be trained Clinimix E Generic Name: leucine, phenylalanine, lysine, methionine, isoleucine, valine, histidine, threonine, tryptophan, alanine, glycine, arginine, proline, serine, tyrosine, sodium acetate, dibasic potassium phosphate, magnesium chloride, sodium chloride, calcium chloride, dextrose Dosage Form: injection Overview Side Effects Interactions Reviews Q & A More Indications and Usage for Clinimix E Clinimix E is indicated as a source of calories, protein, and electrolytes for patients requiring parenteral nutrition when oral or enteral nutrition is not possible, insufficient, or contraindicated. Clinimix E may be used to treat negative nitrogen balance in patients. Slideshow A Joint Effort: A Provider's Guide To Orthopedic Pain Options Clinimix E Dosage and Administration Preparation Prior to Administration Tear protective foil overwrap across top at slit and remove solution container. Small amounts of moisture may be found on the solution container from water permeating from inside the container. The amount of permeated water is insufficient to affect the solution significantly. If larger amounts of water are found, the container should be checked for tears or leaks. Inspect the bag prior to activation. Some opacity of the plastic due to moisture absorption during the sterilization process may be observed. This is normal and does not affect the solution quality or safety. The opacity will diminish gradually. Evaluate the following: o If the outlet or additive port protectors are damaged, detached, or not present, discard container as solution path sterility may be impaired. o Check to ensure seal between chambers is intact, solutions are contained in separate chambers, and the content of the individual chambers is clear, colorless or slightly yellow. Discard if the seal is broken or if the solution is bright yellow or yellowish brown. o Check for minute leaks by separately squeezing each chamber. If external leaks or leakage between the chambers are found, discard solution as sterility or stability may be impaired. Lipids and/or additives can be introduced to the container after opening seal between chambers. Because additives may be incompatible, evaluate all additions to the plastic container for compatibility. Activate chambers of bag prior to introduction of additives. Mix thoroughly when additives have been introduced. Supplemental medication may be added with a 19 to 22 gauge needle through the medication port. Calcium and phosphate ratios must be considered. Excess addition of calcium and phosphate, especially in the form of mineral salts, may result in the formation of calcium phosphate precipitates [see Warnings and Precautions (5.1) ]. Inspect the bag to ensure precipitates have not formed during the mixing or addition of additives. A slight yellow color does not alter the quality and efficacy of this product. If lipid has been added, ensure the emulsion has not separated. Separation of the emulsion can be visibly identified by a yellowish streaking or the accumulation of yellowish droplets in the mixed emulsion. Discard the admixture if any of the above are observed. Important Administration Instructions Set the vent to the closed position on a vented intravenous administration set to prevent air embolism. Use a dedicated line without any connections to avoid air embolism. Clinimix E is for intravenous infusion only into a central or peripheral vein. The choice of a central or peripheral venous route should depend on the osmolarity of the final infusate. Solutions with osmolarity of 900 mOsm/L or greater must be infused through a central catheter [see Warnings and Precautions (5.7) ] . o For central vein infusion only: Clinimix E 2.75/10, 4.25/10, 4.25/25, 5/15, 5/20, 5/25 o For central or peripheral vein infusion: Clinimix E 2.75/5 and 4.25/5 The solution should be inspected for precipitates before admixing, after admixing, and again before administration. Use a 0.22 micron filter for administration of CLINIMIX E. If a lipid is also administered, use a 1.2 micron filter. If lipid emulsion is added, do not use administration sets and lines that contain di-2-ethylhexyl phthalate (DEHP). Administration sets that contain polyvinyl chloride (PVC) components have DEHP as a plasticizer. Ceftriaxone must not be administered simultaneously with calcium-containing intravenous solutions such as Clinimix E via a Y-site. However, in patients other than neonates, ceftriaxone and Clinimix E may be administered sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid [see Contraindications (4) , Warnings and Precautions (5.2) ] . Instructions for Use 1. Open by tearing protective foil overwrap across top at slit and remove solution container. 2. Lay the bag onto a flat surface. Grasp the container firmly on each side of the top of the bag ( Figure 1 ). 3. Starting from the top squeeze and roll bag to open seal between chambers until the peel-seal is completely broken as shown in Figure 2 . 4. If the seal has not been separated completely flip the bag over and repeat process. 5. Mix the contents thoroughly by inverting the bag upside down to ensure a homogenous admixture ( Figure 3 ). 6. Once the bag is mixed, check for leaks. 7. Make additions (if prescribed). Because additives may be incompatible, evaluate all additions to the bag for compatibility and stability of the resulting preparation. Consult with pharmacist, if available. Questions about compatibility may be directed to Baxter. If it is deemed advisable to introduce additives, use aseptic technique. For information on adding lipid emulsions see Dosage and Administration (2.4) . a. Prepare medication port. b. Using syringe with 19 to 22 gauge needle, puncture resealable medication port and inject. c. Mix solution and medication thoroughly ( Figure 3 ). For high density medication (high specific gravity), such as potassium chloride, squeeze ports while ports are upright and mix thoroughly. 8. Inspect final solution for discoloration and particulate matter. Check for leaks. 9. Spike and hang bag. a. Suspend container from eyelet support. b. Twist off protector from outlet port at bottom of container ( Figure 4 ). c. Attach administration set. Refer to complete directions accompanying set. For single dose only. Discard unused portion. Figures 1 4: Instructions on Storage Storage After Removal of Overwrap: Once removed from the protective foil overwrap, mixed (peel seal activated) or unmixed (peel seal intact), Clinimix E Injection solutions may be stored under refrigeration for up to 9 days. Storage Once any Additive is Added: Use promptly after mixing. Any storage with additives should be under refrigeration and limited to a brief period of time, less than 24 hours. After removal from refrigeration, use promptly and complete the infusion within 24 hours. Any remaining mixture must be discarded. Preparation and Addition of Lipid Emulsion 1. Prior to adding lipid emulsion, mix amino acid and dextrose injection as shown in Figures 1-3 . 2. Prepare lipid emulsion transfer set following instructions provided. 3. Attach transfer set to lipid emulsion container using aseptic technique. 4. Twist off protector on the additive port of the container. 5. Attach the transfer set to the exposed additive port. 6. Open clamp on transfer set. 7. After completing transfer, use appropriate plastic clamp or metal ferrule to seal off additive port tube. 8. Remove transfer set. 9. Mix contents of container thoroughly. Inspect final solution for discoloration and particulate matter. Check for leaks. Storage Once Lipids are Added: Use promptly after mixing. Any storage with additives should be under refrigeration and limited to a brief period of time, no longer than 24 hours. After removal from refrigeration, use promptly and complete the infusion within 24 hours. Any mixture remaining must be discarded. Dosing Considerations The dosage of Clinimix E should be individualized based on the patient s clinical condition (ability to adequately metabolize amino acids and dextrose), body weight and nutritional/fluid requirements, as well as additional energy given orally/enterally to the patient. Prior to initiating Clinimix E the following patient information should be reviewed: review of all medications, gastrointestinal function and laboratory data such as electrolytes (including magnesium, calcium, and phosphorus), glucose, urea/creatinine, liver panel, complete blood count and triglyceride level (if adding lipid emulsion). Refer to the complete prescribing information of lipid emulsion for dosing information. Clinimix E formulations have varying concentrations of protein, carbohydrate and a standard concentration of electrolytes; thus infusion rates to achieve requirements will vary. Protein, caloric, fluid and electrolyte requirements all need to be taken into consideration when determining individual patient dosage needs. The dosage selection is based only on the recommended protein requirements. The maximum dextrose infusion rates and calorie and fluid requirements must also be considered when determining the clinically appropriate infusion rate for patients. Clinimix E meets the total nutritional requirements for protein and dextrose in stable patients, and can be individualized to meet specific needs with the addition of nutrients. Total daily fluid requirements can be met beyond the volume of amino acids solution by supplementing with non-carbohydrate or carbohydrate-containing electrolyte solutions. 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. Prior to administration of Clinimix E correct severe fluid, electrolyte and acid-base disorders. Monitor levels of serum potassium during therapy. It may be necessary to add additional potassium to the Clinimix E admixture. Lipid emulsion administration should be considered with prolonged use (more than 5 days) of Clinimix E in order to prevent essential fatty acid deficiency (EFAD). Serum lipids should be monitored for evidence of EFAD in patients maintained on fat-free parenteral nutrition. See prescribing information of lipid emulsion. The flow rate should be increased gradually. The flow rate must be adjusted taking into account the dose being administered, the daily volume intake, and the duration of the infusion. Recommended Dosage in Adults The recommended daily nutritional requirements for protein and dextrose compared to the amount of nutrition provided by Clinimix E are shown in Table 1 . As indicated on an individual basis, maintenance vitamins, additional electrolytes, trace elements and other components (including lipids) should be administered as required to prevent deficiencies and complications from developing. The maximum infusion rates in adult patients are show in Table 2 . In addition to meeting protein needs, the administration rate should be governed, especially during the first few day of therapy, by the patient s tolerance to dextrose. Daily intake of amino acids and dextrose should be increased gradually to the maximum required dose as indicated by frequent determinations of blood glucose levels. Table 1: Nutritional Comparison Adult Patients * Do not use in patients with conditions that are contraindicated [see Contraindications (4) ]. Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Recommended Nutritional Requirements 1 Recommended Clinimix E Adult Dosage Stable Patients Critically Ill Patients * Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Fluid (mL/kg/day) 30 to 40 Minimum needed to deliver adequate nutrition 29 to 40 29 to 40 19 to 40 19 to 40 19 to 40 16 to 40 16 to 40 16 to 40 Protein (g/kg/day) (Nitrogen g/kg/day) 0.8 to 1 (0.13 to 0.16) 1.5 to 2 (0.24 to 0.32) 0.8 to 1.1 (0.13 to 0.18) 0.8 to 1.1 (0.13 to 0.18) 0.8 to 1.7 (0.13 to 0.27) 0.8 to 1.7 (0.13 to 0.27) 0.8 to 1.7 (0.13 to 0.27) 0.8 to 2 (0.13 to 0.32) 0.8 to 2 (0.13 to 0.32) 0.8 to 2 (0.13 to 0.32) Dextrose (g/kg/day) 10 5.8 1.45 to 2 2.9 to 4 0.95 to 2 1.9 to 4 4.75 to 10 2.4 to 6 3.2 to 8 4 to 10 Table 2: Maximum Infusion Rate in Adult Patients * Rate limiting factor Maximum Infusion Rates in Adults Patients Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Maximum Infusion Rate (mL/kg/hour) 3.6 2.5 2.4 2.4 1 1.67 1.25 1 Corresponding infusion rate Amino Acid (g/kg/hour) 0.1 * 0.07 0.1 * 0.1 * 0.04 0.08 0.06 0.05 Dextrose (g/kg/hour) 0.18 0.25 * 0.12 0.24 0.25 * 0.25 * 0.25 * 0.25 * Dosage Modifications in Patients with Renal Impairment Prior to administration, correct severe fluid or electrolyte imbalances. Closely monitor serum electrolyte levels and adjust the volume of Clinimix E administered as required [see Warnings and Precautions (5.11) ] . Patients with renal impairment not needing dialysis require 0.6 to 0.8 g of protein/kg/day. Serum electrolyte levels should be closely monitored. Patients on hemodialysis or continuous renal replacement therapy should receive 1.2 to 1.8 g of protein/kg/day up to a maximum of 2.5 g of protein/kg/day based on nutritional status and estimated protein losses. 2 The Clinimix E dosage can be adjusted based on the severity of renal impairment, supplementing protein as indicated. If required, additional amino acids may be added to the Clinimix E bag or infused separately. Compatibility of additions should be evaluated by a pharmacist and questions may be directed to Baxter. Recommended Dosage in Pediatric Patients The dosage and constant infusion rate of intravenous dextrose must be selected with caution in pediatric patients, particularly neonates and low weight infants, because of the increased risk of hyperglycemia/hypoglycemia [see Use in Specific Populations (8.4) ] . Frequent monitoring of serum glucose concentrations is required when dextrose is prescribed to pediatric patients, particularly neonates and low birth weight infants. The infusion rate and volume should be determined by the consulting physician experienced in pediatric intravenous fluid therapy. In pediatric patients, Clinimix E is dosed on the basis of protein provided as amino acids. The recommended dosage, by age group is provided in Tables 3 - 6 . Infusion rates are based on protein and do not take carbohydrates, fluid or electrolytes into consideration. This product does not contain the amino acids cysteine and taurine, considered conditionally essential for neonates and infants. If possible, these amino acids should be added to this product if used in this pediatric population. Table 3: Preterm and Term Infants Less than 1 Month of Age * Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Recommended Nutritional Requirements 1 Recommended Clinimix E Dosage in Preterm and Term Infants Less than 1 Month of Age Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Infusion Rate Range (mL/kg/hr) 4.5 to 6 4.5 to 6 2.9 to 3.9 2.9 to 3.9 2.9 to 3.3 2.5 to 3.3 2.5 to 3.3 2.5 to 3.3 Fluid (mL/kg/day) 100 to 150 108 to 144 108 to 144 70 to 94 70 to 94 70 to 79 60 to 79 60 to 79 60 to 79 Protein * (g/kg/day) (Nitrogen g/kg/day) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) 3 to 3.4 (0.48 to 0.54) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) 3 to 4 (0.48 to 0.64) Dextrose (g/kg/day) 7 to 20 5.4 to 7.2 10.8 to 14.4 3.5 to 4.7 7 to 9.4 17.5 to 19.8 9 to 11.9 12 to 15.8 15 to 19.8 1. Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Table 4: Pediatric Patients 1 Month to Less than 1 Year of Age * Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Recommended Nutritional Requirements 1 Recommended Clinimix E Dosage in Pediatric Patients 1 Month to Less than 1 Year of Age Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Infusion Rate Range (mL/kg/hr) 3 to 4.5 3 to 4.5 2 to 2.9 2 to 2.9 2 to 2.9 1.7 to 2.5 1.7 to 2.5 1.7 to 2.5 Fluid (mL/kg/day) 100 mL/kg for the first 10 kg + 50 mL/kg for the second 10 kg. 72 to 108 72 to 108 48 to 70 48 to 70 48 to 70 41 to 60 41 to 60 41 to 60 Protein * (g/kg/day) (Nitrogen g/kg/day) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) 2 to 3 (0.32 to 0.48) Dextrose (g/kg/day) 7 to 20 3.6 to 5.4 7.2 to 10.8 2.4 to 3.5 4.8 to 7 12 to 17.5 6.1 to 9 8.2 to 12 10.2 to 15 Table 5: Pediatric Patients 1 Year to Less than 11 Years of Age * Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Recommended Nutritional Requirements 1 Recommended Clinimix E Dosage in Pediatric Patients 1 Year to Less than 11 Years of Age Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Infusion Rate Range (mL/kg/hr) 1.5 to 3 1.5 to 3 1 to 2 1 to 2 1 to 2 0.8 to 1.7 0.8 to 1.7 0.8 to 1.7 Fluid (mL/kg/day) 100 mL/kg for the first 10 kg + 50 mL/kg for the second 10 kg + 20 mL/kg for weight > 20 kg 36 to 72 36 to 72 24 to 48 24 to 48 24 to 48 19 to 41 19 to 41 19 to 41 Protein * (g/kg/day) (Nitrogen g/kg/day) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) 1 to 2 (0.16 to 0.32) Dextrose (g/kg/day) 7 to 14 1.8 to 3.6 3.6 to 7.2 1.2 to 2.4 2.4 to 4.8 6 to 12 2.9 to 6.1 3.8 to 8.2 4.8 to 10.2 Table 6: Pediatric Patients 11 Years to 17 Years of Age * Protein is provided as amino acids. When infused intravenously amino acids are metabolized and utilized as the building blocks of protein. Recommended Nutritional Requirements 1 Recommended Clinimix E Dosage in Pediatric Patients 11 Years to 17 Years of Age Clinimix E 2.75/5 Clinimix E 2.75/10 Clinimix E 4.25/5 Clinimix E 4.25/10 Clinimix E 4.25/25 Clinimix E 5/15 Clinimix E 5/20 Clinimix E 5/25 Infusion Rate Range (mL/kg/hr) 1.2 to 2.3 1.2 to 2.3 0.8 to 1.5 0.8 to 1.5 0.8 to 1.5 0.7 to 1.3 0.7 to 1.3 0.7 to 1.3 Fluid (mL/kg/day) 100 mL/kg for the first 10 kg + 50 mL/kg for the second 10 kg + 20 mL/kg for weight > 20 kg 29 to 55 29 to 55 19 to 36 19 to 36 19 to 36 17 to 31 17 to 31 17 to 31 Protein * (g/kg/day) (Nitrogen g/kg/day) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) 0.8 to 1.5 (0.13 to 0.24) Dextrose (g/kg/day) 5 to 9 1.4 to 2.8 2.9 to 5.5 1 to 1.8 1.9 to 3.6 4.8 to 9 2.5 to 4.7 3.4 to 6.2 4.2 to 7.8 Discontinuation of Clinimix E To reduce the risk of hypoglycemia after discontinuation, a gradual decrease in flow rate in the last hour of infusion should be considered. Dosage Forms and Strengths Clinimix E injection is available in 1000 mL and 2000 mL dual chamber bags. The individual chambers contain essential and nonessential amino acids with electrolytes and dextrose with calcium. Table 7 describes the individual components of CLINIMIX E. Table 7 INGREDIENTS PER 100mL OF CLINIMIX E * Balanced by ions from amino acids. Derived from glacial acetic acid (for pH adjustment) and sodium acetate. Contributed by calcium chloride, lysine hydrochloride, magnesium chloride, and sodium chloride. pH of sulfite-free amino acid injection with electrolytes in the outlet port chamber was adjusted with glacial acetic acid. Strength of CLINIMIX E CLINIMIX E 2.75/5 sulfite free (2.75% Amino Acid in 5% Dextrose) Injection CLINIMIX E 2.75/10 sulfite free (2.75% Amino Acid in 10% Dextrose) Injection CLINIMIX E 4.25/5 sulfite free (4.25% Amino Acid in 5% Dextrose) Injection CLINIMIX E 4.25/10 sulfite free (4.25% Amino Acid in 10% Dextrose) Injection Clinimix E 4.25/25 sulfite free (4.25% Amino Acid in 25% Dextrose) Injection CLINIMIX E 5/15 sulfite free (5% Amino Acid in 15% Dextrose) Injection CLINIMIX E 5/20 sulfite free (5% Amino Acid in 20% Dextrose) Injection CLINIMIX E 5/25 sulfite free (5% Amino Acid in 25% Dextrose) Injection Dextrose Hydrous, USP (g/100 mL) 5 10 5 10 25 15 20 25 Amino Acids (g/100 mL) 2.75 2.75 4.25 4.25 4.25 5 5 5 Total Nitrogen (mg/100 mL) 454 454 702 702 702 826 826 826 Essential Amino Acids (mg/100 mL) Leucine 201 201 311 311 311 365 365 365 Isoleucine 165 165 255 255 255 300 300 300 Valine 160 160 247 247 247 290 290 290 Lysine (added as the hydrochloride salt) 159 159 247 247 247 290 290 290 Phenylalanine 154 154 238 238 238 280 280 280 Histidine 132 132 204 204 204 240 240 240 Threonine 116 116 179 179 179 210 210 210 Methionine 110 110 170 170 170 200 200 200 Tryptophan 50 50 77 77 77 90 90 90 Nonessential Amino Acids (mg/100 mL) Alanine 570 570 880 880 880 1035 1035 1035 Arginine 316 316 489 489 489 575 575 575 Glycine 283 283 438 438 438 515 515 515 Proline 187 187 289 289 289 340 340 340 Serine 138 138 213 213 213 250 250 250 Tyrosine 11 11 17 17 17 20 20 20 Electrolytes (mg/100 mL) Sodium Acetate Trihydrate, USP 217 217 297 297 297 340 340 340 Dibasic Potassium Phosphate, USP 261 261 261 261 261 261 261 261 Sodium Chloride, USP 112 112 77 77 77 59 59 59 Magnesium Chloride, USP 51 51 51 51 51 51 51 51 Calcium Chloride Dihydrate, USP 33 33 33 33 33 33 33 33 Electrolyte Profile (mEq/L) * Sodium 35 35 35 35 35 35 35 35 Potassium 30 30 30 30 30 30 30 30 Magnesium 5 5 5 5 5 5 5 5 Calcium 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) 4.5 (2.2 mmol/L) Acetate 51 51 70 70 70 80 80 80 Chloride 39 39 39 39 39 39 39 39 Phosphate (as HPO 4 ) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) 30 (15 mmol/L) pH (Range) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) 6.0 (4.5 to 7.0) Osmolarity (mOsmol/L) (calc) 665 920 815 1070 1825 1395 1650 1900 Caloric Content (kcal/L) From Dextrose 170 340 170 340 850 510 680 850 From Amino Acids 110 110 170 170 170 200 200 200 TOTAL (Dextrose and Amino Acids) 280 450 340 510 1020 710 880 1050 Contraindications The use of Clinimix E is contraindicated in: Neonates (less than 28 days of age) receiving concomitant treatment with ceftriaxone, even if separate infusion lines are used, due to the risk of fatal ceftriaxone calcium salt precipitation in the neonate s bloodstream [see Warnings and Precautions (5.2) , Use in Specific Populations (8.4) ] . Patients with known hypersensitivity to one or more amino acids or dextrose [see Warnings and Precautions (5.3) ] . Patients with inborn errors of amino acid metabolism due to risk of severe metabolic and neurologic complications. Patients with pulmonary edema or acidosis due to low cardiac output. Warnings and Precautions Pulmonary Embolism due to Pulmonary Vascular Precipitates Pulmonary vascular precipitates causing pulmonary vascular emboli and pulmonary distress have been reported in patients receiving parenteral nutrition. In some cases, fatal outcomes due to pulmonary embolism have occurred. Patients, especially those with hypophosphatemia, may require the addition of phosphate. To prevent hypocalcemia, calcium supplementation should always accompany phosphate administration. Excessive addition of calcium and phosphate increases the risk of the formation of calcium phosphate precipitates. Precipitates have been reported even in the absence of phosphate salt in the solution. Precipitation following passage through an in-line filter and suspected in vivo precipitate formation has also been reported. If signs of pulmonary distress occur, stop the infusion and initiate a medical evaluation. In addition to inspection of the solution [see Dosage and Administration (2.1 , 2.2 , 2.3 , 2.4 )] , the infusion set and catheter should also periodically be checked for precipitates. Precipitation with Ceftriaxone Precipitation of ceftriaxone-calcium can occur when ceftriaxone is mixed with calcium-containing parenteral nutrition solutions, such as CLINIMIX E, in the same intravenous administration line. Do not administer ceftriaxone simultaneously with Clinimix E via a Y-site. Deaths have occurred in neonates (less than 28 days of age) who received concomitant intravenous calcium-containing solutions with ceftriaxone resulting from calcium-ceftriaxone precipitates in the lungs and kidneys, even when separate infusion lines were used. Clinimix E is contraindicated in neonates receiving ceftriaxone [see Contraindications (4) , Use in Specific Populations (8.4) ]. In patients older than 28 days (including adults), ceftriaxone and Clinimix E may be administered sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid . Hypersensitivity Reactions Hypersensitivity/infusion reactions including anaphylaxis have been reported with CLINIMIX E. Stop infusion immediately and treat patient accordingly if any signs or symptoms of a hypersensitivity reaction develop. Signs or symptoms may include: hypotension, hypertension, peripheral cyanosis, tachycardia, dyspnea, vomiting, nausea, urticaria, rash, pruritus, erythema, hyperhidrosis, pyrexia, and chills. Risk of Infections Patients who require parenteral nutrition are at high risk of infections because the nutritional components of these solutions can support microbial growth. Infection and sepsis may also occur as a result of the use of intravenous catheters to administer parenteral nutrition. The risk of infection is increased in patients with malnutrition-associated immunosuppression, hyperglycemia exacerbated by dextrose infusion, long-term use and poor maintenance of intravenous catheters, or immunosuppressive effects of other concomitant conditions, drugs, or other components of the parenteral formulation (e.g., lipid emulsion). To decrease the risk of infection, ensure aseptic technique in catheter placement and maintenance, as well as aseptic technique in the preparation and administration of the nutritional formula. Monitor for signs and symptoms (including fever and chills) of early infections, including laboratory test results (including leukocytosis and hyperglycemia) and frequent checks of the parenteral access device and insertion site for edema, redness and discharge. Refeeding Syndrome Refeeding severely undernourished patients may result in refeeding syndrome, characterized by the intracellular shift of potassium, phosphorus, and magnesium as the patient becomes anabolic. Thiamine deficiency and fluid retention may also develop. To prevent these complications, monitor severely undernourished patients and slowly increase nutrient intakes. Hyperglycemia or Hyperosmolar Hyperglycemic State When using Clinimix E in patients with diabetes mellitus, impaired glucose tolerance may worsen hyperglycemia. 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 and treat hyperglycemia to maintain optimum levels while administering CLINIMIX E. Insulin may be administered or adjusted to maintain optimal blood glucose levels during Clinimix E administration. Vein Damage and Thrombosis Solutions with osmolarity of 900 mOsm/L or greater must be infused through a central catheter. Clinimix E solutions containing more than 5% dextrose have an osmolarity greater than or equal to 900 mOsm/L. Clinimix E 2.75/10, 4.25/10, 4.25/25, 5/15, 5/20, and 5/25 are indicated for administration into a central vein only, such as the superior vena cava [see Dosage and Administration (2.2) ] . The infusion of hypertonic nutrient injections into a peripheral vein may result in vein irritation, vein damage, and/or thrombosis. Clinimix E 2.75/5 and 4.25/5 are indicated for peripheral administration, or may be infused into a central vein [see Dosage and Administration (2.2) ] . The primary complication of peripheral access is venous thrombophlebitis, which manifests as pain, erythema, tenderness or a palpable cord. Remove the catheter as soon as possible, if thrombophlebitis develops. Hepatobiliary Disorders Hepatobiliary disorders are known to develop in some patients without preexisting liver disease who receive parenteral nutrition, including cholecystitis, cholelithiasis, cholestasis, hepatic steatosis, fibrosis and cirrhosis, possibly leading to hepatic failure. The etiology of these disorders is thought to be multifactorial and may differ between patients. Increase in blood ammonia levels and hyperammonemia may occur in patients receiving amino acid solutions. In some patients this may indicate hepatic insufficiency or the presence of an inborn error of amino acid metabolism [see Contraindications (4) ] . Monitor liver function parameters and ammonia levels. Patients developing signs of hepatobiliary disorders should be assessed early by a clinician knowledgeable in liver diseases in order to identify possible causative and contributory factors, and possible therapeutic and prophylactic interventions. Aluminum Toxicity Clinimix E contains no more than 25 mcg/L of aluminum. However, with prolonged parenteral administration in patients with renal impairment, the aluminum contained in CLINIMX E may reach toxic levels. Preterm infants are at a greater risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum. Patients with renal impairment, including preterm infants, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day, accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration. Risk of Parenteral Nutrition Associated Liver Disease Parenteral Nutrition Associated Liver Disease (PNALD) has been reported in patients who receive parenteral nutrition for extended periods of time, especially preterm infants, and can present as cholestasis or steatohepatitis. The exact etiology is unknown and is likely multifactorial. If Clinimix E treated patients develop liver test abnormalities consider discontinuation or dosage reduction. Electrolyte Imbalance and Fluid Overload Patients with renal impairment, such as pre-renal azotemia, renal obstruction, and protein-losing nephropathy may be at increased risk of electrolyte and fluid volume imbalance. Patients with cardiac insufficiency due to left ventricular systolic dysfunction are susceptible to excess fluid accumulation. Use Clinimix E with caution in patients with cardiac insufficiency or renal impairment. Clinimix E dosage may require adjustment with specific attention to fluid, protein, and electrolyte content in these patients. Monitor renal function parameters. Patients developing signs of renal impairment should be assessed early by a clinician knowledgeable in renal disease in order to determine the appropriate Clinimix E dosage and other treatment options. Monitoring/Laboratory Tests Monitor fluid and electrolyte status, serum osmolarity, blood glucose, liver and kidney function, blood count and coagulation parameters throughout treatment. In situations of severely elevated electrolyte levels, stop Clinimix E until levels have been corrected. Adverse Reactions The following serious adverse reactions are discussed in greater detail in other sections of the prescribing information. Pulmonary embolism due to pulmonary vascular precipitates [see Warnings and Precautions (5.1) ] Death in neonates due to calcium-ceftriaxone precipitates [see Warnings and Precautions (5.2) ] Hypersensitivity reactions [see Warnings and Precautions (5.3) ] Risk of Infections [see Warnings and Precautions (5.4 profits
strolling Clinimix E foremost
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