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College of Pharmacy

HelixTalk Episode #113 - The Top 10 Clinical Pearls for Total Parenteral Nutrition (TPN)

Date posted: May 19, 2020, 6:00 am

In this episode, we review ten clinical pearls about total parenteral nutrition (TPN) that all pharmacists should know.

Key Concepts

  1. Essential fatty acid deficiency (EFAD) can be prevented by giving 500 mL of 20% lipids per week. “Lazy” lipid dosing based on 250 mL bottle sizes can make dosing lipids straightforward.
  2. Most patients do not need escalating calcium doses in TPN when accounting for hypoalbuminemia. Higher calcium or phosphate concentrations can cause TPN compatibility problems.
  3. Review the sodium content of a TPN in mEq/L and put the concentration in the context of more familiar IV solutions (D5W, 1/2NS, LR, NS).  In many cases, hyponatremia or hypernatremia are problems with too much or too little free water and not the sodium content of a TPN.
  4. Use mostly acetate-based electrolyte salts to increase serum bicarbonate or decrease serum chloride (e.g. in cases of metabolic acidosis); use chloride-based electrolyte salts to accomplish the opposite effect (e.g. for patients with metabolic alkalosis).
  5. In general, avoid adding insulin to TPN formulations.  Instead, consider modifying TPN dextrose content and utilizing subcutaneous insulin.

References

  • Derenski K, Catlin J, Allen L. Parenteral Nutrition Basics for the Clinician Caring for the Adult Patient. Nutr Clin Pract. 2016 Oct;31(5):578-95. doi: 10.1177/0884533616657650.