Severe nausea and vomiting caused by composite potassium hydrogen phosphate injection

Severe nausea and vomiting caused by composite potassium hydrogen phosphate injection

• Yang Zhang   Ping Wang   Jing Guo
• (Department of Pharmacy, The People’s Hospital of Langfang, LangFang, Hebei 065000, China)




• ABSTRACT
• Objective By sharing a case of severe nausea and vomiting caused by parenteral nutrition, explore ways to improve the safety of parenteral nutrition infusion. Methods The causes of total parent nutrition for nausea and vomiting were analyzed by group infusion. Results After two days parenteral nutrition solution, the patient experienced nausea and vomiting. Through the design of the group, the patients were given fluids according to the group. Nausea and vomiting occurred again when the infusion was given to the compound potassium hydrogen phosphate injection and 0.9% sodium chloride injection group, and the infusion was stopped immediately for symptomatic treatment. After symptoms abate, patients continue to be infused with other medications, None of the above adverse reactions occurred again. Conclusion Considering that the patient's nausea and vomiting are related to complex potassium hydrogen phosphate, it is recommended to give separate infusion during parenteral nutrition therapy.
• Keywords:Composite potassium hydrogen phosphate injection;Total parenteral nutrition;Severe vomiting












• Compound potassium hydrogen phosphate injection   is mainly used   as   a phosphorus supplement in parenteral nutrition   [1] . It’s main components are dipotassium hydrogen phosphate   and   potassium   dihydrogen phosphate, which belong to high concentration electrolytes and have the effect of correcting hypophosphatemia   [2] .   Healthy   adults need about 900mg of phosphorus per day, and they also expel the same amount each day.   Phosphorus   participate s   in   sugar phosphorylati on   in   sugar   metabolism   in human   body,   constitutes   phospholipids in   membrane   components,   and   is   one   of the   important   components   of ribonucleic acid(RNA), deoxyibonucleic acid (DNA) and




• many coenzymes in cells [3] . Phosphorus is also involved in energy storage, conversion, transportation and the regulation of body fluid buffering   [4] . Therefore, phosphorus supplementation is necessary for patients who cannot eat.
• 1 Clinical Data
• 1.1 Case Overview The patient, a 67-year- old   female, was   admitted to   our hospital on July 6, 2023 for further treatment due to recurrence of ovarian cancer after surgery and chemotherapy. The patient had no history of drug or food allergy. Physical examination in hospital: temperature 36℃, pulse 99 times/ min, breathing 22 times/min, blood pressure











• 115/73mmHg, weakness and poor spirit. The abdomen was puffy in appearance, without gastric type, intestinal type and peristaltic wave . The abdomen was soft, and there was light tenderness around the umbilical cord. There was no tenderness in the rest   area . Laboratory examination on the second day of admission: total protein 54.3g/L, albumin 27.0g/ L, sodium   128mmol/L, chlorine 97mmol /L, calcium   1.92mmol /L, magnesium 0.6mmol/
• L . Admission   diagnosis:   ovarian   cancer; Esophageal cancer (after chemoradiotherapy); Hypoproteinemia; Electrolyte disturbance; Incomplete intestinal obstruction.
• 1.2 Treatment Process The patient was diagnosed with incomplete ileus, was forbidden to eat or drink, and was given total parent nutrition(TPN) support on day 2 of admission. Parenteral nutrition preparations included: 30% fat milk injection 250ml,   18AA compound amino acid injection 900ml, a variety of trace elements 10ml, 1 water-soluble vitamin, 10ml fat-soluble vitamin, 50% glucose injection 350ml,   15% potassium chloride injection 6g, compound potassium hydrogen phosphate injection 2ml, 10% sodium chloride injection 60ml,   10% calcium gluconate injection   1g, 25% magnesium sulfate injection 0.7g, insulin injection 30 units. The route of administration was   intravenous   drip.   The   frequency   of administration was once a day. The patient experienced nausea and vomiting several times during the infusion of nutrient solution on day 1, which was not corrected After metoclopramide injection.
• On the   second   day,   100mg   of vitamin B6 was added to the total parenteral nutrition solution, and the symptoms of nausea and vomiting were aggravated. Then,    ondansetron

injection of 8mg was injected intravenously, but with poor effect.

• On the third day, the drugs in the nutrient solution were transfused in groups as follows:
• Prescription   1:30% fat milk injection + water-soluble vitamin for injection + fat-soluble vitamin injection;
• Prescription 2:10% glucose injection +50% glucose injection + insulin injection +15% potassium   chloride injection +   compound potassium hydrogen phosphate injection;
• Prescription   3:0.9%   sodium   chloride injection +10% sodium chloride injection;
• Prescription 4:25% magnesium   sulfate injection +10% glucose injection;
• Prescription   5:10%   calcium gluconate injection +10% glucose injection;
• Prescription 6: Compound amino acid 18AA injection +15% potassium chloride injection.
• The patient entered the above prescriptions in turn, and when "prescription 1" was injected, the patient was normal. During the infusion of "Prescription 2", the patient had severe nausea and vomiting and immediately stopped the infusion. Meanwhile the patient was given 20mg metoclopramide by intramuscular injection . About 2 hours later, the patient returned to normal and continued to be injected with other nutrient solutions.The patient did not have any adverse reactions of nausea and vomiting later.
• 2 Results After the change of treatment regimen, the patient did not appear nausea and vomiting again, the condition was stable, the condition was good, and the indicators were better than before.
• 3 Discussion
• 3.1 Relevance evaluation On the third day, all nutrient solutions were no longer fully integrated and were administered separately








• by group. When "Prescription 1" was injected, the patient was normal. During the infusion of "Prescription 2," the patient experienced severe nausea and vomiting. There was a time correlation between drug use and the occurrence of adverse reactions. When the patient returned to normal, the intravenous infusion of other groups of drugs continued and the patient did not develop the above adverse reactions. According to the evaluation standards of the National Adverse Drug Reaction Monitoring Center, the adverse reaction in this case belongs to serious adverse reaction [5]. According to the Naranjo adverse drug reaction score of 6 points, the correlation evaluation is very likely.
• 3.2 Mechanism Analysis Parenteral nutrition refers to the infusion of nutrients through an external intestinal pathway (i.e. an intravenous route). Nutrients include nutrients such as water, glucose, amino acids, fat milk, electrolytes, multiple trace elements and vitamins. Patients were   divided into TPN   and partial parent nutrition(PPN)   according to the degree of satisfaction   of nutritional needs   [6] .   For patients with gastrointestinal dysfunction and critical illness, reasonable parenteral nutrition support can improve their weight and muscle function, improve treatment responsiveness and patients' quality of life, effectively reduce the number of days in hospital, and reduce clinical complications and mortality   [7] . Parenteral nutrition is a mixture of various nutritional drugs, which is an unstable system, and its stability is affected by pH, cation concentration, glucose concentration and other factors [8,9]. Parenteral nutrition has become an important nutritional therapy widely used in critically ill patients in clinical practice, but parenteral nutrition solution has been listed as a high




• warning drug by the drug safety study in the United   States . Improper use of parenteral nutrition may cause harm or even death to patients   [10] . Parenteral nutrition solution contains a variety of drugs, each of which may cause adverse drug reactions. Common amino acid injection and magnesium sulfate injection can cause nausea and vomiting [11,12]. Through searching the databases of Chinese National Knowledge Internet(CNKI), Wanfang Database and Pubmed, it was found that most of the adverse reactions caused by parenteral nutrition were   liver   function   injury   and   abnormal glucose and lipid metabolism [13], while severe nausea and vomiting caused by compound potassium hydrogen phosphate injection added to parenteral nutrition solution were rarely reported. This case suggests that severe nausea and vomiting in patients receiving parenteral nutrition solution may be caused by complex potassium hydrogen phosphate injection.
• 3.3 Consult literature and drug instructions It has been reported that there is compatibility reaction between complex potassium hydrogen phosphate and compound vitamin preparations [14]. In this case, when the patient was given parenteral total nutrition two days ago, the prescription contained water-soluble and fat- soluble vitamins, and the severe nausea and vomiting in the patient could not be ruled out as caused by the compatibility of complex potassium hydrogen phosphate with water- soluble and fat-soluble vitamins.
• Referring to the instructions of compound potassium hydrogen phosphate injection and related literature, the routine usage and dosage of this drug is 2.5 ml per 1000 kcal. Excessive use of complex potassium hydrogen phosphate injection may   cause hyperphosphosemia,hypocal ce mia,   muscle   twitch,   spasm, gastrointestinal discomfort, etc. In this case, the doctor calculated the conventional dose according to the patient's own situation by using the formula, there was no overuse, and the patient had serious nausea and vomiting symptoms, rather than mild   symptoms   of gastrointestinal discomfort. Therefore, this case is not the adverse reaction reported in the drug instructions, and clinical workers should be carefully considered when using it, especially when treating parenteral total nutrition, to reduce the occurrence of such adverse events as much as possible.
• 4 Summary
• When   TPN   needs   to   add   compound potassium hydrogen phosphate, the pharmacist recommends separate infusions. For patients requiring phosphorus supplementation through parent era l   nutrition,   organophosphorus preparations (sodium glycerophosphate) are recommended. Organophosphorus preparations have lower dissociation degree in solution, can ensure compatibility and stability with some electrolytes (calcium, magnesium, potassium, sodium plasma) within a large concentration range, and greatly reducing the impact on the stability of parenteral nutrient solution [15].
• reference
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