Department of Pharmacy Policies & Procedures

Number: 5:12

Effective Date: October, 1984

Revisions: 5/99; 5/00; 12/04; 12/05; 10/08

Reviewed: 9/09

Approval: 5/99

Subject: TOTAL PARENTERAL NUTRITION

A. POLICY

All Total Parenteral Nutrition (TPN) solutions for adult and pediatric inpatients will be prepared by the inpatient pharmacy in the IV Admixture area.

B. ORDERING PROCEDURE

1. All orders for TPN are entered into the hospital computer order entry system and verified by pharmacy.

2. The TPN order must be reentered completely each 24 hours. All orders should be renewed by 1600 daily.

3. All adult TPN fluids will be hung at 2000 daily. New orders will start at 2000 on the day written.

C. PHARMACY PROCEDURE

1. The pharmacist will review the physician's order for completeness.

2. For new TPN orders the pharmacist will:

a. Create a new patient record in the TPN order entry software system.

b. Check new TPN for adherence to guidelines for initiating TPN

           (i.e. < 200 gm Dextrose on day 1; < 150 gm for diabetic patients).   

c. Labels for I.V. lipids are generated upon pharmacist order verification.

3. For continuing TPN orders the pharmacist will:

a. Select the appropriate patient profile in the TPN software, generate a “new order” and make appropriate revisions. 

b. Labels for I.V. lipid orders will generate in the appropriate IVPB delivery based on scheduled administration times.

c. The calcium/phosphate ratio will be checked for incompatibilities (total < 45 mEq/L in TPN).

d. The TPN will be monitored for peripheral/central line administration guideline adherence (> 10% dextrose, < 4% amino acids, 24 hour lipids, < 80 mEq K+/ L, < 154 mEq Na+/L).

4. For Neonatal orders the following steps will be taken:

a. Weights are updated in the hospital computer order entry system by nursing and medical staff. The prescriber has the option of entering the weight upon physician order entry. Pharmacy manually updates the weights in the TPN software based on the information provided on the TPN order requisition.

b. Orders will be checked for the following:

i) For peripheral IV, no calcium in the TPN.

ii) Final amino acid concentration ≥ 0.8 gm/100 mL if Ca+ & PO4 present. Call if concentration is greater than 4.5% for a peripheral IV.

iii) Calcium/phosphate ratio < 45mEq/L. (If ≥ 45 mEq/L, add cysteine 20mg/gm of amino acid to increase the solubility to 55 mEq/L)

iv) Multivitamins

(1) 1.5 mL/day for ≤ 1 kg; no more than 1.5 mL/30 mL TPN

(2) 3.25 mL/day for > 1 kg; no more than 3.25 mL/65 mL TPN

5. Incomplete or questionable orders will be clarified with the physician.

6. The solution order will be entered into the TPN order entry software system via a formulary template by a pharmacist or technician trained and certified in the use of the system. All entries will be double-checked against the order.

7. TPN solutions are given a 36 hour expiration date.

8. Labels are generated by the TPN order entry software system. One formula container label is affixed to the bag; the other formula container label is affixed to the back of the TPN order requisition for quality assurance purposes. The other two labels are clipped to the TPN order requisition.

9. A second pharmacist will double check the label against the order before compounding begins and initial the “Label Check” blank.

10. Before compounding begins, the corresponding bar code located on the formula label must be scanned to identify the correct TPN solution.

11. The solutions are mixed in the horizontal laminar air flow hood using the Baxa Exacta-Mix 2400 Compounder (EM2400).

a. The solution is prepared on the compounder according to the corresponding EM2400 Technical Manual. Upon completion of compounding, the EM2400 will indicate the percent error between the calculated bag weight and actual bag weight.  Any discrepancy > 3% must be investigated and the bag remade as necessary. If no manual additive is required, the pharmacist will initial the container formula label affixed to the bag. Upon completion of compounding, a MixCheck Report will automatically print.

b. If an air (bubble) or occlusion alarm is indicated during compounding, it should be resolved according to the instructions in the corresponding EM2400 Technical Manual.   After compounding is complete, the preparing pharmacist will initial any resolved alarms that may have occurred during compounding on the printed MixCheck Report.

c. If a manual addition is required for the solution, it should be added in an adjoining horizontal laminar air flow hood. The pharmacist who makes these additions will initial next to the "manual" specification on the MixCheck Report.  After making the additions, the pharmacist will initial the formula container label affixed to the bag.

12. The MixCheck Report will be checked for completeness by a pharmacist other than the pharmacist who added the manual ingredients. The checking pharmacist will initial the "Manual Check" blank on the MixCheck Report, certifying that all ingredients requiring manual addition are initialed as having been added by the preparing pharmacist. The checking pharmacist also will verify the label check has been performed and will initial the “Label Check” blank on the MixCheck Report. Finally, the checking pharmacist will perform a “Solution Check” (adding volumes on the MixCheck Report and comparing that final volume to the final volume on the solution formula label) and a “Details Check” and will initial the appropriate blanks on the report. The solution formula label and “Label Check” label are placed on the back of the MixCheck Report and filed for quality assurance purposes.

13. The completed TPN will be visually inspected for integrity.

14. The IV room pharmacists will periodically verify the TPN orders from the hospital computer order entry system and clear them from the MM Worklist after compounding of the TPN has occurred.

15. The completed adult solutions are refrigerated until 1900. All adult TPN solutions and lipids are delivered at this time for administration at 2000.

16. All neonatal TPN solutions and lipids are sent to the appropriate unit as they are completed. The lipids are sent with the TPN. Lipids for the nursery are drawn up individually for each infant with proper labeling for administration.  Standardized volumes of 25 ml/30ml syringe (for ordered lipids < 15mL) and 50ml /60ml syringe (for ordered lipids ≥ 15mL) are used.