174 Questions
What is the primary benefit of implementing a standardized PN order form?
To reduce waste and improve patient safety
Which of the following is a common factor associated with PN prescribing errors?
Inadequate knowledge regarding PN therapy
What is the recommended maximum preparation and hang time for each PN solution that is not refrigerated?
30 hours
Which organization has made recommendations for medical documentation to minimize errors?
All of the above
What is the estimated annual savings from reducing PN wastage and standardizing PN solutions?
$10,000 to $76,803
What is the primary benefit of parenteral nutrition formulations in patients with gastrointestinal dysfunction?
Providing a lifeline for those with permanent loss of the GI tract
What is the purpose of including contact information for the person writing the PN order on the PN form?
To clarify unclear or inappropriate orders
What is a common characteristic of parenteral nutrition formulations?
They are complex admixtures containing 40 or more components
Why is education cited as necessary for successful implementation of a standardized PN order form?
To improve prescriber knowledge of PN therapy
What is the recommended frequency for reordering PN for an existing patient?
Each institution shall dictate the frequency
What was the outcome of improperly prepared and administered PN formulations?
Serious harm and death
What led to a FDA Safety Alert?
Two deaths due to errors in PN compounding
What is the purpose of including a space for institutional resources on the PN form?
To provide access to individual consultants or a nutrition support service
What is the primary goal of creating and maintaining a standardized PN order form?
To minimize errors and improve patient safety
What was the cause of death in a pediatric patient who received an incorrect PN formulation?
Overdose of dextrose
What was the mistake made by the hospital pharmacy in preparing the PN formulation?
Misinterpreting the dextrose content on the label
What was the outcome of the fatality involving pharmacy-compounding operations for pediatric dextrose solutions?
The infant was overdosed with dextrose
What was the benefit of an interdisciplinary approach to PN therapy?
Improving efficacy, reducing complications, and facilitating efficient, cost-effective PN therapy
What was the final concentration of dextrose solution administered to an underdosed infant?
1.75%
What was the cause of iron overload and liver toxicity in a child receiving PN?
Misinterpretation of a label
How many children were infected as a result of receiving contaminated PN admixtures?
Four
What was the cause of death of a 2-year old child receiving home PN?
Excessively high level of potassium
What was the result of an automated PN compounder malfunction in two premature infants?
Magnesium toxicity
What is the primary benefit of standardized PN order forms?
Reduce prescribing errors
What is the result of reducing the incidence of incompatible concentrations of electrolytes and omissions of nutrients?
Reduction in prescribing errors
What is the benefit of physician education in PN therapy?
Especially important for clinicians unfamiliar with PN therapy
What is the result of implementing standardized order writing processes in PN therapy?
Reduction in prescribing errors
What is the percentage reduction in the cost of processing and preparation of an initial PN order for a standardized solution?
55%
What should the PN order form contain to assure venous access is appropriate for the osmolarity of the ordered PN formulation?
The location of the venous access device
Why is knowledge of patient dosing weight vital in PN formulation?
To assess nutrient needs and identify dosing errors
What should be addressed specifically on the PN order form regarding calcium and phosphorus?
Compatibility
What is the purpose of including a general statement on the PN order form regarding PN formulation incompatibilities?
To warn of potential incompatibilities
What is the purpose of including basic PN education tools on the PN order form?
To guide prescribers in creating an initial order
What is the purpose of including example calculations on the PN order form?
To guide prescribers in determining patient-specific total calories
What should be included in the guidelines for ordering appropriate baseline laboratory tests on the PN order form?
Both options A and B
Why are guidelines for stopping or tapering PN important to include on the PN order form?
Both options A and B
What type of information should be included regarding commercial multivitamin and trace element preparations on the PN order form?
Both options A and B
What type of insulin guidelines should be included on the PN order form?
Institution-specific guidelines
What is the primary advantage of using grams per total volume in a 24-hour nutrient infusion system?
It is the most consistent with the nutrient label, requiring the least number of calculations.
What is the purpose of including the amount per day on the PN label?
To facilitate review of the order for appropriate nutrient doses.
Why is it useful to include quantity per liter in parenthesis on the PN label?
To determine electrolyte compatibility and infusion via peripheral or central vein.
What is included on the PN label for neonatal and pediatric patients?
Amount per kg and amount per day.
What is the dosing weight used for on the PN label?
To evaluate if the doses of nutrients are appropriate.
What is the purpose of including the administration date and time on the PN label?
To indicate the date and time the PN is scheduled to be administered to the patient.
What is the benefit of using automated compounding devices in the 24-hour nutrient infusion system?
They are more accurate and faster than gravity-fill PN admixture systems.
Why is it important to manage acute electrolyte disorders separately from the PN?
Until the time that electrolyte changes in the PN go into effect.
What is the purpose of including a supplemental label template for IVFE?
For those instances when IVFEs are administered separate from the PN admixture.
What is the benefit of using a standardized PN label template?
It provides a clear and concise format for labeling PN admixtures.
What is the purpose of including the dosing weight on the PN label?
To individualize nutrient requirements for each patient
What is the acceptable range for protein requirements in catabolic patients?
1.2-2 g/kg
What is the purpose of including electrolyte additives on the label?
To provide individualized electrolyte requirements
What is the recommended range for total calories per kilogram of body weight?
20-30 kcal/kg
What is the purpose of including the amount per day on the label?
To support the use of the 24-hour nutrient infusion system
What is the recommended range for fluid requirements per kilogram of body weight?
30-40 mL/kg
What is the purpose of including the phosphorus content on the label?
To provide individualized phosphorus requirements
What is the purpose of including the infusion duration and rates on the label for cycled PN formulations?
To provide individualized infusion rates and durations
What is the purpose of including the total calories provided per day on the auxillary label?
To provide individualized nutrition information
What is the purpose of including the percent of total calories provided by carbohydrate and fat on the auxillary label?
To provide individualized macronutrient information
What is the typical duration of PN therapy in acute care institutions?
10-14 days
What is the purpose of including guidelines for nutrient restriction or supplementation in PN orders?
To follow published clinical guidelines
How are PN base components typically labeled?
All of the above
What is the recommended daily dose of folic acid in a parenteral vitamin formulation?
600 mcg/day
What is the primary benefit of using grams of base components per liter in PN labeling?
Simplifies conversion of nutrients to calorie and gram doses
Why is it necessary to state the specific amino acid product name used in compounding on the PN label?
To account for its electrolyte content
What is the recommended daily dose of vitamin K in a parenteral vitamin formulation?
150 mcg/day
What can occur if a pharmacist-to-pharmacist interaction does not occur during patient transfer between healthcare environments?
PN label misinterpretation
Why should patients receiving warfarin be monitored closely when receiving vitamin K?
To ensure adequate anticoagulation
Why are guidelines for long-term PN administration beneficial?
They address the use of cyclic versus continuous PN infusion
What is the recommended daily dose of thiamin in PN patients with a history of alcohol abuse?
25–50 mg/day
What is the purpose of including recommendations for monitoring or supplementation in PN guidelines?
To provide specific guidance for long-term PN patients
What is a common issue with PN labeling?
Lack of standardization
Why are restrictions of potassium, phosphate, or magnesium required in patients with renal disease?
Due to impaired excretion
What is the primary benefit of standardizing PN labels?
Minimizes confusion and misinterpretation
What is the purpose of adjusting the chloride and acetate content in PN formulations?
To maintain acid-base balance
Why are commercially available amino acid injection products considered in determining compatibility?
They contain phosphorus
What can occur if PN labels are not standardized?
Misinterpretation of PN labels
What is the recommended frequency of parenteral vitamin preparation administration?
Daily
What is the purpose of using approximately equal amounts of chloride and acetate in PN formulations?
To maintain acid-base balance
What is the recommended daily fluid requirement for pediatric patients weighing 10 kg?
100 mL/kg
What is the daily protein requirement for preterm neonates?
3-4 g/kg
Why is it necessary to choose PN components with the lowest aluminum content possible?
To minimize parenteral aluminum exposure
What is the recommended frequency for providing IVFE to adult and pediatric patients who are NPO?
Daily
What is the consequence of omitting parenteral vitamins from PN formulations?
Refractory lactic acidosis and death
What is the recommended daily energy requirement for pediatric patients aged 1-7 years?
75-90 kcal/kg
Why should parenteral iron supplementation be limited in patients receiving PN therapy?
To limit it to conditions of iron deficiency when oral iron supplementation fails
What is the consequence of overdosing or underdosing nutrients in PN formulations?
Severe harm or death
What is the recommended approach when the use of a commercially available multiple trace element combination product results in or increases the risk of trace element toxicity or deficiency states?
Use individual trace element products
What is the purpose of screening PN orders?
To prevent serious disorders and death due to inappropriate nutrient compositions
What is the primary method for assessing energy expenditure in obese patients?
Indirect calorimetry
What is the recommended percentage of nonprotein calories as fat in parenteral nutrition formulations?
15-30%
What is the minimum percentage of total caloric intake as linoleic acid required to prevent essential fatty acid deficiency?
2-4%
What is the maximum amount of fat that can be administered per kilogram of body weight per day in parenteral nutrition formulations?
2.5 g/kg/day
What is the primary benefit of hypocaloric feeding in preventing essential fatty acid deficiency?
Liberalization of essential fatty acids from endogenous fat stores
What is the estimated time period for developing biochemical evidence of essential fatty acid deficiency in hospitalized adults receiving fat-free PN?
4-6 weeks
What is the primary factor influencing the need for continued provision of intravenous fat emulsions in patients receiving home PN?
Efficiency of absorption
What is the primary benefit of topical essential fatty acid application in preventing essential fatty acid deficiency?
Effective in preventing EFAD in most patients
What is the primary limitation of using predictive equations in estimating energy expenditure in obese patients?
Limited applicability in obese patients
What is the primary consideration in determining the need for protein supplementation in patients receiving renal replacement therapy?
Nutritional status
What is the recommended schedule for administering vitamin B12 during periods of short supply?
At least once per month
What is the primary reason for monitoring iron status in patients receiving long-term PN therapy?
To minimize the risk of iron overload
What is the recommended daily intake of manganese in adult PN formulations?
60-100 mcg
In patients with iron deficiency anemia, what is the estimated dose of iron required to meet maintenance requirements?
25-50 mg once monthly
Why should reductions in manganese and copper dosing be considered in patients with hepatobiliary disease?
Due to impaired excretion
What is the recommended frequency for monitoring serum ferritin in patients receiving long-term PN therapy?
Every 1-3 months
What is the primary reason for not adding iron dextran to TNA?
Due to compatibility limitations
What is the recommended daily intake of zinc in adult PN formulations?
2.5-5 mg
What is the primary benefit of monitoring serum concentrations of trace elements in patients receiving long-term PN therapy?
To minimize the risk of trace element toxicity
Why should iron supplementation be limited to conditions of iron deficiency in patients receiving PN therapy?
To minimize the risk of iron overload
What is the primary reason for adding L-cysteine hydrochloride to the 2-in-1 PN formulation in neonatal patients?
To improve calcium and phosphorus solubility
What is the recommended dose of L-cysteine hydrochloride per gram of amino acids in neonatal PN formulations?
40 mg
Why is the 20% IVFE preferred over the 10% product in neonates and infants?
It has a greater caloric content per unit volume
What is the accepted limit for IVFE administration in small for gestational age neonates and preterm neonates less than 32 weeks gestational age?
3 g/kg/day
Why do neonates and infants have a higher risk of developing essential fatty acid deficiency (EFAD) syndrome?
They have a limited endogenous store of fatty acids
What is the primary reason for the differences in calcium and phosphorus requirements between neonates and infants versus older children and adults?
Different nutritional requirements
What is the recommended dosage of calcium and phosphorus in pediatric PN formulations?
Higher than adult requirements
Why may alteration of trace element dosage be required in cases of hepatic or renal dysfunction?
Because the liver and kidneys are responsible for trace element metabolism
What is the consequence of using multiple trace element products at recommended doses in pediatric patients?
Excessive serum concentrations of chromium
Why is it necessary to consider individual patient variation when using guidelines for vitamin and trace element additions to PN solutions in pediatric patients?
Because the guidelines are only approximations of need
What is the primary responsibility of the pharmacist in reviewing PN prescriptions?
To assess the appropriateness of dose and nutrient composition
What is the definition of a balanced nutrient formulation in PN?
The presence of the proper proportion of calories, protein, fluid, electrolytes, vitamins, and trace elements
What is the purpose of reviewing the additive sequence in PN compounding?
To optimize and validate the safety and efficacy of the compounding method
What type of analysis can be used to indirectly assess the accuracy of individual additives in PN compounding?
Gravimetric analysis
What is the recommended frequency for in-process or end-product testing of PN formulations?
Daily
What is the purpose of visually inspecting PN formulations for signs of gross particulate contamination?
To detect potential compatibility or stability problems
What is the primary goal of implementing quality assurance practices in PN compounding?
To improve the safety and efficacy of PN formulations
What is the purpose of reviewing the compounding method for PN formulations?
To optimize and validate the safety and efficacy of the compounding method
What is the recommended approach for evaluating the compatibility of PN components?
Using physicochemical data to ensure stability and compatibility
What is the primary benefit of using automated compounding devices in PN compounding?
Improving the accuracy and safety of PN formulations
What is the main issue with sterilization of PN products?
Instability of certain amino acids and vitamins
What is the significance of storing PN products away from light?
To prevent oxidation of tryptophan
What is the consequence of vitamin degradation in PN formulations?
Night blindness in patients with marginal body stores
Which of the following is susceptible to instability in PN formulations?
Vitamins and IVFE
What is the focus of PN formulation stability from a clinical perspective?
Vitamin instability
What is the consequence of improper storage of PN products?
Acceleration of physicochemical destabilization
What is the significance of the Maillard reaction in PN formulations?
Complexation of carbohydrates by certain amino acids
What is the benefit of preparing amino acid and dextrose combinations in a pharmacy?
Determination of the stability of the final formulation
Why was the parenteral vitamin supplement insufficient in meeting the patient's needs?
Vitamins were added up to a week before the solution was administered, leading to degradation and adsorption
What is a common risk of incompatibility in PN formulations?
Solid precipitates exceeding 5 microns
Why is calcium gluconate preferred over calcium chloride in PN formulations?
Calcium gluconate is less reactive than calcium chloride
What can occur when ascorbic acid is added in supraphysiologic quantities to PN formulations?
Formation of insoluble products with calcium
Why is medication administration with PN not advised?
There is a high risk of physicochemical interactions
What is a necessary consideration when adding insulin to PN formulations?
All of the above
Why is it important to add phosphate before adding calcium to PN formulations?
To avoid the formation of insoluble products
What is a risk associated with using bicarbonate salts in PN formulations?
Formation of insoluble products with calcium
Why is it recommended to use sodium or potassium acetate instead of bicarbonate salts in PN formulations?
Acetate salts are less reactive with calcium than bicarbonate salts
What is a characteristic of ascorbic acid that makes it difficult to use in PN formulations?
It is highly unstable and reactive with calcium
What should be confirmed before administering a medication with a PN formulation?
Physical and chemical compatibility of the medication with the PN formulation
What should be done if there is no information concerning the compatibility of a medication with PN?
Administer the medication separately from the PN
What is a crucial consideration when evaluating the compatibility of a medication with a TNA?
The concentration of the medication used
What should be verified prior to the initial administration of PN through a CVC?
The catheter tip location
What is recommended for neonatal/infant patients in terms of PN formulation?
A 2-in-1 formulation with separate administration of IVFE
What should be confirmed and/or validated in pediatric patients as growth and maturity occur?
The catheter tip placement
What is essential for safe administration of PN?
Adequate understanding of multiple integrated key concepts
What should be evaluated according to concentration of the medication used and base formulation?
The compatibility information
What should be done if no information exists regarding the stability and compatibility of the PN?
Consult with the manufacturer before dispensing to the patient
What should be ensured when administering insulin in PN?
The insulin is administered in a consistent manner
What is the recommended target blood glucose level in patients receiving PN?
100-150 mg/dL
What is the maximum amount of dextrose that should be administered on day 1 of PN?
150-200 grams
What is the initial insulin dosage ratio in PN formulation for patients previously treated with insulin or oral hypoglycemic agents?
0.1 units of insulin per gram of dextrose
What is the recommended frequency for monitoring capillary glucose levels in patients receiving PN?
Every 6 hours
What is the recommended approach for administering insulin in patients receiving PN with dynamic or difficult-to-predict insulin needs?
Using a separate intravenous insulin infusion
What is the maximum amount of insulin that should be given per gram of dextrose in PN formulation before considering a separate intravenous insulin infusion?
0.3 units of insulin per gram of dextrose
What is the recommended approach for carbohydrate administration in patients receiving PN?
Administering up to 20-25 kcal/kg/day of carbohydrate
What is the recommended approach for modifying the insulin dosage in PN formulation?
Modifying the dosage daily based on the amount of insulin given with sliding-scale insulin coverage
What is the recommended approach for managing hyperglycemia in patients receiving PN?
All of the above
What is the recommended approach for co-infusing medications with PN?
Co-infusing medications through the same intravenous tubing
What is the primary reason for using in-line filters during the administration of PN formulations?
To eliminate or reduce infusion of particulates, microprecipitates, microorganisms, pyrogens, and air
What is the potential consequence of particles 5 microns or larger in PN formulations?
Both A and B
Why is visual inspection of PN formulations limited in detecting microprecipitates?
Because particles of 50 microns cannot be easily detected with the unaided eye
What should be done if a clogged filter and associated infusion pump alarm occur during PN administration?
The infusion should be stopped and the filter should be replaced
What is the primary reason for dedicating catheter access devices solely to PN usage?
To reduce the incidence of catheter associated sepsis
What is the role of education in reducing the incidence of catheter associated sepsis?
Educating nurses on the proper care of the CVC based on established standards and guidelines
What is the potential consequence of microprecipitates in PN formulations?
Serious problems, such as occlusion of the pulmonary vasculature
Why is it important to ensure continued care and monitoring of PN administration beyond the acute care setting?
To ensure that the patient and/or caregiver are educated on proper care techniques
Study Notes
Parenteral Nutrition (PN)
- PN has become a crucial therapy in various disease states over the past four decades
- PN formulations benefit patients with significant disruption in gastrointestinal function and are a lifeline for those with permanent loss of the GI tract
Importance of Proper Preparation and Administration
- Improperly prepared and administered PN formulations have resulted in serious harm and death
- Early PN programs focused on minimizing complications, and an interdisciplinary approach was found to improve efficacy, reduce complications, and facilitate efficient, cost-effective PN therapy
Errors in PN Preparations
- Two deaths occurred due to errors in PN compounding, leading to a FDA Safety Alert
- Errors led to infusion of incorrect formulas, leading to patient deaths and harm
- Errors were related to pharmacy practices, misinterpretation of labels, and improper preparation of PN formulations
Ordering PN
- Life-threatening errors continue to occur in the preparation and delivery of PN admixtures to patients
- Errors are related to the ordering process, including lack of uniformity, incorrect units of measure, and errors of omission
- Standardized PN order forms can reduce prescribing errors by 9% to 82%
Benefits of Standardized PN Order Forms
- Provide more precise guidelines for PN prescribing
- Educate physicians on PN therapy
- Reduce prescribing errors
- Improve efficiency and productivity of nutrition support
- Allow comprehensive nursing and dietary care of the patient
- Reduce pharmacy inventory and costs
Common Factors Associated with PN Prescribing Errors
- Inadequate knowledge regarding PN therapy
- Certain patient characteristics related to PN therapy
- Calculation of PN dosages
- Specialized PN dosage formulation characteristics and prescribing nomenclature
Principles for Creating a PN Order Form
- Mandatory components: data to be collected on the form, information to be communicated to the clinician, and contact information
- Strongly recommended components: basic PN education tools, example calculations, guidelines for ordering laboratory tests, and guidelines for stopping or tapering PN
- Worthy of consideration components: additional guidelines for nutrient restriction, specialty amino acids, and long-term PN administration
Labeling PN Formulations
- Lack of standardization in labeling PN ingredients causes confusion
- Standardized labels are essential for patient safety and to avoid misinterpretation
- Labels should express clearly and accurately what the patient is receiving
- Methods of labeling: percent of original concentration, percent of final concentration, grams per liter, and grams per total volume### PN Label Requirements
- The PN label should express components as amount/kg/day, in addition to amount/day, for neonatal and pediatric patients.
- The label may include an additional column expressing components as amount/liter or amount/100 ml in parenthesis.
- The label should specify the route of administration, administration date and time, and beyond-use date and time.
- The dosing weight should be provided so that anyone evaluating the contents of the label may determine if the doses of nutrients are appropriate.
- The inorganic phosphorus content should be provided as both the mmol quantity of phosphorus and the mEq quantity of the additive salt's cation (potassium or sodium).
- If the PN formulation includes overfill, it should be clearly stated on the label.
- Rate should be expressed in mL/hour over 24 hours, and if the PN formulation is cycled, the infusion duration and rates should be expressed on the label.
Auxillary Labels
- Auxillary labels may be used to list individual electrolytes as mEq and phosphorus content as mmol provided per day.
- The auxillary label could also express the total calories provided per day, as well as the percent of total calories provided by carbohydrate and fat.
Practice Guidelines
- The labels for PN formulations should be standardized and include the amount per day as the only column required on the label for the base formula, electrolyte additives, micronutrients, and medications.
- Auxillary labels or information may be used.
- Patient transfer between healthcare environments requires pharmacist-to-pharmacist communication and documentation to ensure the accurate transfer of the PN prescription.
- The PN label should be compared with the PN order and for beyond-use date before administration.
Nutrient Requirements
Adults
- Protein requirements:
- Maintenance: 0.8-1 g/kg
- Catabolic patients: 1.2-2 g/kg
- Chronic renal failure (renal replacement therapy): 1.2-1.5 g/kg
- Acute renal failure + catabolic: 1.5-1.8 g/kg
- Energy requirements: 20-30 kcal/kg
- Fluid requirements: 30-40 mL/kg
- Fat content of the PN formulation should not exceed 2.5 g/kg/day and carbohydrate content should not exceed 7 g/kg/day.
- Essential fatty acid deficiency (EFAD) may occur if fat content is less than 2% to 4% of total caloric intake as linoleic acid and 0.25% to 0.5% of total caloric intake as alpha linolenic acid.
Pediatrics
- Standard nutrient ranges for infants and children receiving PN have been established.
- Requirements for fluids, protein, and energy are substantially higher on a unit-of-weight basis for children than for adults.
- Careful monitoring of growth is necessary to assess adequacy of nutrient provision.
- Above 18 years of age, estimated nutritional requirements should be established using nutrient ranges suggested for the adult population.
- Protein restriction in certain disease states such as hepatic and renal failure should be done with caution and in consideration of the need for adequate protein to support growth in the pediatric population.
Electrolytes, Vitamins, and Trace Elements
- Standard ranges for electrolytes, vitamins, and trace elements for infants and children with normal organ function are provided.
- Calcium and phosphorous requirements of the neonate and infant are substantially different from those of the older child and adult.
- Guidelines for vitamin and trace element additions to PN solutions for pediatric patients up to age 11 have been published.### Pediatric Parenteral Nutrition
- Long-term use of multiple trace element products at recommended doses can lead to excessive serum concentrations of chromium.
- The ratio of trace elements in commercially available pediatric multiple trace element products can result in excessive intake of manganese if recommended doses of zinc are given.
Iron Needs in Pediatric Patients
- Iron needs in pediatric patients can be dramatically lower compared to adults.
- Vigilance is necessary regarding iron doses administered to pediatric patients.
Fluid Requirements for Pediatric Patients
- Daily fluid requirements for pediatric patients vary based on body weight:
- 1500 g: 130-150 mL/kg
- 1500-2000 g: 110-130 mL/kg
- 2-10 kg: 100 mL/kg
- 10-20 kg: 1000 mL for 10 kg + 50 mL/kg for each kg > 10
- 20 kg: 1500 mL for 20 kg + 20 mL/kg for each kg > 20
Protein Requirements for Pediatric Patients
- Daily protein requirements for pediatric patients vary based on age and weight:
- Preterm neonates: 3-4 g/kg
- Infants (1-12 months): 2-3 g/kg
- Children (10 kg or 1-10 years): 1-2 g/kg
- Adolescents (11-17 years): 0.8-1.5 g/kg
Energy Requirements for Pediatric Patients
- Daily energy requirements for pediatric patients vary based on age:
- Preterm neonate: 90-120 kcal/kg
- 6 months: 85-105 kcal/kg
- 6-12 months: 80-100 kcal/kg
- 1-7 years: 75-90 kcal/kg
- 7-12 years: 50-75 kcal/kg
- 12-18 years: 30-50 kcal/kg
Practice Guidelines
- Determine protein, calorie, fluid, electrolyte, vitamin, and trace element components of a PN formulation based on standard nutrient requirements.
- Provide IVFE in a dose sufficient to prevent EFAD in adults and pediatric patients who are NPO.
- Provide a parenteral vitamin preparation on a daily basis to all patients receiving PN.
- Choose PN components with the lowest aluminum content when possible.
- Use individual trace element products when necessary to prevent toxicity or deficiency states.
- Limit parenteral iron supplementation to conditions of iron deficiency when oral iron supplementation fails.
Sterile Compounding of Parenteral Nutrition Formulations
- Review each PN prescription for appropriateness of dose and adequacy of nutrient composition.
- Assess each PN component for appropriateness of dose and potential compatibility or stability problems.
- Question and clarify any dose of a nutrient outside a normal range not explained by a specific patient condition or history.
PN Compounding Practice Guidelines
- Optimize and validate the additive sequence in compounding as a safe and efficacious method.
- Review the compounding method if it has not been recently reviewed or if the contract with a manufacturer is about to change.
- Ensure the safety and support of the automated compounding device and avoid splitting PN contracts unless combinations have adequate physicochemical data.
Quality Assurance of the Compounding Process
- Perform gravimetric analyses to assess the accuracy of individual additives delivered or the final contents of the PN.
- Incorporate chemical analyses to directly measure the final content of individual additives.
- Use refractometric analysis as an alternative or indirect measure of final additive concentration.
- Perform in-process or end-product testing of PN formulations daily to assure a safe final formulation is dispensed to the patient.
- Adhere to the USP (797) Pharmaceutical Compounding-Sterile Preparations Chapter and the ASHP Guideline on Quality Assurance for Pharmacy-Prepared Sterile Products.
PN Stability
- Maillard reaction, also known as the browning reaction, is a concern in PN formulations, as it involves the complexation of carbohydrates by certain amino acids, such as lysine, which is facilitated by sterilization temperatures.
- Amino acid and dextrose combinations are typically prepared in the pharmacy, with stability determined by storage conditions prior to administration.
- Sterile compounding of PN accelerates the rate of physicochemical destabilization.
- Certain amino acids, vitamins, and IVFE are most susceptible to instability.
- Vitamin degradation can lead to clinical disturbances, particularly in patients with marginal body stores who are dependent on long-term PN support.
PN Compatibility
- Complex PN formulations pose several physicochemical incompatibility risks.
- Macroprecipitates exceeding 5 microns in the formulation can pass into the central circulation, posing a serious risk to the patient.
- Calcium salts, such as calcium gluconate, are commonly used in PN formulations, but can react with other additives to form insoluble products.
- Order of compounding is crucial to avoid the formation of insoluble precipitates.
- Phosphate should be added first, and calcium near the end of the compounding sequence.
Medication Administration with PN
- Admixture of medications with PN is not advised due to potential physicochemical interactions.
- If admixture is necessary, medication stability and compatibility with the PN or TNA must be assured.
- Evidence must support the clinical value of the medication administered in this manner.
- Insulin use in PN requires a consistent approach, with a defined protocol, and adherence to a reasonable target glucose range (100-150 mg/dL).
- Glucose control in patients with diabetes or stress-induced hyperglycemia receiving PN should aim to avoid hyperglycemia (blood glucose > 150 mg/dL).
Practice Guidelines
- Verify the dose, admixture preparation, packaging, delivery process, and storage and administration method to ensure PN stability and compatibility.
- Responsible pharmacists should verify the safe and clinically appropriate administration of drugs with PN.
- Compatibility information should be evaluated according to medication concentration and base formulation (2-in-1 or TNA).
- Insulin use in PN should be done consistently, according to a method that healthcare personnel have adequate knowledge.
PN Administration
- Optimal, safe PN administration requires an adequate understanding of multiple integrated key concepts.
- Correct venous access device selection, care, and assessment are crucial.
- Catheter tip placement should be verified radiographically prior to initial PN administration.
- Dedicated catheter access devices for PN usage can reduce infectious complications.
- Education of patients and/or caregivers in proper care techniques is essential.
Learn about the importance of parenteral nutrition in disease states, its benefits, and proper preparation and administration to avoid serious harm.
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