initiating TPN

[PharmDstudent]

Does anyone know of a method to add electrolytes to a TPN before the patient gets low on them? I'm interested in an approach that would curb some of the electrolyte loss that occurs when initiating TPN therapy, ie the "if they don't need it, don't add it" approach.

In other words, if some lab values are in normal range at the beginning of therapy, is there a way to supplement those normal values without overdosing the patient in order to prevent electrolyte loss from occurring over time?

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[iFarm]

How would you know if the electrolyte levels will drop (or change in either direction) until you draw labs (AFTER therapy is initiated)?

 

[rxlea]

Why not throw on a rider if you have to?

 

[xiphoid2010]

If pharmacy is managing the TPN then the clinical should be tracking electrolyte trend daily and hopefully make adjustment before going out of range.

Also don't your hospital have something along the line of a K/Mg protocol? Ask the attending, or nephrology if on board, if it's appropriate to put the patient on it.

 

[type b pharmD]

If pharmacy is managing the TPN then the clinical should be tracking electrolyte trend daily and hopefully make adjustment before going out of range.

Also don't your hospital have something along the line of a K/Mg protocol? Ask the attending, or nephrology if on board, if it's appropriate to put the patient on it.

In the LTAC setting, the staff pharmacist is the manager and the clinical pharmacist all in one, many times.

Props to PharmDStudent for staying afloat in a tough practice environment!

 

[spacecowgirl]

Why not throw on a rider if you have to?

Agreed. You can't remove the additives from the TPN once they're in and then you've wasted the bag.

The literature on customized TPNs isn't very compelling vs standard mixtures. At least it wasn't 3 or so years ago when I last looked.

 

[PharmDstudent]

Why not throw on a rider if you have to?

Typically, we reserve riders for values within a certain range and "critical values". Riders also have to be ordered by a physician, so that would add another step. But if the patient needs it, then pharmacy could get it ordered... which brings us back to the dilemma of "if they don't need it, don't add it".

If pharmacy is managing the TPN then the clinical should be tracking electrolyte trend daily and hopefully make adjustment before going out of range.

Also don't your hospital have something along the line of a K/Mg protocol? Ask the attending, or nephrology if on board, if it's appropriate to put the patient on it.

We do our best to monitor electrolytes on a daily basis. Sometimes that turns out to be enough, but sometimes it doesn't, because the lab values may already be low by the second day.

No. What is a K/Mg protocol exactly?

In the LTAC setting, the staff pharmacist is the manager and the clinical pharmacist all in one, many times.

Right. That's why I like working for an LTAC, but it has drawbacks, obviously, too.

Agreed. You can't remove the additives from the TPN once they're in and then you've wasted the bag.

The literature on customized TPNs isn't very compelling vs standard mixtures. At least it wasn't 3 or so years ago when I last looked.

Yeah... you can't take them out.

Ok. I was hoping there might be a MEQ/kg rule when starting TPN, but maybe there isn't.

 

[cycloketocaine]

Typically, we reserve riders for values within a certain range and "critical values". Riders also have to be ordered by a physician, so that would add another step. But if the patient needs it, then pharmacy could get it ordered... which brings us back to the dilemma of "if they don't need it, don't add it".

We do our best to monitor electrolytes on a daily basis. Sometimes that turns out to be enough, but sometimes it doesn't, because the lab values may already be low by the second day.

No. What is a K/Mg protocol exactly?

Right. That's why I like working for an LTAC, but it has drawbacks, obviously, too.

Yeah... you can't take them out.

Ok. I was hoping there might be a MEQ/kg rule when starting TPN, but maybe there isn't.

There is a mEq/kg rule in neonates, but that's the TPN's I play with so I can't comment on others.

 

[xiphoid2010]

K/Mg protocols or electrolyte replacement protocol is what the name implies. Essentially a predefined standing /PRN orders to give X amount ount of replacement for Y lab values. K and Mag are the most common ones, but calcium and phos ones are around too.