From: Mickala M. Thompson
To: Pharmacy Clinical Specialist, Pharmacy Residents
Sent: Monday, October 23, 2017 3:21:45 PM
Subject: Parenteral Nutrition Audits

Pharmacists,

Over the past several weeks, I have audited several of our adult TPN consultations. In doing so, I noted some significant findings: 

1. Indications were often not documented on the rear page of the bifold form. Please complete this section for all TPN consults. TPNs for which you cannot determine an indication are often inappropriately prescribed. A call to the physician is warranted at that time to determine if enteral nutrition would be more appropriate.

2. On several occasions, I/O and Tmax information failed to be documented for ICU patients. This should be recorded on all patients daily.

3. Incorrectly adjusted weights were sometimes calculated. AdjBW = IBW + 0.25 (Actual BW - IBW). The multiplier 0.4 (used for antimicrobials) was often used, which may result in patient overfeeding.

4. Occasionally, appropriate protein goals were not targeted in ICU patients. A target of 1.1 g/kg is too low for a patient with septic shock or a patient on dialysis. A more appropriate starting place would be 1.5 g/kg (unless you are providing hypocaloric feedings).

5. Propofol calories were not always considered when formulating regimens. Don't forget to decrease your TPN lipid content accordingly.

6. TPN fat content was sometimes high in critically ill patients. Keep in mind that the lipid emulsion we administer to adult patients is pro-inflammatory and may prove harmful to the critically ill. Please limit lipid kcals to 30% in these patients. PPNs are the exception (up to 40% of calories may be derived from fat in these cases).

If you notice a discrepancy in any TPN iCare entry (when compared to folder documentation), or inappropriate additives, please e-mail me. We use this information for educational purposes. Thank you.

Mickala M. Thompson, Pharm.D., BCPS, BCNSP Clinical Pharmacy Specialist Huntsville Hospital Department of Pharmacy