Steps to safe parenteral nutrition preparation and administration

Parenteral nutrition (PN). It’s a valuable source of nutrition for critically and chronically ill patients who are unable to receive the nutrients they need via the oral or enteral route. It’s also a complex process with room for errors. It certainly takes a “village”—an interdisciplinary approach—involving multiple healthcare professionals and several steps to ensure its safe delivery and administration.¹ And it all starts with assessing your patient’s need for PN.

1. Assessment¹:
During this first step in the PN use process, the dietitian and/or nutrition support team will:
- Review patient data
- Conduct a nutrition assessment including estimation of nutrient requirements
- Determine nutrition intervention and nutrition prescription based on therapy goals and clinical condition
- Communicate with the prescriber
2. Prescription¹:
When determining an appropriate prescription for PN, a clinician must decide²:
- Appropriate use
  What’s my patient’s indication for the use of PN?
- IV access
  How long will my patient be on PN? Will they need a peripheral line or a central line?
- PN ingredients
  How much protein, lipids, and dextrose will my patient need? What about vitamins, trace elements, electrolytes, and total volume?
- PN instructions
  What’s the infusion rate and the start and stop times?
  - A safety tool in prescribing PN is to use a standardized PN order format and sequence of PN components
3. Review, verification, and transcription^1,3:
Once the PN is prescribed, the pharmacist will review and verify that the received order is appropriate before any preparation or compounding begins. This process includes two steps:
- A clinical review to verify that the indication and the dosing of each nutrient is appropriate for the patient
- A pharmaceutical review to verify the compatibility of the PN components and the stability of the final preparation
After these steps are completed, the pharmacist will then transcribe the PN order from handwritten (although not recommended), printed, or CPOE system to the automated compounding device (ACD). An additional independent double check is performed to ensure accuracy of the PN prescription.
4. Preparation, compounding, and dispensing^1,3:
Once the prescription is deemed appropriate, the pharmacist and pharmacy technician will prepare and compound the PN following sterile compounding techniques. Before the final preparation goes out the door to be dispensed, the pharmacist must assure that it is properly labeled, delivered, and stored.
5. Administration¹:
Finally, the PN admixture has made it from the pharmacy to the nurse or caregiver who is responsible for its safe administration. They should be knowledgeable and acquire the skills needed to verify the correct PN order, avoid administration errors, and maintain infection control.
6. Monitoring¹:
The final step in the PN use process is monitoring. An experienced nutrition care team will closely monitor their patient to prevent and detect any complications that may occur throughout their patient’s journey with PN.

For more information on the safe use of the Fresenius Kabi Nutrition portfolio, please reach out to a PN Specialist or click here to access an abstract by pharmacist Dr. Joseph I. Boullata reviewing the PN use process.

Click here for more expert content by Dr. Boullata and Dr. Jay Mirtallo on PN safety

Click here to view ASPEN’s PN Resources.

References: 1. Boullata JI. Overview of the parenteral nutrition use process. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):10S-13S. 2. Ayers PA, et al. ASPEN Parenteral Nutrition Handbook. 2014;111-132. 3. Boullata JI, Holcombe B, Sacks G, et al. Standardized Competencies for Parenteral Nutrition Order Review and Parenteral Nutrition Preparation, Including Compounding: The ASPEN Model. Nutr Clin Pract. 2016;31(4):548-555.

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Can I manage my own parenteral nutrition? Tips to help you flourish on parenteral nutrition at home

You’re going home on parenteral nutrition. We know you’re happy, but you’re probably also nervous and have some questions like “Can I administer my own parenteral nutrition?” and “Can I still do the things I enjoy?”

We get it; you’re not alone. Many people require parenteral nutrition at home for many different reasons. In fact, more than 25,000 patients manage their parenteral nutrition within the comfort of their own homes.¹ Let’s talk about some tips that can help you feel more confident throughout your journey with home parenteral nutrition.

Understand and get comfortable with your own parenteral nutrition regimen²:

Your healthcare team will provide training on how to safely administer PN at home and avoid complications. This includes learning how to properly store and prepare your bags, how to inject additives into your bags, how to attach the tubing to your catheter, and how to use the IV pump. If you have questions, reach out to your nurse, pharmacist, dietitian, or healthcare team. They’re there to help you feel as confident as possible in administering your own parenteral nutrition. Your healthcare team will also talk with you about monitoring your weight, hydration status, and any laboratory measurements that may be needed.
Establish an infusion schedule that’s convenient for you²:

Home parenteral nutrition infusions typically take 8 to 12 hours a day.³ If you can sleep well while you’re hooked up to an IV, you may consider a nighttime schedule. However, if you cannot sleep while infusing, a daytime schedule may be your best option. Work with your healthcare team to determine your home infusion schedule.
Learn how to care for your IV line²:

During your home PN training, you will learn how to take care of your IV line. This training is very important in preventing infection. Ask your doctor or nurse for specific instructions on how to properly care for your line.
Monitor your side effects²:

Like with any medication, parenteral nutrition comes with its own risks and possible side effects. Your healthcare team will teach you about the side effects of parenteral nutrition and how to monitor for them. Knowing how your body responds to your infusions will help you recognize any side effects that may occur along the way. If you experience side effects that are bothersome or won’t go away, contact your doctor immediately as they may decide to adjust your regimen as necessary.
Educate your friends and family²:

Your friends and family are your biggest fans. Teaching them about parenteral nutrition, why you need it, and even how to administer it can help them understand the challenges you’re facing. And when they understand those challenges, they will be able to support you even more in the ways that you need most.
Seek out a support group²:

Support groups, such as the Oley Foundation, bring together people with similar therapy and nutritional needs. These organizations serve as a beneficial resource to individuals on parenteral nutrition. Click here to visit the Oley Foundation support group page.

Remember, at any point in your nutrition journey if you have questions or concerns, contact your healthcare team for guidance and support.

Here at Fresenius Kabi we aim to inspire hope in critically and chronically ill patients by delivering innovations that nourish at every age and stage—from hospital to home. To explore our comprehensive portfolio of parenteral nutrition products, click here. Remember to keep checking our Intellectual Nourishment blog for updated content.

References: 1. Mundi MS, Pattinson A, McMahon MT, Davidson J, Hurt RT. Prevalence of Home Parenteral and Enteral Nutrition in the United States. Nutr Clin Pract. 2017;32(6):799-805. 2. Shieh S. 10 Tips for Adjusting to Your Life With TPN (Total Parenteral Nutrition). AmeriPharma Specialty Care. https://ameripharmaspecialty.com/10-tips-for-adjusting-to-your-life-with-tpn-total-parenteral-nutrition/. October 7, 2021. Accessed February 3, 2022. 3.Kirby DF. Improving outcomes with parenteral nutrition. Gastroenterol Hepatol (N Y). 2012;8(1):39-41.

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What good are guidelines and recommendations?

Without guidelines and recommendations, we would live in chaos! We would be back in the Wild West making wild guesses and assumptions. So we have guidelines and recommendations. Not hard and fast like laws, guidelines and recommendations do offer some leeway to use one’s clinical judgment. But because guidelines and recommendations are based on the strongest available scientific evidence, they shouldn’t be ignored. But what good are they really? Let’s look at parenteral nutrition guidelines and recommendations for an example. The American Society for Parenteral and Enteral Nutrition (ASPEN) is a great resource for guidelines and recommendations.

What do the guidelines say about nutrition support therapy in the adult critically ill patient? The ASPEN-SCCM clinical guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality.

Read more
When is parenteral nutrition appropriate? Consensus recommendations by Worthington P, et al, aim to delineate appropriate parenteral nutrition use and promote clinical benefits while minimizing the risks associated with the therapy. Read the full document.

Read more
What is appropriate dosing for parenteral nutrition? Persistent shortages of parenteral nutrition components have led to a tendency of practitioners to provide less than adequate dosing, which can lead to nutrient deficiencies that impair growth and healing. This document provides the requirements and recommendations for dosing of nutrients for a complete parenteral nutrition prescription.

Dosing for PN
What about alternative lipid injectable emulsions (ILEs)? There are expert recommendations regarding the use of alternative ILEs in surgical and critical care patients. The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology to develop consensus statements regarding the use of alternative ILEs.
How do I achieve photoprotection for parenteral nutrition? A position paper by Robinson DT, et al, reviews the scientific literature on the formation of quantifiable peroxides and other degradation products when parenteral nutrition admixtures and lipid injectable emulsions are exposed to light and reports adverse clinical outcomes in premature infants exposed to parenteral nutrition.

Read more

Whether you have a question on dosing or storage or delivery, there’s probably a clinical recommendation for it. The American Society for Parenteral and Enteral Nutrition (ASPEN) has guidelines and consensus recommendations that are based on literature and practices to help guide the use of parenteral nutrition to minimize errors associated with parenteral nutrition therapy. But that’s just one resource. There are also the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the Society of Critical Care Medicine (SCCM).

Whether a patient is in the hospital, a long-term care facility, or is being discharged to home, these guidelines and recommendations exist to help guide the safe and effective use of parenteral nutrition. As a pioneer of clinical nutrition, we believe it’s of the utmost importance to stay on top of these guidelines. That’s why we post any updates and links to these professional societies on our Resources page.

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The 411 on parenteral nutrition

Before we dive into our innovations that nourish, let’s start with the basics.

What is parenteral nutrition? Well, it’s nutrition. It’s nourishment…but not as you may know it. To be more technical, it’s the intravenous administration of nutrition, which may include protein, carbohydrates, fat, minerals and electrolytes, vitamins, and other trace elements.¹ When patients are unable to maintain good nutritional status by mouth or through tube feeding formula, they may need parenteral nutrition.¹ There are a variety of diseases or conditions that prevent patients from being able to eat, digest, or absorb the nutrition they need, including critical illness, bowel obstruction, GI fistulas, and severe acute pancreatitis.¹ In 2014, there were about 34,000 U.S. hospitalized patients receiving parenteral nutrition.²

Did you know that parenteral nutrition can be used outside of the hospital? Patients can receive parenteral nutrition in long-term care facilities and at home. In fact, about 25,000 patients receive parenteral nutrition at home.³ And patients can live well on parenteral nutrition, whether they need it for a short time or a long time.¹

What should you know about parenteral nutrition?

Rapid absorption.

Because parenteral nutrition is administered intravenously, it bypasses the gastrointestinal tract, meaning it doesn’t have to be digested before being absorbed by the blood.¹ The parenteral nutrition solution is delivered immediately into the bloodstream to exert its therapeutic effects.⁴
Nutritional support for all ages.

Patients of all ages, including infants (yes, infants!), may receive parenteral nutrition.¹ According to the 2014 National Inpatient Survey data (the latest available statistics), patients received parenteral nutrition in over 290,000 hospital stays.¹ You may be surprised to know that children and newborns made up about 43% of those.¹
There are choices!

There are a lot of parenteral nutrition products available on the market today. And as a pioneer in clinical nutrition, we’re always speaking with experts in the field to find new ways to fulfill the nutritional needs of patients who need parenteral nutrition. We specialize in innovations that help nourish critically and chronically ill patients in a variety of clinical settings. From lipid injectable emulsions to three-chamber bags, our products are designed to help your patients flourish from hospital to home.

To explore our comprehensive portfolio of parenteral nutrition products, click here. Remember to keep checking back for more updates!

References: 1. What is Parenteral Nutrition? American Society for Parenteral and Enteral Nutrition. Accessed September 23, 2021. http://www.nutritioncare.org/about_clinical_nutrition/what_is_parenteral_nutrition/. 2. John J, Seifi A. Total parenteral nutrition usage trends in the United States. J Crit Care. 2017;40:312-313. 3. Mundi MS, Pattinson A, McMahon MT, Davidson J, Hurt RT. Prevalence of Home Parenteral and Enteral Nutrition in the United States. Nutr Clin Pract. 2017;32(6):799-805. 4. Le J. Drug Administration. Merck Manual Consumer Version. Revised October 2020. Accessed September 27, 2021. https://www.merckmanuals.com/home/drugs/administration-and-kinetics-of-drugs/drug-administration.