels and treat hyperglycemia to maintain optimum levels.

• Hepatic impairment: Use with caution in patients with hepatic impairment; dosage adjustments may be necessary. Consider volume status in patients with hepatic failure, may require concentrated total parenteral nutrition formula.

• Renal impairment: Use with caution in patients with renal impairment; may be at risk of electrolyte and fluid volume imbalance; dosage adjustments may be necessary. May contain aluminum, which may accumulate following prolonged administration in patients with renal impairment.

Concurrent drug therapy issues:

• Ceftriaxone: Precipitation of ceftriaxone-calcium may occur when ceftriaxone is mixed with calcium-containing parenteral nutrition solutions in the same IV line. Do not administer ceftriaxone simultaneously via a Y-site with calcium-containing parenteral solutions. Concurrent use is contraindicated in neonates <28 days receiving ceftriaxone. In patients ≥28 days, may administer sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid.

Dosage form specific issues:

• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal impairment. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register 2002). See manufacturer's labeling.

• Precipitates: Periodically inspect solution, infusion set and catheter for precipitates. Pulmonary vascular precipitates causing pulmonary vascular emboli and pulmonary distress has been reported (some fatal). If signs of pulmonary distress occur, stop the infusion.

• Sulfites: Some products may contain sulfites as preservatives.

Other warning/precautions:

• Administration: For central or peripheral IV administration; peripheral administration of nutrition is dependent upon osmolality of solution.

• Extravasation: Vesicant; ensure proper catheter or needle position prior to and during infusion. Avoid extravasation.

Animal reproduction studies have not been conducted. Following administration, an increase of some amino acids is observed in the fetus (Ronzoni 1999; Ronzoni 2002). In women with nausea and vomiting of pregnancy, parenteral nutrition should be used as a last option for any woman who cannot maintain her weight because of vomiting; enteral nutrition is preferred (ACOG 2015).