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Parenteral Nutrition - Adult - Inpatient/Ambulatory

Parenteral Nutrition - Adult - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


Parenteral Nutrition - Adult -
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 4
METHODOLOGY ............................................................................................................ 5
DEFINITIONS ................................................................................................................. 6
INTRODUCTION ............................................................................................................. 6
RECOMMENDATIONS ................................................................................................... 6
TABLE 1. GENERAL GUIDELINES ADULT ENERGY REQUIREMENTS FOR
HOSPITALIZED PATIENTS ........................................................................................... 7
TABLE 2. GUIDELINES FOR PROTEIN REQUIREMENTS .......................................... 8
TABLE 3. USUAL ADULT ELECTROLYTE REQUIREMENTS ..................................... 9
TABLE 4. VITAMIN DAILY REQUIREMENTS AND VITAMIN CONTENT OF
MULTIVITAMIN CONCENTRATE ................................................................................ 10
TABLE 5. RECOMMENDATIONS FOR TRACE ELEMENT REQUIREMENTS .......... 11
UW HEALTH IMPLEMENTATION................................................................................ 16
APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................... 18
APPENDIX B. IDEAL BODY WEIGHT ESTIMATES.................................................... 19
APPENDIX C. CALCULATING OSMOLARITY OF PERIPHERAL PARENTERAL
NUTRITION ................................................................................................................... 20
APPENDIX D. COMPATIBILITY .................................................................................. 21
APPENDIX E. HOME PARENTERAL NUTRITION ...................................................... 25
REFERENCES .............................................................................................................. 27
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org



Contact for Content:
Name: Caitlin Curtis, PharmD, BCNSP, Clinical Nutrition Support
Phone Number: (608) 265 -1746
Email Address: CCurtis@uwhealth.org

Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS, Drug Policy Manager
Phone Number: (608) 265 -0341
Email Address: PTrapskin @uwhealth.org

Guideline Author(s):
Caitlin Curtis, PharmD, BCNSP; Pharmacy
Susan Stone, PharmD, BCNSP, CNSC; Pharmacy
Gretchen Manthei, PharmD, BCNSP, Pharmacy

Coordinating Team Members:
Amanda Condon, PharmD, Pharmacy
Carin Endres, PharmD, BCPS, Drug Policy Program

Review Individuals/Bodies:
Kenneth Kudsk, MD; Surgical Nutrition
Cassandra Knight, MS, RD, PhD; Clinical Nutrition
Marie Pietruszka, PharmD, CNSC; Pharmacy
Susan Kleppin, RPh, FASHP; Chartwell
Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE; Endocrinology/Diabetes
Debbie Johnson, MS, RN, CWOCN, CNS Wound, Skin, Ostomy

Committee Approvals/Dates:
Nutrition Support Committee (02/2016)
Pharmacy & Therapeutics Committee (Last Periodic Review: 01/19/2017)

Release Date: February 2017 | Next Review Date: February 2019










Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Executive Summary
Guideline Overview
This guideline describes the optimal use of parenteral nutrition in adult patients.

Key Revisions (2016 Periodic Review)
1. Added recommendations for withholding parenteral nutrition for critically ill patients in septic shock,
regardless of nutrition status
2. Added recommendations for energy calculations for critically ill patients with BMI > 30 or who are
severely malnourished
3. Updated recommendations for management of hypertriglyceridemia associated with fat
supplementation
4. Information regarding altered vitamin requirement in macrocytic anemia, scurvy or coagulopathy was
added
5. Added recommendations for iron supplementation, monitoring and formulation
6. Updated levocarnitine stability information
7. Updated laboratory monitoring parameters and frequency for parenteral nutrition in both the inpatient
and outpatient setting
8. Added recommendations for parenteral nutrition in end-of-life situations

Key Practice Recommendations
1. The use of PN should only be considered if all attempts at enteral feeding are unsuccessful
2. Indications for parenteral nutrition
2.1 Lack of enteral access and/or inadequate enteral nutrition
2.2 Gastrointestinal dysfunction
2.3 P reoperative nutrition
3. Nutritional requirements that may be utilized in parenteral nutrition include
3.1 Total Calories
3.2 Energy
3.3 Protein
3.4 Dextrose
3.5 Intravenous Fat Emulsion (IVFE)
3.6 Fluid
3.7 Electrolytes
3.8 Vitamins
3.9 Trace Elements
4. Regular insulin should be considered to manage hyperglycemia
5. In adult patients, percutaneous catheters advanced into the subclavian vein are preferred
6. Administration safe practices should be followed for each patient receiving parenteral nutrition
7. Physical traits and limitations of parenteral nutrition include stability and Y-siting of medicatio ns
8. Monitoring of parenteral nutrition includes
8.1 Anthropometrics
8.2 Blood chemistries including magnesium and phosphate
8.3 Point- of-care blood glucose
8.4 Triglycerides (if receiving IVFE)
8.5 Pre-albumin
8.6 C-reactive protein
8.7 Weekly CBC
9. Cyclic parenteral nutrition may be used in patients receiving multiple blood products, antibiotics, or
antifungals that are incompatible with parenteral nutrition, but should be avoided in patients with
compromised renal or cardiovascular function
10. Transitioning to enteral requirements should be evaluated on a case- by -case basis
11. Abrupt discontinuation of parenteral nutrition should be avoided due to risk for hypoglycemia
12. The decision to provide, withhold, or withdraw parenteral nutrition is ultimately the responsibility of the
attending physician
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

13. Home parenteral nutrition may be indicated for patients who are stable enough for discharge but
cannot receive sufficient energy and protein enterally or orally to meet their needs

Companion Documents
Adult/Pediatric Surgical Nutrition Support Team (SNST) - Developing, Ordering, and Monitoring a
Nutrition Support Plan
Concentrated Intravenous Electrolytes – Adult – Inpatient Clinical Practice Guideline

Scope
Disease/Condition(s): Initiation, advancement, and monitoring of parenteral nutrition as well as
supplementation for the adult population.

Clinical Specialty: This guideline may be used by any clinician

Intended Users: Physicians, Advanced Practice Providers, Pharmacists, Dieticians and Nurses.

Objective(s): The objective of this guideline is to standardize the use of parenteral nutrition
throughout the institution to improve patient outcomes and safety.

Target Population: Adult patients requiring parenteral nutrition .

Interventions and Practices Considered: Initiation, modification, and discontinuation
of parenteral nutrition in the adult population.

Major Outcomes Considered:
Successful management of patients receiving parenteral nutrition including:

Safe and effective infusion of parenteral nutrition, alleviation of signs and symptoms of malnutrition,
appropriate wound healing and monitoring, and limitation of complications of parenteral nutrition.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Methodology
Methods Used to Collect/Select the Evidence:
A review of PubMed database was conducted with combinations of the keywords: parenteral nutrition ,
intravenous fat emulsion, parenteral nutrition compatibility, electrolyte replacement, enteral nutrition,
insulin management, parenteral nutrition stability, or special populations. References from the articles
were also searched. Finally, the personal libraries of the authors were queried.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external organizations and/or
arrived at a consensus through discussion of the literature and expert experience. All recommendations
endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or
committees (as appropriate).

Methods Used to Assess the Quality and Strength of the Evidence:
Internally developed recommendations, or those adopted from external sources without an assigned
evidence grade, were evaluated by the guideline workgroup using a modified Grading of
Recommendations Assessment, Development and Evaluation (GRADE) methodology developed by the
American Heart Association and American College of Cardiology1 (see Appendix A ).

Rating Scheme for the Strength of the Evidence and
Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities:
Socioeconomic factors may affect parenteral nutrition provision. Home parenteral nutrition is an
expensive therapy that often requires insurance pre-certification prior to coverage. 2,3 Therefore,
socioeconomic status and insurance coverage may impact who can receive parenteral nutrition in the
home care setting. Additionally, one study reported a potential for racial or geographic disparities in the
provision and complication rates of parenteral nutrition in certain subsets of malnourished patients with
inflammatory bowel disease, although the mechanism of this difference was not determined. 3














Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Definitions
1. PN : Parenteral Nutrition, can be central or peripheral
2. Central Parenteral Nutrition is intravenous nutrition delivered into a large diameter vein, usually the
superior vena cava, adjacent to the right atrium. PN is formulated to meet 100% of estimated
nutrient needs.
3. Peripheral Parenteral Nutrition is intravenous nutrition infused through a peripheral vein. The
solution must be diluted to less than 900 mOsm/L to reduce risk for phlebitis.
4. Premixed Parenteral Nutrition: PN that comes from the manufacturer in standard concentrations of
amino acids, dextrose, with or without electrolytes
5. Customized Parenteral Nutrition: parenteral nutrition products that contain amino acids and
dextrose with or without fat emulsion along with electrolytes that are made for a specific patient,
based on their clinical status on a given day
6. Three- in-one (3- in-1) PN: a PN that contains amino acids, dextrose, and fat all in the same bag.
7. Two- in-one (2- in-1) PN: a PN that contains amino acids and dextrose in the same bag. Fat may be
Y-sited or not given at all.
8. IVFE: Intravenous Fat Emulsion is an oil- in-water emulsion of oils, egg yolk phospholipids, and
glycerol
9. EN: enteral nutrition is delivery of nutrients by tube into the stomach or small intestine.
10. Dosing Weight: a patient-specific weight determined by the prescriber upon which to dose the PN.
It may be the actual body weight, the ideal body weight, or an estimated dry body weight.
Introduction
The provision of parenteral nutrition includes an assessment of the patient’s weight, nutritional status, and
gastrointestinal function, as well as potential route of access for the delivery of nutrients. Protein,
dextrose, fat, as well as electrolytes, vitamins, and minerals are calculated based on the individual
patient’s parameters and are adjusted daily based on the patient’s laboratory values and clinical
condition. The patient’s gastrointestinal function and availability of enteral access is evaluated daily, and
the patient is transitioned to oral or enteral nutrition as soon as is feasible. If a patient’s gastrointestinal
function does not return, or the patient has a disease state or clinical condition in which oral/enteral
nutrition is contraindicated, then the patient may be transitioned to home PN.

Recommendations
1. The use of PN should only be considered if all attempts at enteral feeding are unsuccessful, if EN
is contraindicated due to a disease state or clinical condition, or if bowel function is not expected
to return within a time frame that is reasonable according to the patient’s state of nourishment 4 .
(UW Health Class I, Level C)

2. Indications
2.1 Lack of enteral access and/or inadequate enteral nutrition for at least: 5
2.1.1 7 – 10 days if well-nourished prior to admission (UW Health Class IIa, Level C)
2.1.2 3 – 5 days if malnourished prior to admission (UW Health Class IIa, Level C)
2.1.3 For critically ill patients, 7 days if well-nourished prior to admission, 6,7 and earlier
if malnourished prior to admission (UW Health Class IIb, Level B)
2.1.3.1 For critically ill patients in septic shock, recommend withholding PN
regardless of nutrition status (well-nourished or malnourished) 8 . (UW
Health Class I, Level B)
2.2 Gastrointestinal dysfunction: 5 (UW Health Class I level C)
2.2.1 Short-bowel syndrome or other documented malabsorption states
2.2.2 High-output enterocutaneous fistula (>500 mLs output per 24 hours)
2.2.3 Paralytic ileus
2.2.4 Bowel obstruction
2.2.5 Mesenteric ischemia
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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2.2.6 Gastrointestinal graft versus host disease or mucositis related to bone marrow
transplantation or chemotherapy
2.2.7 Chylothorax or chylous ascites
2.3 Peri-operative nutrition 9-13 (UW Health Class I, Level A)
2.3.1 Peri-operative PN should be given to moderately to severely malnourished
patients before gastrointestinal surgery (5-7 days before an operation and after
surgery until bowel function returns)

3. Nutritional Requirements
3.1 Total Calories
3.1.1 In order to determine nutritional requirements, assessment of the patient is essential.
An assessment includes determining the patient's energy reserves, somatic and
visceral protein mass, weight loss history, and degree of catabolism. Several methods
can be used to estimate th e patient’s energy and protein requirements. It should be
recognized that the values derived from these methods are estimates. 5 (UW Health
Class I, Level C)
3.1.2 Another criterion in determining energy needs is evaluation of the patient’s current
body mass index (BMI).
3.1.2.1 Undernutrition BMI < 18.5 kg/m 2
Normal weight BMI 18.5- 24.9 kg/m 2
Overweight BMI 25-29.9 kg/m 2
Obese BMI 30- 40 kg/m 2
Morbid obesity BMI > 40 14 kg/m 2

3.2.3 BMI values tend to increase with age; therefore, an older adult can be evaluated by a
different standard. A desirable BMI for the age group 55-65 years is 23-28 and over age 65
is 24-29. 15 (UW Health Class I, Level C)

3.2 Energy
3.2.1 Total Calories (kcals) Resting energy expenditure (REE) can be estimated by kcal/kg,
Indirect Calorimetry, or regression based formulas that are population specific but not
described here. 16,17 (UW Health Class IIa, Level C)
Table 1. General guidelines adult energy requirements for hospitalized patients
Patient Characteristics Energy Recommendations5
Normal/maintenance, BMI <30 25 kcal/kg
Normal/maintenance, BMI 30-39 22-25 kcal/kg IBW
Normal/maintenance, BMI > 40 25-30 kcal/kg IBW
Refeeding syndrome 20 kcal/kg
Young adult trauma
30 -35 kcal/kg

3.2.2 For general care (non-critically ill) patients with a BMI > 30 kg /m 2, use IBW to calculate
total energy needs. The IBW is calculated based on BMI of 24 or 26 kg/m 2, and
adjusted by age (Appendix B ). 15 (UW Health Class IIa, Level C)
3.2.3 Use indirect calorimetry (IC) to measure an estimate of energy expenditure. Possible
indications for use of IC include conditions that alter resting energy expenditure such
as multiple traumas, sepsis, burns, use of paralytic agents, and large or multiple open
wounds. Other indications include when estimated needs do not appear to meet the
patient’s needs as determined by their clinical condition or when malnutrition is
present with altered body composition such as underweight, obesity, amputations, or
edema.16,17 (UW Health Class I, Level C)
3.2.4 For critically ill patients with a BMI >30, if indirect calorimetry is unavailable or not
feasible (i.e., continuous renal replacement therapy, chest tubes, etc.), may use the
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Penn State University 2010 predictive equation, or the modified Penn State equation if
the patient is over the age of 60 years old. Evidence also supports feeding protein 2
to 2.5 g/kg of IBW and 25 to 30 kcal/kg of IBW in patients without severe renal disease
or hepatic dysfunction18 . (UW Health Class IIa, Level A)
3.2.5 For critically ill patients who are severely malnourished, consider using lower energy
goal (80% of estimated energy needs) with normal protein load (1.2 grams per kg) for
the first week of the intensive care unit stay 8 .
3.3 Protein (4kcal/g)
3.3.1 Include protein calories in the total daily energy requirement. 5 (UW Health Class I ,
level C).
3.3.2 Estimate protein requirements based on the clinical state of the patient. Some
individuals require large amounts while others do not tolerate normal amounts due to
renal and/or hepatic dysfunction (Table 2). 19 (UW Health Class I , Level C)
Table 2. Guidelines for protein requirements
Patient Characteristics Protein Recommendations
(IBW or dry weight) Comments
Maintenance 1 to 1.5 gm/kg 5
Stressed/repletion 1.2 to 2.0 gm/kg 3
Acute kidney injury 1 to 1.5 gm/kg 19
Renal failure, pre-dialysis 0.8 to 1.0 gm/kg 5 to keep BUN<100
Renal failure,
peritoneal/hemodialysis 1.2 to 1.5 gm/kg
5

Renal failure, CRRT 1.5 to 2.5 gm/kg 20
Compensated liver
disease 1.0 to 1.5 gm/kg
5

Acute hepatic
encephalopathy
(temporary)
0.8 to 1.0 gm/kg 5
Monitor BUN and ammonia
and increase protein once
BUN <100 and ammonia is
within normal limits
Obesity 2 to 2.5gm/kg 3

3.4 Dextrose (3.4 kg/cal/g) 5 (UW Health Class 1, Level C)
3.4.1 Begin dextrose content at 2 - 3 mg/kg/min (UW Health Class 1, Level C)
3.4.2 Advance by 0.5 - 1 mg/kg/min per day until at goal (UW Health Class 1, Level C)
3.4.3 Goal dextrose is 2.5 - 4 mg/kg/min (UW Health Class 1, Level C)
3.4.4 Maximal dextrose dose is 10 g/kg/day (not to exceed 7 mg/kg/minute)* may exceed 7
mg/kg/min only if there is close monitoring of the patient (i.e. weekly CMP, Mg Phos,
+/ - liver panel) (UW Health Class I, Level C)
3.5 Intravenous Fat Emulsion (IVFE) (10 kcal/g) 5
3.5.1 Avoid IVFE administration to patients with egg allergy as IVFE is an oil- in-water
emulsion of oils, egg yolk phospholipid and glycerol. (UW Health Class I, Level C)
3.5.2 Minimum fat requirement is 4% of total calories as linoleic acid (16:2), the most
common essential fatty acid (EFA). For most adult patients, the equivalent of 80 mL of
20% fat emulsion daily is sufficient to prevent EFA deficiency. 21-23 (UW Health Class I,
Level A)
3.5.3 Limit fat to less than 2.5g/kg/day, although less than or equal to 1g/kg/day are
sufficient to meet the needs of most patients.24 (UW Health Class 1, Level C)
3.5.4 Limit administration rate to less than 0.125 g/kg/h. 25 (UW Health Class I, Level C)
3.5.5 Adjust the amount of calories in the PN based if patients are concomitantly receiving
propofol or other medications that require lipid emulsions as a diluent. 22 Propofol is a
lipid-based sedative and provides 1.1 kcal/mL. 26 (UW Health Class IIa, Level C)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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3.5.6 If lipid emulsion is part of a 3- in-1 PN, it may be infused for up to 24 hours. 5,27 (UW
Health Class I, Level B)
3.5.7 If lipid emulsion is Y-sited with a 2- in-1 PN or infused in a separate lumen or line,
infuse for a maximum of 12 hours. 26 (UW Health Class I, Level B)
3.5.8 Altered IVFE requirements
3.5.8.1 If serum triglyceride level is greater than 400 mg/dL, IVFE should be held and
a repeat triglyceride level should be checked in 48 hours 1. (UW Health Class
1, Level C)
3.5.8.2 Levocarnitine may be added to the PN at a dose starting at 500 mg daily, up
to 10 to 20 mg/kg. 5 If, after 48 hours, the triglyceride level is <400mg/dL,
IVFE may be re-started at a lower dose or at a less frequent interval. The
levocarnitine may be continued after the IVFE is restarted. (UW Health Class
IIb, Level C)
3.6 Fluid5
3.6.1 Fluid requirements are altered in various clinical conditions. Design parenteral nutrition
regimens to provide adequate caloric and protein intake within fluid volume
administered. (UW Health Class I, Level C)
3.6.2 Maintenance fluid requirements for adults in general are 30-40 mL/kg of body weight.
(UW Health Class I, Level C)

3.7 Electrolytes
3.7.1 Prior to initiation of PN, replete intracellular electrolytes for a goal of potassium ≥ 3.8
mmol/L, magnesium ≥ 1.8 mg/dL, and phosphorus ≥ 3.0 mg/dL. (UW Health Class I,
Level C)
(See UWHC Guidelines for the Use of Concentrated Intravenous Electrolyte
Guidelines in Adults)

Table 3. Usual adult electrolyte requirements
Electrolyte Recommendations per 24 Hours5
Calcium 10 to 15 mEq/day
Magnesium
8 to 20 mEq/day
Potassium 1 to 2 mEq/kg
Sodium 1 to 2 mEq/kg
Chloride as needed to maintain acid-base balance
Acetate as needed to maintain acid-base balance
Phosphorus 20 to 40 mmol/day

3.7.2 Altered Electrolyte requirements
3.7.2.1 Altered electrolyte requirements may be seen in hepatic or renal disease or
congestive heart failure.28 (UW Health Class I, Level C)
3.7.2.2 Patients with large nasogastric fluid losses, high ileostomy or pancreatic
fistula outputs, small bowel losses, losses associated with diarrhea, or graft-
versus host disease of the gut often require substantial quantities of sodium
per day. (UW Health Class I, Level C)
3.7.2.3 Patients with refeeding syndrome are at risk of fluid and electrolyte
abnormalities, including severe hypokalemia, hypomagnesemia,
hypophosphatemia, and volume overload.25,29-33 (UW Health Class I, Level B)

3.8 Vitamins
3.8.1 Routinely provide vitamins as generic adult multivitamin concentrate 10 mL daily to
prevent vitamin deficiencies. 34 (UW Health Class I, Level C)
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Table 4. Vitamin daily requirements and vitamin content of multivitamin concentrate
Vitamin
Adult DRI*
>19 years old
Adult FDA
Parenteral
Requirements
Infuvite
10 mL***
Male Female**
Vitamin A, IU
3000 2330 3300 3300
Vitamin D, mcg 5-15 5-15 5 5
Vitamin E, mg 15 15 10 10
Thiamine, mg 1.2 1.1 6 6
Riboflavin, mg 1.3 1.1 3.6 3.6
Pyridoxine, mg 1.3 -1.7 1.3 -1.5 6 6
Niacin, mg 16 14 40 40
Pantothenate, mg 5 5 15 15
Biotin, mcg
30 30 60 60
Folic Acid, mcg
400 400 600 600
Cyanocobalamin, mcg 2.4 2.4 5 5
Vitamin K, mcg 120 90 150 150
Ascorbic Acid, mg
90 75 200 200
* DRI = Dietary Reference Intakes for oral/enteral diets
** most requirements are increased for pregnant and lactating women
*** multivitamin content varies based on manufacturer
3.8.2 Altered vitamin requirements
3.8.2.1 Dialysis: provide additional folic acid 1 mg, pyridoxine 50 mg and thiamine 100
mg for patients on hemodialysis or CRRT. 28,35 (UW Health Class I, Level C)
3.8.2.2 Alcoholism: provide thiamine 50 to 250 mg for 3 days. 36 (UW Health Class I,
Level C)
3.8.2.3 Refeeding syndrome: give additional thiamine 100 mg for 3 days to patients at
risk for refeeding syndrome. 36 (UW Health Class IIb, Level C)
3.8.2.4 Macrocytic anemia with high methylmalonic acid levels: give cyanocobalamin
100 mcg daily for 10 days 37 (UW Health Class I, Level C)
3.8.2.5 Documented scurvy and/ or patients with non-healing wounds: give ascorbic
acid 50 mg daily for 7 to 10 days 37 (UW Health Class I, Level C)
3.8.2.6 Coagulopathy: consider giving phytonadione 1 mg daily 37 (UW Health Class I,
Level C)
3.9 Trace elements 2
3.9.1 Routinely add trace elements as standard trace element solution to prevent depletion
of trace elements.
3.9.2 Iron is not included in the standard trace element solution. If a patient requires long-
term PN (greater than 3 months), monitoring and replacement of iron stores is
necessary. Iron sucrose is the best intravenous choice for iron replacement. 37 (UW
Health Class I, Level C)
3.9.3 Altered trace element requirements
3.9.3.1 Zinc requirements may be increased in patients with severe diarrhea and
enterocutaneous fistula: zinc losses are 12 mg/L of output. 38 (UW Health
Class II, Level C)
3.9.3.2 Patients with large open burn wounds and /or high output pancreatic fistulae
may require increased amounts of zinc, copper, and selenium due loss of
these vitamins through wound exudates 39 (UW Health Class II, Level A)
3.9.3.3 Administer only zinc, chromium and selenium to patients with cholestatic liver
disease with direct bilirubin > 5 mg/dL or a total bilirubin > 10 mg/dL. Impaired
biliary excretion decreases elimination of copper and manganese. 19 (UW
Health Class I, Level C)
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Table 5. Recommendations for trace element requirements
Trace element Daily IV Intake Recommended 34
Multitrace-5
(American Regent)*
Solution 3 mL
Chromium 10 to 15 mcg 12 mcg
Copper 0.3 to 0.5 mg 1.2 mg
Manganese 0.06 to 0.1 mg 0.3 mg
Selenium 20 to 60 mcg 60 mcg
Zinc 2.5 to 5 mg 3 mg
* content of trace element product varies by manufacturer


4. Insulin (inpatient)
4.2 Add regular human insulin to keep blood glucose between 100 to 180 mg/dL. Consider
adding regular human insulin to PNs in patients who are hyperglycemic or at risk of
hyperglycemia. Patients who are at risk of hyperglycemia are patients with a history of
diabetes Type 1 or 2, patients on high doses of steroids, patients requiring vasopressor
support, and patients with infection.5,40 -42 (UW Health Class I, Level A)
4.3 Minimize risk for PN-associated hyperglycemia 43
4.3.1 Recommend ≤ 2 mg/kg/min of dextrose on day 1 of PN (this meets obligate glucose
needs). (UW Health Class I, Level C)
4.3.2 Day 1 of PN should start at 25 mL/hour and advance by 25 mL/hour to goal rate only if
glucose is < 180 mg/dL. (UW Health Class I, Level C)
4.3.3 Add human regular insulin to the PN formulation to keep blood glucose concentrations
less than 180 mg/dL. A common initial regimen is 0.1 units of insulin per gram of
dextrose in the PN infusion. (UW Health Class I, Level C)
4.3.4 If the patient is already hyperglycemic (> 180 mg/dL), use 0.15 units of insulin per
gram of dextrose (UW Health Class I, Level C)
4.3.5 If the blood glucose is > 200 mg/dL, PN should not be initiated until glycemic control is
improved (< 200 mg/dL). The physician from the primary team should be contacted
and if agreed upon, an insulin drip should be started via the insulin infusion order set
listed below in 4.5. (UW Health Class I, Level C)
4.3.6 Obese patients with type 2 diabetes may require as much as 0.1 units of insulin for
every 0.5 grams of dextrose. (UW Health Class I, Level C)
4.3.7 Lean patients with type 1 diabetes may require only 0.1 units of insulin per 2 grams of
dextrose. (UW Health Class I, Level C)
4.3.8 Coordinate with the primary service or Diabetes Management Service to ensure all
patients with Type 1 diabetes have subcutaneous basal insulin ordered to avoid
diabetic ketoacidosis in the context of PN discontinuation. (UW Health Class I, Level
C)
4.3.9 In general, do not increase the dextrose content of the PN until glucose
concentrations during the previous 24-hour period are consistently < 200 mg/dL. (UW
Health Class I, Level C)
4.3.10 Modify the insulin dosage in the PN formulation daily based on the amount of insulin
given with supplemental insulin coverage over the previous 24 hours. (UW Health
Class I, Level C)
4.3.11 If hyperglycemia persists when 0.3 units of insulin per gram of PN dextrose is
exceeded OR the patient is critically ill, initiate a separate insulin infusion to achieve
more appropriate glycemic control. (UW Health Class I, Level C)
4.3.12 The maximum recommended insulin in the PN solution is 100 units/L. (UW Health
Class I, Level C)
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4.3.13 Patients with impaired renal function can have lower insulin requirements since insulin
is renally eliminated. (UW Health Class I, Level C)
4.3.14 Approximately 5-10 units of insulin may adhere to the plastic PN bag.
4.3.15 If insulin is added to the PN, then order correctional insulin per the IP-Diabetes
Management Without Pump-Adult-Supplemental order set.
4.4 Subcutaneous Insulin Administration - See Diabetes Nursing Practice Guideline for further
information
4.5 Intravenous insulin infusion
4.5.1 Wisconsin Insulin Infusion Standard Dose-Adult-Practice Protocol
4.5.2 Wisconsin insulin Infusion HIGH Dose-Adult-Practice Protocol (ICU only )
4.5.3 IP - Insulin Infusion – Adult - Supplemental
4.6 Hypoglycemia - Adult Hypoglycemia Treatment Algorithm

5. Route of Administration
5.2 In adult patients, percutaneous catheters advanced into the subclavian vein are preferred to a
jugular or a femoral site to minimize the risk of infection with non-tunneled central venous
catheters.28 (UW Health Class I, Level B)
5.3 For long term home parenteral nutrition, tunneled line, PICCs and ports are acceptable. 44 -46
(UW Health Class I, Level B)
5.4 Peripheral Parenteral Nutrition (PPN) 27
5.4.1 Contraindications include (UW Health Class IIa Level C):
5.4.1.1 Fluid restricted patients
5.4.1.2 Hypermetabolic patients whose daily caloric needs exceed 2500-3000 calories
5.4.1.3 Patients with limited venous access
5.4.1.4 Patients in the home setting
5.4.2 Maintain total mOsm/L of PPN less than 900 mOsm/L (UW Health Class IIa Level C)
(see Appendix C to estimate PPN osmolarity.)
5.4.3 Administer IVFE as a 20% solution at a rate of 0.15 to 0.2 mL/kg/h (approximately 30 -
50% of kcal) as a separate infusion to dilute osmolarity and protect the vein by coating
the venous epithelium. Hang each bottle for ≤ 12 hours. (UW Health Class IIa Level C)
5.4.4 To decrease thrombophlebitis, , a major complication of solutions with osmolarities over
800 mOsm/L, may add hydrocortisone 10 mg and heparin 1 unit/mL . 47
5.4.5 Change infusion sites every 72 - 96 hours (unless midline placement) and monitor
frequently for signs of inflammation. (UW Health Class IIa Level C)
5.5 Insertion and care of the catheter should reflect the current hospital policy 2.3.14 Insertion,
Maintenance, and Discontinuation of Central Vascular Access Devices for Prevention of
Central Vascular Access Devices for Prevention of Central Line-Associated Bloodstream
Infection (CLABSI) and the nursing policy 1.56 Central Vascular Access Device Use,
Maintenance, and Removal (Adult & Pediatric) nursing

6. Administration Safe Practices 27
6.1 Administration sets (tubing) should be changed with every new unit. 2,26 (UW Health Class
IIb, Level C)
6.1.1 For a 3- in-1 PN, tubing should be changed every 24 hours when a new container of
PN is hung.
6.1.2 For a 2-in-1 PN, with IVFE Y-sited, the tubing for the IVFE should be changed every
12 hours when a new unit of IVFE is hung, and the entire administration set should be
changed every 24 hours when the new unit of 2- in-1 PN is hung.
6.1.3 For a 2-in-1 PN, with or without IVFE, the tubing should be changed every 24 hours
when a new container of PN is hung.
6.2 Infusion time.
6.2.1 PNs should be infused within 24 hours of initiating the infusion (UW Health Class I,
Level C)
6.3 A 3- in-1 PN may infuse for 24 hours, as the higher osmolarity and lower pH of a 3- in-1 PN
inhibits microbial growth.
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6.3.1 IVFE should be infused no longer than 12 hours after initiating the infusion. (UW
Health Class IIa, Level B)
6.4 Filter requirements 2, 26 (UW Health Class IIb, Level C)
6.4.1 Filters are used to prevent infusion of compounding particles (rubber stopper pieces),
precipitates, air, and large lipid emulsion globules that may lead to problems such as
pulmonary embolism. The filters (1.2 micron) may also reduce (but not eliminate) the
inoculum of micro-organisms such as bacteria or fungi and the infusion of pyrogens.
6.4.2 Use a 1.2 micron filter for the following PNs (UW Health Class IIb, Level C):
6.4.2.1 A 3- in-1 PN
6.4.2.2 A 2- in-1 PN when the lipids are Y-sited. The filter should be placed below the
Y-site and as close to the patient as possible.
6.4.3 Use a 0.22 micron filter for a 2-in-1 PN when no IVFE is used. This filters out smaller
particulates, including micro-organisms. (UW Health Class IIb, Level C) . Change filters
with every new unit hung.
6.4.3.1 For a 3- in-1 PN, filters should be changed every 24 hours when a new
container of PN is hung
6.4.3.2 For a 2- in-1 PN with IVFE Y-sited, filters should be changed every 12 hours
when the tubing is changed with the lVFE.
6.4.3.3 For a 2- in-1 PN with no IVFE, filters should be changed every 24 hours when
a new container of PN is hung.
6.4.4 Clogged filters should be replaced.
6.5 If possible, minimize the risk of infection, by not using the PN line for multiple purposes (e.g.,
blood draws, medication administration, hemodynamic monitoring). (UW Health Class IIb,
Level C)
6.6 Compatibility – see Appendix D for compatibility table.

7. Physical Traits and Limitations of Parenteral Nutrition 27
7.1 Stability of 3- in-1 PNs
7.1.1 In order to keep the lipid emulsion stable in a 3- in-1 PN, the macronutrients should be
in the following percentages: amino acids, dextrose, and IVFE greater than or equal
to 4%, dextrose 10%, and 2% of total volume. 48 (UW Health Class I, Level B)
7.1.2 To maintain the lipid emulsion stable in a 3- in-1 PN, the total divalent and trivalent
cation content (predominately magnesium and calcium) should be kept less than 20
mEq per liter 48 . (UW Health Class I, Level B)
7.2 Medications in or Y-sited with PNs
7.2.1 Medications should only be added or Y-sited with PN if they are deemed compatible
by a reputable source at the dose and concentration described in that source 49 (UW
Health Class I, Level B)
7.2.2 Levocarnitine may be added to PN with lipids at a dose of 200 mg/liter for 24 hours
at room temperature or for 30 days at refrigeration 48 . Levocarnitine may be added to
PN without lipids at a dose of 420mg/L at room temperature for 24 hours. At UW
Hospital, levocarnitine is only added to 2-in-1 PNs. Doses are added in increments
of 500mg up to a maximum of 1000mg due to vial size availability. (UW Health
Class I, Level C),
7.3 Limitations (UW Health Class I, Level C)
7.3.1 Depending on pH, temperature, and additives to a PN, there is a limit to the amount
of calcium and phosphate that can be added to the PN. The Sterile Products Area
(IV) pharmacist will alert the prescriber as to this limit. The potential consequences
of exceeding this limit include calcium-phosphate infusion resulting in loss of IV
access, soft tissue deposition, pulmonary embolus, and death.
7.3.2 For safety, the limit for sodium in the PN is 154 mEq/liter, which is the equivalent of
0.9% sodium chloride.
7.3.3 The limit for potassium infusion rate for adults in the hospitalized patient (due to
frequent monitoring) is 20 mEq/hour unless the patient is on telemetry. The limit for
potassium infusion in the adult home PN patient should be limited to 10 mEq per hour
with rare exception.
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8. Monitoring2 (UW Health Class I, Level C)
8.1 Baseline assessment – Obtain the following prior to PN initiation, if possible:
8.1.1 Anthropometrics
8.1.1.1 Height
8.1.1.2 Weight – obtain weight closes to usual weight, which may be admission
weight, or weight before fluid resuscitation
8.1.1.3 Body mass index (BMI)
8.1.1.4 History of recent weight loss or weight gain
8.1.1.5 Date and time of NPO status
8.1.2 Blood chemistries
8.1.2.1 Electrolytes (sodium, potassium, chloride, bicarbonate), BUN, creatinine,
glucose, alanine aminotransferase (ALT), aspartate aminotransferase (AST),
alkaline phosphatase, total bilirubin
8.1.2.2 Magnesium
8.1.2.3 Phosphate
8.1.2.4 Triglyceride
8.1.2.5 C-reactive protein
8.1.2.6 Albumin if third party payor requires it
8.2 Clinical Monitoring
8.2.1 In most patients, the following should be checked for the first four days of PN:
8.2.1.1 Electrolytes (sodium, potassium, chloride, bicarbonate), BUN, creatinine
8.2.1.2 Magnesium
8.2.1.3 Phosphate
8.2.2 Point- of-care (capillary) glucoses every six hours for the first 48 hours of PN
administration should be checked on all patients and then discontinued if glucose is
controlled without insulin administration
8.2.3 The following should be considered at least once weekly for patients who continue
PN for more than 5 days while hospitalized:
8.2.3.1 Electrolytes (sodium, potassium, chloride, bicarbonate), glucose, BUN,
creatinine, calcium, total bilirubin, AST, ALT, alkaline phosphatase
8.2.3.2 Magnesium
8.2.3.3 Phosphate
8.2.3.4 Triglyceride (if receiving IVFE)
8.2.3.5 Pre-albumin
8.2.3.6 C-reactive protein
8.2.3.7 For patients receiving PN for one month with no oral or enteral intake, obtain
carnitine level. If carnitine levels are low, then add levocarnitine to the PN (10
to 20 mg/kg) and recheck carnitine level in 3 months 50. (UW Health Class IIb,
Level C)
8.2.4 Long-term monitoring parameters (for ambulatory patients)
8.2.4.1 Weekly CBC with differential, electrolytes (sodium, potassium, chloride,
bicarbonate), BUN, creatinine, glucose, magnesium, phosphate, C-reactive
protein, and pre-albumin
8.2.4.2 Monthly triglyceride, alanine aminotransferase (ALT), aspartate
aminotransferase (AST), alkaline phosphatase, and total bilirubin levels
8.2.4.3 For patients who are NPO and who are receiving PN for one month and who
will continue PN, obtain a carnitine level. (UW Health Class IIb, Level C)
8.2.4.4 For patients receiving PN for greater than 3 months, consider obtaining the
following quarterly to semi-annually, depending on clinical condition and ability
to take oral or enteral nutrition
8.2.4.4.1 Carnitine
8.2.4.4.2 Vitamins A, D (specifically 25-hydroxy), and E
8.2.4.4.3 Trace elements: zinc, selenium, copper, chromium, manganese
8.2.4.4.4 If MCV drops below normal limits, obtain an iron level. If further
testing is needed (iron, total iron binding capacity or TIBC,
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percentage saturation, transferrin, ferritin), order these remaining
tests sparingly based on Medicare guidelines
8.2.4.4.5 If MCV is high, obtain a methylmalonic acid level and RBC-folate
level
8.2.4.4.6 Vitamin B6
8.2.4.4.7 Essential fatty acid profile (to evaluate triene:tetraene ratio)


9. Cyclic (Intermittent) Parenteral Nutrition
9.1 Indications/Rationale for cyclic PN include:
9.1.1 Administration of multiple blood products, antibiotics, or antifungals(e.g., amphotericin
B, vancomycin, and others incompatible with PN), or antimicrobial locks (UW Health
Class I, Level C)
9.1.2 Freedom of movement during the day for physical activity, work or school, particularly
with home parenteral nutrition (HPN) (UW Health Class IIa, Level C)
9.1.3 Avoidance of hepatic steatosis secondary to continuous dextrose exposure thereby
decreasing risk of liver complications. 51,52 (UW Health Class I, Level B)
9.1.4 The transition patients from parenteral to oral nutrition
9.2 Avoid cyclic PN in patients with compromised renal/cardiovascular function, unstable fluid
status, and poor glucose control. (UW Health Class III, Level C)
9.3 Transition to a cyclic PN by gradually decreasing the duration of infusion over 2-3 days to
assess tolerance to the glucose and volume load of the faster infusion rate. (UW Heal th
Class I, Level C)
9.4 Monitor Point of Care glucoses 2 to 3 hours after the PN starts (to monitor for
hyperglycemia) and 30 minutes after PN stops (to monitor for rebound hypoglycemia).
(UW Health Class I, Level C)

10. Transitioning to enteral requirements
10.1 Tube Feedings: Decrease PN rate gradually and/or PN macronutrients and/or other
contents as needed as tube feeding volume and concentrations are advanced (usually in
20 to 25 mL/hour increments). Discontinue PN when tube feeding intake is greater than or
equal to 60% of estimated energy needs 8 (UW Health Class I, Level C)
10.2 Oral Feedings: Keep daily calorie counts of oral intake and adjust PN rate according to
intake. Discontinue PN when oral intake approximates 50% of estimated energy needs and
is well tolerated. (UW Health Class 1, Level C)

11. Discontinuation of Inpatient PN (UW Health Class I, Level C)
11.1 Avoid abruptly stopping PN which can result in hypoglycemia 2 (UW Health Class I, Level
C)
11.2 If a patient is not receiving continuous enteral feedings, the PN rate should be reduced by
50% every 1 to 2 hours until the rate is less than or equal to 25 mL/hr ( UW Health Class I,
Level C)
11.3 Stop PN when the PN rate is less than or equal to 25 mL/hr ( UW Health Class I, Level C)
11.4 Monitor a point of care (POC) glucose 30 to 60 minutes after the PN is stopped to ensure
the patient is not hypoglycemic. (UW Health Class I, Level C)

12. Parenteral Nutrition in End- of-Life Situations (UW Health Class 1, Level C)
12.1 The decision to provide, withhold, or withdraw parenteral nutrition is ultimately the
responsibility of the attending physician 8 .
12.2 For terminally ill patients, parenteral nutrition and associated intravenous fluid may not
improve quality of life, and in some instances may cause decreased quality of life (e.g.,
increased secretions, increased need for the bathroom, or increased need for suctioning) 8 .
12.3 Family wishes, cultural, or religious beliefs of the patient may override evidenced-based
medicine in this case, necessitating delivery of PN despite futility of care 8 .

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

13. Home Parenteral Nutrition
13.1 Home PN may be indicated for patients who are stable enough for discharge but cannot
receive sufficient energy and protein enterally or orally to meet their needs. (UW Health
Class I, Level C)
13.2 Patients should be medically stable on the current PN. (UW Health Class I, Level C)
13.3 Care should be coordinated through a home care company and insurance coverage
verified. (UW Health Class I, Level C)
13.4 Caregivers and the patient should be adequately educated on sterile technique and
infusion pump use. (UW Health Class I, Level C)
13.5 A physician should be responsible for the patient’s PN prescription, monitoring, and follow-
up and this should be arranged prior to discharge. The physician may delegate
prescription privileges. However, the physician is ultimately responsible for the patient and
should see the patient in clinic at a minimum once a year. Formulas should, for the
majority of patients, be individualized, and should provide sufficient calories and protein,
along with any enteral or oral intake, to meet their needs. (UW Health Class I, Level C)
13.6 Monitoring
13.6.1 Initially, lab monitoring usually occurs on a weekly basis. However, depending on
the stability of the patient and other clinical parameters, it is acceptable for
monitoring to occur less frequently. (UW Health Class I, Level C)
13.7 Blood glucose and insulin
13.7.1 With home parenteral nutrition, blood glucose less than 200 mg/dL is acceptable.
(UW Health Class I, Level C)
13.7.2 Insulin is added by the patient in the home, so it may be adjusted on a daily basis, if
needed. (UW Health Class I, Level C)
13.7.3 Insulin should be adjusted conservatively in the home patient. (e.g., by 5 units or
less at a time.) (UW Health Class I, Level C)
13.8 For ease of patient use, in the home, a 1.2 micron filter is used to filter all types of PN: 3- in-
1 and 2-in-1 PN. (UW Health Class I, Level C)
13.9 See Appendix E for more detailed information about discharge planning, outpatient care,
patient monitoring, insurance aspects, and patient expectations .
















UW Health Implementation
Potential Benefits:
Benefits of implementation include patient safety when advancing macronutrients; uniform, appropriate
patient monitoring which conforms to national standards; and more optimal, clinically indicated delivery of
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macronutrients (protein, dextrose, fat), fluid, electrolytes, specific amino acids, vitamins, and trace
elements.

Potential Harms:
Harms of implementation are few but include the possibility that patients may not have appropriate
assessment or ongoing evaluation.

Qualifying Statements
Few randomized controlled trials are available for parenteral nutrition. Recommendations may change as
more clinical trials are published.

Pertinent UW Health Policies & Procedures
Adult/Pediatric Surgical Nutrition Support Team (SNST) - Developing, Ordering, and Monitoring a
Nutrition Support Plan
Concentrated Intravenous Electrolytes – Adult – Inpatient Clinical Practice Guideline
Wisconsin Insulin Infusion Standard Dose-Adult-Practice Protocol
Wisconsin insulin Infusion HIGH Dose-Adult-Practice Protocol (ICU only)
IP - Insulin Infusion – Adult - Supplemental
Adult Hypoglycemia Treatment Algorithm
Insertion, Maintenance, and Discontinuation of Central Vascular Access Devices for Prevention of Central
Line-Associated Bloodstream Infection
Standard of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice Guideline
Diabetes Nursing Practice Guideline
1.56 Central Vascular Access Device Use, Maintenance, and Removal (Adult & Pediatric)


Implementation Plan/Tools
1. The guidelines will be presented at pharmacy team meetings and posted on U-Connect. The
guideline writers will be available to present to other practitioners as requested.
2. A competency for practitioners will be developed and made available to physicians, pharmacists,
dietitians, nurses and other allied health professionals and will be available on U-Connect via the
Training and Education Gateway.
3. The guidelines will be presented to every unit to nursing staff for both morning and evening shifts.
The competency will be made available for overnight nursing staff.
4. Orders for PN and IVFE will reflect and support the guideline recommendations.
5. The SNST will ask for direct feedback as to ease and usefulness of the guidelines.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Appendix A. Evidence Grading Scheme(s)

Figure 1. AHA/ACC Grading Scheme

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19

Appendix B. Ideal Body Weight Estimates15,53

Height (inches)
IBW (kg) for
BMI 24 kg/m2
(normalized)
IBW (kg) for
BMI 26 kg/m2
(normalized)
58 52 56.5
59 54 58.5
60 55.8 60.5
61 57.7 62.6
62 59.6 64.6
63 61.5 66.7
64 63.6 68.6
65 65.6 71
66 67.6 73
67 69.7 75
68 71.8 77.7
69 73.9 80
70 76 82.4
71 78.2 84.7
72 80.4 87
73 82.7 89.6
74 85 92
75 87.3 94.5
76 89.6 97


Determining TPN dosing weight (kg) for patients with BMI ≥ 30 kg/m2
Use IBW normalized to BMI 26 if age ≥ 65 years old
Use IBW normalized to BMI 24 if < 65 years old













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20
Appendix C. Calculating Osmolarity of Peripheral Parenteral Nutrition

Maintain total mOsm/L of PPN less than 900 mOsm/L
I Dextrose grams/L x 5 = mOsm/L
II Protein grams/L x 10 = mOsm/L
Convert mOsm/L of electrolytes in PN to mOsm/L





































Electrolyte mEq/mL mOsm/mL
NaCl 4 8
Na Acetate 2 4
KCl 2 4
K Acetate 2 4
Na Phos
Na
Phos
4
3 mmol
7
K Phos
K
Phos
4.3
3 mmol
7.4
Ca 0.465 0.68
Mg 4 4.06
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21
Appendix D. Compatibility
Ideally medications should not be administered with PN, but many patients receive multiple intravenous
medications with limited IV access. Multiple resources evaluate compatibility with PN; however, at times
recommendations conflict and are not always reproducible. 54-57 Some studies evaluate physical
compatibility only, while others evaluate both physical and chemical compatibility. If a medication is
injected concomitantly with a PN through a Y-site, the time of admixture does not allow for substantial
chemical degradation.55 Furthermore, clinically significant chemical degradation reactions seldom occur in
4 hours or less. Unlike chemical incompatibilities, physical or visual incompatibility is identified by
precipitants or change in emulsion. The precipitants can be life- threatening and not always identifiable
due to their small size or translucency or may be obscured by fat emulsion. Compatibility data is not
available for all medications; however, lack of data does not confer compatibility.

Key
C - Compatible
I - incompatible
— Compatibility data not available
C/I - conflicting data with strength of evidence supporting compatibility
I/C - conflicting data with strength of evidence supporting incompatibility
D5W - dextrose 5%
NS - sodium chloride 0.9%

Compatibility Chart 49,55,58,59
Medication Admixture type
2-in-1 lipids 3-in-1
Acetazolamide I — —
Acyclovir sodium 7 mg/mL D5W I I I
Albumin I I I
Aldesleukin C C —
Alprostadil (10 & 20 mcg/mL) C C/I —
Amikacin sulfate 5 mg/mL D5W C C/I C/I
Aminophylline 2.5 mg/mL D5W C/I C C
Amphotericin B 0.6 mg/mL D5W I I I
Ampicillin sodium 20 mg/mL NS C/I C C
Ampicillin/Sulbactam 20/10 mg NS C C C
Argatroban C — —
Ascorbic acid C — —
Atracurium besylate C — —
Aztreonam 40 mg/mL D5W C C C
Bumetanide 0.04 mg/mL D5W C C C
Buprenorphine 0.04 mg/mL D5W C C C
Butorphanol 0.04 mg/mL D5W C C C
Calcium Chloride C C C
Calcium Gluconate 40 mg/mL (0.19 mEq/mL) D5W C — C
Caffeine citrate C — —
Carboplatin 5 mg/mL D5W C C C
Cefazolin 20 mg/mL D5W I C C
Cefepime C C C
Cefotaxime 20 mg/mL C C C
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22
Medication Admixture type
2-in-1 lipids 3-in-1
Cefoxitin 20 mg/mL D5W C C C
Ceftazidime 40 mg/mL C C C
Ceftriaxone 20 mg/mL D5W C/I C C
Cefuroxime 30 mg/mL D5W C C C
Chloramphenicol C C —
Chlorpromazine 2 mg/mL D5W C C C
Ciprofloxacin 1 mg/mL D5W I C C
Cisplatin 1 mg/mL undiluted I C I
Clindamycin 10 mg/mL D5W C C C
Cyclophosphamide 10 mg/mL D5W C C C
Cyclosporine 5 mg/mL D5W I C/I I
Cytarabine 50 mg/mL undiluted C C I
Dexamethasone 1 mg/mL D5W C C C
Diazepam C — —
Digoxin 0.25 mg/mL undiluted C C C
Diphenhydramine 2 mg/mL D5W
Diphenhydramine 50 mg/mL undiluted
C

C

C
C
Dobutamine 4 mg/mL D5W C C C
Dopamine 3200 mcg/mL D5W C C/I I
Doxorubicin 2 mg/mL undiluted C — C
Doxycycline 1 mg/mL D5W C I I
Droperidol 0.4 mg/mL D5W C I I
Enalaprilat 0.1 mg/mL D5W C C C
Epinephrine C — —
Epoetin alfa C — —
Ertapenem — — —
Erythromycin C C C
Fentanyl 12.5 mcg/mL D5W
Fentanyl 50 mcg/mL undiluted
C
C
C

C

Fluconazole 2 mg/mL undiluted C C C
Fluorouracil 16 mg/mL I C/I I
Folic acid C — —
Foscarnet C — —
Fosphenytoin 50 mg PE/mL C — —
Furosemide 3 mg/mL D5W I C C
Ganciclovir 20 mg/mL D5W I I I
Gentamicin 5 mg/mL D5W C C C
Haloperidol 0.2 mg/mL D5W C I C
Heparin 100 Units/mL undiluted C I I
Hydrocortisone 1 mg/mL D5W C C C
Hydromorphone 0.5 mg/mL D5W C I/C I
Hydroxyzine 2 mg/mL D5W C C C
Ifosfamide 25 mg/mL D5W C — C
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23
Medication Admixture type
2-in-1 lipids 3-in-1
Imipenem-Cilastatin 10 mg/mL NS C C C
Immune Globulin — — —
Insulin, regular human 1 units/mL D5W C C C
Iron dextran C/I — I/C
Isoproterenol C C C
Leucovorin 2 mg/mL D5W C C C
Lidocaine C C C
Linezolid C — —
Lorazepam 0.1 mg/mL D5W C I I
Magnesium sulfate 100 mg/mL (0.81 mEq/mL) D5W C C C
Mannitol 15% undiluted (150 mg/mL) C C C
Meperidine 4 mg/mL D5W C C C
Meropenem 20 mg/mL D5W — C C
Mesna 10 mg/mL D5W C C C
Methotrexate 15 mg/mL D5W I C C
Methylprednisolone 5 mg/mL D5W C C C
Metoclopramide 5 mg/mL D5W I C C
Metronidazole undiluted C C C
Midazolam 2 mg/mL I I I
Milrinone C — —
Mitoxantrone 0.5 mg/mL D5W I C C
Morphine 1 mg/mL D5W
Morphine 15 mg/mL undiluted
C
— C/I
C
I
Nafcillin 20 mg/mL D5W C — C
Nalbuphine 10 mg/mL undiluted C I C
Nitroglycerin 400 mcg/mL D5W C C C
Nitroprusside 400 mcg/mL D5W C C C
Norepinephrine16 mcg/mL D5W C C C
Octreotide 10 mcg/mL D5W C C C
Ondansetron 1 mg/mL D5W C I I
Oxacillin C C C
Paclitaxel 1.2 mg/mL D5W C C C
Penicillin G potassium C C C
Penicillin G sodium C — —
Pentobarbital 5 mg/mL D5W C I I
Phenobarbital 5 mg/mL D5W C I I
Phenytoin I I —
Phosphate potassium 3 mmol/mL undiluted I I I
Phosphate sodium 3 mmol/mL undiluted I I I
Phytonadione C C —
Piperacillin/Tazobactam 40/5 mg/mL D5W C C C
Potassium chloride 0.1 mEq/mL D5W C C C
Prochlorperazine 0.5 mg/mL D5W C C C
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24
Medication Admixture type
2-in-1 lipids 3-in-1
Promethazine 2 mg/mL D5W I C C
Propofol 10 mg/mL undiluted C — —
Ranitidine 2 mg/mL D5W C C C
Sodium bicarbonate 1 mEq/mL undiluted I I I
Tacrolimus 1 mg/mL D5W C C C
Ticarcillin/Clavulanate 30/0.1 mg/mL D5W C — C
Tobramycin 5 mg/mL D5W C — C
Trimethoprim -Sulfamethoxazole 0.8/4 mg/mL D5W C C C
Vancomycin 10 mg/mL D5W C C C
Vecuronium C — —
Zidovudine 4 mg/mL D5W C C C

































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Appendix E. Home Parenteral Nutrition 60 -64
Parenteral nutrition can be provided in the home setting for patients requiring PN beyond their hospital
stay who are medically and metabolically stable. Patients also need to be able to care for themselves or
have a willing, capable caregiver in the home. Home PN is provided through collaboration of healthcare
personnel within and outside the hospital including a home infusion pharmacy, a home health agency and
the prescribing team to provide safe care for a patient. It is essential that care plan elements are in place
prior to discharging a patient home.

1. Home PN referral: Discharge planning for home PN begins when the team identifies the patient
as requiring PN beyond their hospital stay. For patients who are currently inpatient at UWHC, a
referral for home PN is initiated by the social worker or case manager. Chartwell Midwest
Wisconsin is the UWHC affiliated home infusion pharmacy; however, patients are provided all of
their options for in network home infusion pharmacies who participate with their insurer.
Ultimately, the SNST will work closely with the home infusion pharmacy to coordinate the
transition of PN therapy from hospital to home and ensure appropriate clinical information and
orders (formula, lab schedule, ancillary orders) have been provided. In developing the home PN
care plan, elements to consider may include immediate and long term nutritional goals,
anticipated duration of therapy, and target weight or growth. Once the PN formula is stable,
cycling goals have been met, the patients and/or caregiver have received adequate training, the
outpatient care team has been confirmed, and the home infusion pharmacy is established, the
patient can be safely discharged.
2. Outpatient accountable team managing patient: It is essential that an agreement has been
reached with a physician to order and monitor PN in the outpatient setting prior to the patient
being discharged from UWHC. As PN is a complex therapy, a knowledgeable multidisciplinary
clinical team is needed to successfully minimize and manage the associated potential
complications (metabolic, infectious, mechanical). For patients with the agreeable ordering
physician in the UW Health system, the patient may have care coordinated for co-management
under UWHC delegation protocol by a member of the UW SNST, PNST or Chartwell pharmacist
team. This aspect of the care plan additionally requires confirmation prior to discharge and
appropriate activation of the delegation protocol for the outpatient case.
3. IV access: The patient must have an appropriate functional central venous access device to
safely receive PN in the home. Commonly used devices include implantable ports, tunneled
central venous catheters or peripherally inserted central catheters. The home infusion pharmacy
will require written documentation of line type and tip confirmation. Peripheral IV lines are not
acceptable for use with home PN.
4. Outpatient PN initiation: Outpatient PN start is discouraged in most scenarios due to patient
safety considerations. Certain patient populations can be at risk for electrolyte changes after TPN
initiation and require close monitoring. In weighing risks and benefits, it is safer for most patients
to be admitted to the hospital to initiate and stabilize the patient on an appropriate regimen before
going home. Anticipating a 3-5 day stay to initiate PN in the hospital is reasonable.
5. Insurance aspects: Insurance considerations need to be kept in mind when arranging for home
PN. Verifying reimbursement early in the home PN referral process is essential as insurance
coverage and criteria can significantly impact the home PN care plan and documentation needs.
Particularly for patients with Medicare, there are very stringent criteria from the Centers for
Medicare and Medicaid Services which must be met and documented in the patient’s clinical
record prior to hospital discharge to meet Medicare B coverage. Requests for changes in the
outpatient setting such as calorie changes, frequency of administration changes, oral intake
status, or introduction of enteral nutrition may have impacts on Medicare B coverage of the PN
therapy in the outpatient setting.
6. Patient expectations: Patients can expect extensive training and education in the hospital by
Chartwell RNs (if Chartwell patient) and initial home health RN involvement with the expectation
that the patient or caregiver become independent in administration with the PN. The aim of
education is to reduce the risk of complications and optimize safe practices in the home setting.
Patients will always have phone support from the home infusion pharmacy. Patients can expect
to need labs drawn on a frequent basis (often weekly) that may decrease in frequency over time.
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Patients will need to keep records of items such as weight and intake/output for the team. Some
patients may need to check blood sugars. Patients need to maintain a relationship with the MD of
record and have an office visit at least annually.
7. Outpatient monitoring: All PN patients are monitored closely after discharge from the hospital.
The home infusion pharmacy and outpatient managing medical team work together to provide
long-term ongoing monitoring of the patient. Adjustments in PN formulas are made based upon
laboratory values, intake/output records, patient assessments and nutritional goals or desired end
points.





















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27
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