Approved Hospital Formulary
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Approved Hospital Formulary
9/27/21 mt TPN Sodium
September 27, 2021
From: "Mickala M. Thompson" <mickala.thompson@hhsys.org>
To: "Pharmacy Residents" <grp_pharmres@hhsys.org>
Cc: "Pharmacy Clinical Specialist" <grp_pharmclinspec@hhsys.org>, "Brad Higginbotham" <brad.higginbotham@hhsys.org>, "Melanie Jones" <melanie.jones@hhsys.org>
Sent: Monday, September 27, 2021 12:13:17 PM
Subject: TPN Sodium
Good afternoon.
I have learned of issues related to NO sodium being added to TPN solutions. I want to clarify the confusion regarding the addition of sodium to new TPNs when there is an existing IV fluid ordered. Sodium should be added unless the patient is hypernatremic. Things to take into consideration when determining the amount of sodium to add to a new TPN include the:
1) Sodium content of the existing fluid,
2) Length of time the patient has been on the fluid, and
3) Patient's serum sodium trends on the existing IVF.
For example, if the patient is becoming hypernatremic on maintenance NS (154 mEq/L sodium), you may elect to instead utilize 77 mEq/L (1/2NS) sodium in your TPN on the first day, and adjust sodium content based on daily trends. Likewise, if a patient's serum sodium is well maintained on NS (154 mEq/L sodium), it would be inappropriate to omit sodium from the first day's TPN bag. For new TPN patients with normal serum sodium and no maintenance fluids, consider starting with 77 mEq/L sodium (1/2 NS) and adjusting as needed thereafter.
These same considerations should be taken into account for other electrolytes as well (e.g. if a patient is requiring a potassium-containing fluid to maintain normokalemia). Once a TPN is ordered, we typically aim to maintain the same total fluid volume by reducing the maintenance fluid accordingly. However, please remember to discuss with the provider the need for the additional maintenance fluid, especially when it is causing lab abnormalities (e.g. D5W in a hyponatremic or hyperglycemic patient) or patient harm (e.g. volume overload, unwanted calories).
If you recognize any significant TPN errors/discrepancies, please enter a QRR and send me an email with the patient information and a brief summary of the error. Please let me know if you have any questions.
Thank you,