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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
TARGET AUDIENCE
All Alfred and Sandringham Hospital Medical, Nursing, Pharmacy and Nutrition Staff.
Parenteral nutrition is not available at Caulfield Hospital.
PURPOSE
The intention of this guideline is to ensure evidence-based practice for the management of patients
receiving Parenteral Nutrition (PN) at Alfred Health. This will ensure safe practice that is consistent
across the organisation and ensure optimal patient outcomes.
TABLE OF CONTENTS
Section
Page(s)
1. Definition of PN
2
2. Indication for PN
2
3. Contraindications to PN
2
4. Complications/Precautions to PN
2
5. Route of Administration
3
6. Available PN Formulations
4
6 a. Indications and contraindications for the use of glutamine containing PN
4
6 b. Additions to PN formulations
5
7. Initiation of PN
5
8. Monitoring of PN
5
9. Cessation of PN
6
10. Storage and Handling
6
11. Roles and Responsibilities of the Multidisciplinary Team
7
12. Key Related Documents
7
13. References
8
Appendices
10
1. Composition of PN Formulations at Alfred Health
2. Standard Monitoring Requirements for PN
3. Algorithm for Ceasing PN
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
11
12
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
GUIDELINE
1. DEFINITION OF PN
Parenteral Nutrition is the provision of nutrition through the supply of nutrients directly into the
bloodstream in individuals who are unable to absorb nutrients via the gastrointestinal tract, in order to
maintain the individual’s nutritional status and prevent or treat malnutrition.
The infusion may be termed Total Parenteral Nutrition (TPN) when it provides the patient’s total
nutrition requirements(1) and Supplemental PN when it is used as an adjunct to the provision of enteral
nutrition if absorption of nutrition via the oral or enteral route is insufficient to meet a patient’s total
nutrition requirements.
2. INDICATIONS for PARENTERAL NUTRITION (1-3)
PN is indicated in patients who:
 Do not have access to administer oral or enteral nutrition,
OR
 Do not have a functioning gastrointestinal tract,
AND
 Have not received or tolerated > 60% of nutrition requirements via the oral or enteral route for ≥
3 days AND are likely to require PN for ≥ 5 days (or less if malnourished*)
* Malnutrition Definition as per the ICD-10:
BMI < 18.5 kg/m2 or unintentional loss of weight (≥10%=severe, 5-9%=mild-moderate) with evidence
of suboptimal intake resulting in loss of subcutaneous fat and/or muscle wasting.
Note: Refer to the Alfred Health Identification and Management of Malnutrition Guideline for the
definition of malnutrition and malnutrition risk.
3. CONTRAINDICATIONS to PARENTERAL NUTRITION

PN is not indicated in patients who do not meet the above criteria, or are for palliative
management.
4. COMPLICATIONS/PRECAUTIONS to PARENTERAL NUTRITION
Metabolic complications include, but are not limited to:
 Hyperglycaemia
 Dyslipidaemia (for extra precautions for patients on propofol, see Alfred Health Propofol
Infusion for ICU Sedation Guideline)
 Electrolyte and fluid imbalances
 Deranged liver function
 Refeeding syndrome (refer to Alfred Health Refeeding Syndrome Identification and
Management Guideline)
For precautions related to glutamine containing parenteral nutrition, refer to section 6a.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
Line & septic complications include, but are not limited to:
 Central line-associated bloodstream infections (CLABSI)
 Localised/site infection
 Pneumothorax
 Haematoma formation
 Thrombus
 Line Occlusion
 Line migration or displacement
 Air embolus
 Catheter breakage
 Accidental disconnection
For monitoring of these potential complications, refer to section 8 ‘Monitoring of PN’ and the Central
Venous Access Device: Access and Management guideline, Section 8; CVAD Risk Management.
Allergy
 PN should be used with caution in patients with an allergy to the ingredients in lipid emulsions
(fish, egg, soya). Patients with allergies to peanuts and/or corn may potentially be allergic to
soya oil as well. Should, based on expert judgment of the clinician, PN be prescribed for a
patient with suspected allergies to any of these components, administration should be initiated
with due caution and with a slow infusion to observe for any untoward reactions
5. ROUTE OF ADMINISTRATION

PN must be administered via a central venous access device (CVAD). This includes a central
venous catheter (CVC), peripherally inserted central catheter (PICC), and Hickman catheter. If
a central line with a dedicated purpose is to be used to administer the TPN, please discuss this
with the relevant medical unit before proceeding.

As PN contains glucose, amino acid and fat it carries a higher risk of supporting microbial
growth. For this reason PN must not be disconnected from the CVAD unless lines and flasks
are changed ie: a ‘closed’ system must be maintained.

PN SHOULD BE GIVEN VIA A DEDICATED LINE AND LUMEN AND SHOULD NOT BE COADMINISTERED WITH ANY OTHER MEDICATION BESIDES INSULIN. THIS REDUCES THE RISK OF
BLOCKING OR CONTAMINATING THE LINE. THEREFORE, A DOUBLE LUMEN CVAD IS A MINIMUM
REQUIREMENT FOR PN.
o If line access for multiple medications is of concern, discuss with the senior clinical
pharmacist regarding specific compatibility information.

NOTE:
O
TOTAL PARENTERAL NUTRITION MUST NOT BE GIVEN VIA A PERIPHERAL LINE DUE TO THE
HYPER OSMOLAR NATURE OF THE STANDARD PN FORMULATION, DIFFICULTIES WITH
MAINTAINING PERIPHERAL ACCESS SOLELY FOR FEEDING PURPOSES AND INABILITY TO
SUPPLY ADEQUATE CALORIES VIA THIS METHOD.
o
The administration of single macronutrients such as lipids or amino acids may be
considered in special circumstances in consultation with the Nutrition Manager and
Director of Pharmacy, and the Director of ICU for patients in the intensive care unit.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
 Administration lines and Needless Access Devices
o Administration lines for PN should be changed with the PN bag.
o Needless access devices for PN should be changed every 7 days on antimicrobial
CVCs and every 96 hours on all other CVADs.

For further information regarding the insertion, management and infection prevention related to
CVADs please refer to the following:
Alfred Health Central Venous Access Device: Access and Management Guideline
Alfred Health Aseptic Technique Guideline
Alfred Health Central Line Insertion – Infection Prevention Guideline
6. AVAILABLE PN FORMULATIONS





Two PN formulations containing glucose, amino acids, lipids and electrolytes are available in
premixed bags (Standard PN and Glutamine PN).
All premixed bags contain trace elements and vitamins.
A standard Electrolyte Free formulation is available.
Lipid free, low dextrose or any other formulations are not available.
See Appendix 1 for nutrition composition.
6a. Indications and Contraindications for the Use of Glutamine Containing PN.
Glutamine is an amino acid that is considered to be conditionally essential during catabolic stress,
when glutamine in skeletal muscle stores becomes rapidly depleted.
Indications:(4-7)
 Major Gastrointestinal Surgery
 Intra-abdominal Sepsis
 Severe Acute Pancreatitis
 Trauma
 Burns
AND /OR
 Patients who are likely to have or have measured glutamine depletion.
Contraindications
 ICU patients with shock AND renal failure who are not receiving Continuous Venovenous
Heamodiafiltration (CVVHDF) / Renal Replacement Therapy (RRT)(8,9).
Dose
 A dose 0.2–0.4 g/kg/day of L-glutamine should not be exceeded (e.g. 0.3–0.6 g/kg/day alanylglutamine dipeptide)(1).
6b. Additions to PN Formulations
 If additional intravenous electrolytes, vitamins or trace elements are required they will be
prescribed separately on the medication chart or intravenous order form.
 Additions to parenteral nutrition bags will not be made. Potassium supplementation for
Haematology patients is the only exception. This will be prepared in Pharmacy.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
7. INITIATION OF PN
 The decision to commence PN should be made collaboratively by the multidisciplinary team. PN will
not be dispensed without this discussion.
 The unit dietitian will document a PN regimen, which includes the PN formula, starting rate and
plan to reach target rate in patients’ medical history.
 Medical staff will prescribe PN formulation (standard, glutamine, electrolyte free) and rate on the
IV order form daily.
 Clinical pharmacist to review PN therapy and order PN bag daily.
 Nursing staff to commence PN as per nutrition note and IV order form.
 It is recommended that PN be commenced using the following strategy:
o Commence PN at 40 ml/hour for 4 hours*.
o Increase the rate of PN by 20 ml every 4 hours to target rate or as recommended by
dietitian.
o The rate/formula may be varied according to the patient's medical condition, re-feeding
syndrome risk and blood glucose control.
o If hyperglycaemia already exists (two blood glucose readings >12 mmol/L in the past 24
hours) inform the Endocrinology team prior to commencing PN.
o If blood glucose level (BGL) > 12mmol/L it is advisable to maintain current rate of TPN
for a further 6 hours before increasing and the medical team should be informed.
*For information regarding commencement and management of PN in patients at risk of refeeding
syndrome, please refer to: Alfred Health Refeeding Syndrome Identification and Management
Guideline.
8. MONITORING OF PN
 Refer to Appendix 2 for Standard Monitoring Requirements of PN.
 Monitoring of PN is required to assess for complications: biochemical markers, metabolic function,
fluid and electrolyte balance, nutritional status and to identify signs of line infection.
 Monitoring of PN is the responsibility of the dietitian, pharmacist, medical team and nursing staff.
Blood glucose monitoring and management of hyperglycaemia
 Aim for target blood glucose between 5-10mmol/L.
 Monitor blood glucose levels (min. 6 hourly) or as per medical unit/Endocrinology team.
 If 2 x BGL >12mmol/L in 24 hours notify Endocrinology team to consider commencing insulin.
 For further information regarding blood glucose monitoring refer to Alfred Health Blood Glucose
Monitoring Guideline.
NOTE:
 Monitoring results must be interpreted in light of the patient’s overall condition and full assessment
performed with any previous result(s) available. Use caution when interpreting monitoring results
in isolation.
 In the acutely ill or medically unstable patient, the frequency and extent of monitoring
recommended may need to be increased based on clinical judgement.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
9. CESSATION OF PN(1,10)

The decision to cease PN should be made collaboratively by the multidisciplinary team.

PN should be reduced as oral or enteral intake is introduced, established and approximately 6075% of nutrition requirements are met.
The dietitian is responsible for determining the rate of reduction in the PN infusion. The amount of
nutrition provided by oral or enteral nutrition prior to ceasing PN will vary depending on the patients’
clinical condition and nutrition status.
Weaning PN is not required as the risk of rebound hypoglycaemia is low in normoglycaemic
patients (BGL <12mmol/L) who have not been administered insulin.
It is recommended that PN be ceased as per the algorithm in Appendix 3.



NOTE: If a central-line associated bloodstream infection (CLASBI) is suspected or identified refer to the
Alfred Health Central Venous Access Device: Access and Management Guideline (page 27) and seek
medical advice.
10. STORAGE and HANDLING





Once the PN bag is delivered to the ward, it must be stored in the medication fridge until required
for use.
The infusion line should be changed with every bag change. PN has a hang time expiry of 24
hours. The 24-hour hang time starts from when the PN bag is spiked with the giving set (this time
is to be recorded on the PN bag).
PN bags must be changed or connected using an aseptic technique. Refer to the Aseptic
Technique Guideline.
Once PN has been disconnected the bag should be discarded and CVAD lumens flushed.
A light protective cover bag is provided and should be placed over the bag to prevent deterioration
due to UV light.
11. ROLES and RESPONSIBILITIES OF THE MULTIDISCIPLINARY TEAM
Medical Team
 Primary Medical Team in consultation with Unit Dietitian establishes that PN is indicated.
 Ensure central access is available and is monitored regularly for signs of infection.
 Order and review biochemistry and treat as clinically indicated – see appendix 2.
 Prescribe PN on IV orders form daily.
 Review fluid status and communicate any changes to the dietitian.
Dietitian
 Undertake nutrition assessment: including nutrition requirements and care plan.
 Specify PN formulation and commencement and target rate in medical history.
 Monitor changes in nutrition requirements and adjust care plan accordingly.
 Monitor weight, biochemical and clinical parameters.
 Specify weaning regimen transition onto oral or enteral nutrition.
 Discuss patient management with medical team.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
Clinical Pharmacist
 Liaise with medical and nutrition teams daily regarding formulation and prescription.
 Discuss availability and compatibility of central venous access with nursing staff.
 Daily patient clinical review including organ functions, drug therapy, glycaemic control, fluid status,
biochemistry.
 Advise on management including electrolyte replacement and specific drug therapies.
 Daily liaison with pharmacy team regarding supply (and stability issues in special circumstances) .
Nursing
 Ensure PN is given through a dedicated lumen.
 Daily strict fluid balance charts +/- twice weekly weight.
 Monitor BSL and administer insulin according to prescription.
 Monitor central line daily for signs of infection.
 Ensure PN hang time is < 24 hours.
KEY RELATED DOCUMENTS

Key aligned policy
o

Key legislation, acts & standards:
o

Alfred Health Governance Policy
Charter of Human Rights and Responsibilities Act 2006 (Vic)1
Other relevant documents:
o
Aseptic Technique Guideline
o
Blood Glucose Monitoring Guideline
o
Central Line Insertion – Infection Prevention Guideline
o
Central Venous Access Device: Access and Management Guideline
o
ICU Enteral Nutrition Guideline
o
Management of Electrolytes and Antibiotics via CVC in ICU Guideline
o
Refeeding Syndrome Identification and Management Guideline
REFERENCES
1. Singer P, Berger M, Van den Berghe G, Biolo G, Calder P, Forbes A. ESPEN guidelines on parenteral
nutrition: intensive care. Clinical Nutrition. 2009;28:387-400.
2. Heyland D, Dhaliwal R, Drover J. Canadian clinical practice guideines for nutrition support in mechanically
ventilated critically Ill patients. Journal of Parenteral and Enteral Nutrition. 2003;27:355-73.
3. Thomas B. Manual of Dietetic Practice. 4th ed: Blackwell; 2007.
1
REMINDER: Charter of Human Rights and Responsibilities Act 2006 – All those involved in decisions based on this guideline have an
obligation to ensure that all decisions and actions are compatible with relevant human rights.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
8. Wang Y, Jiang Z, Nolan M, Jiang H, Han H, Yu K, et al. The impact of glutamine dipeptide-supplemented
parenteral nutrition on outcomes of surgical patients. A meta-analysis of randomised controlled trials from
Europe and Asia. Clinical Nutrition Supplements. 2010;34:5219. Jiang Z, Jiang H, Furst P. The impact of glutamine dipeptides on outcomes of surgical patients: systematic
review of randomised controlled trials from Europe and Asia. Clinical Nutrition Supplements. 2004;1(1):17-23.
12. Xian-Li H, Qing-Jiu M, Jian-Guo L, Yan-Kui C, Xi-Lin D. Effect of total parenteral nutrition (TPN) with and
without glutamine dipeptide supplementation on outcome in severe acute pancreatitis (SAP). Clinical Nutrition
Supplements. 2004;1(43-47).
17. Lin J, Chung X, Yang C, Lau H. A meta-analysis of trials using the intention to treat principle for glutamine
supplementation in critially ill patients with burn. Burns. 2013;39(565-570).
18. Windle E. Glutamine supplementation in critical illness: evidence, recommendations and implications for
clinical practice in burn care. Journal of Burn Care and Research. 2006;27(764-772).
19. Heyland D, Muscedere J, Wischmeyer P, Cook D, Albert M. A randomised trial of glutamine and antioxidants
in critically ill patients. New England Journal of Medicine. 2013;368(16):1489-97.
20. Heyland D, Gunnare E, Cook D, Berger M, Wischmeyer P, Albert M, et al. Glutamine and Antioxidants in the
Critically Ill Patient: A Post Hoc Analysis of a Large-Scale Randomized Trial. Journal of Parenteral and Enteral
Nutrition. 2014.
24. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on Parenteral
Nutrition: Surgery. Clinical Nutrition. 2009;28:378-86.
Personal communication, Anushia Streetharan, Fresenius Kabi Australia Pty Ltd, 31/08/2016
KEYWORDS
Nutrition therapy, Parenteral nutrition, Glutamine, Refeeding syndrome, Intensive Care
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
AUTHOR / CONTRIBUTORS
* denotes key contact
Name
Position
Service / Program
*A/Prof Ibolya Nyulasi
Manager
Nutrition Services
Lisa Murnane,
Nutrition Support Lead
Nutrition Services
John Coutsouvelis, Diana
Booth
Senior Clinical Pharmacists
Pharmacy
Bianca Levkovich
Deputy Director – Clinical Services
Pharmacy
Carmela Corallo
Formulary Manager
Pharmacy
Prof. Carlos Scheinkestel
Director
Intensive Care Unit
Prof. Duncan Topliss
Director
Department of
Endocrinology and Diabetes
Prof. Peter Gibson
Director
Department of
Gastroenterology
Prof. Michael Dooley
Director
Pharmacy
Pauline Bass
Manager Infection Prevention and Cancer and Medical
Healthcare Epidemiology
Specialities
Endorsed by:
Name/Title: Alfred Health Drug and Therapeutics Committee
Date: 14th September 2016
Approved by:
Name/Title: Alfred Health Operations Leadership Committee
Date: 4th October 2016
Disclaimer: This procedure has been developed within the context of Alfred Health service delivery. Alfred Health shall not be
responsible for the use of any information contained in this document by another organisation outside of Alfred Health.
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
APPENDIX 1: COMPOSITION OF PN FORMULATIONS AT ALFRED HEALTH
Total Bag Volume
Total Energy per 1 L
Standard PN
1990mL
Glutamine PN
2290mL
4668kJ
(1110kcal)
4589kJ
(1092kcal)
Components (g per 1 L)
Amino Acid (excluding glutamine)
50
Glutamine
0
Glucose
125
Lipid (SMOF)
38
Electrolytes (mmol per 1 L)
40
Sodium
30
Potassium
5
Magnesium
2.5
Calcium
13
Phosphate (including lipid)
105
Acetate
35
Chloride
Vitamins (per bag)
Vitamin A units
3300
Thiamine mg
3.1
Riboflavine mg
3.6
Nicotinamide mg
40
Pantothenic Acid mg
15
Vitamin B6 mg
4
Vitamin B12 microg
5
Vitamin C mg
100
Vitamin D units
200
Vitamin E units
10
Biotin microg
60
Folic Acid microg
400
Vitamin K microg
150
Trace Elements (micromol per bag)
157
Zinc
6
Copper
1
Manganese
0.2
Chromium
1
Selenium
1
Iodide
20
Iron
0.2
Molybdenum µmol
50
Fluorine
All bags contain approximately 175 to 200 mg/L of choline
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Electrolyte Free PN
2020mL
4792kJ
(1147kcal)
54
17
109
33
50
0
125
50
35
26
4
2.2
11
91
31
0
0
0
0
0
41
20
3300
3.1
3.6
40
15
4
5
100
200
10
60
400
150
3300
3.1
3.6
40
15
4
5
100
200
10
60
400
150
157
6
1
0.2
1
1
20
0.2
50
100
20
5
0.2
0.4
1
20
0.2
Review & Update by: October 2020
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GUIDELINE
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APPENDIX 2: STANDARD MONITORING REQUIREMENTS FOR PN
Parameter
Frequency
Rationale
Weekly
Assess adequacy of nutrition therapy
Nutritional Requirements
Energy and Protein
Nutrient intake: prescribed vs. received
Assess oral/enteral intake and
adjust PN accordingly
Assess adequacy of nutrition therapy
Daily
Anthropometry
Weight
On admission,
weekly
then
twice
Fluid and energy balance
BMI
On assessment
Marker of nutritional status
Body composition
Fortnightly - monthly
Better long term marker of nutritional status
Fluid Balance, Weight
Daily
Fluid and energy balance
GIT function-
Daily
Ability to tolerate oral/enteral route
Blood Glucose
6 hourly
Assess glycaemia control
Temperature, heart rate, BP
4 hourly
Possible signs of sepsis
IV access site
Daily
Signs of infection (as per CVAD & central line
infection prevention guideline)
Na, K, Ur, Crt
Daily, second daily if stable
Renal function, fluid status
Mg, PO4
Daily, second daily if stable
Re-feeding
Corrected Calcium
Daily, second daily if stable
Hypocalcaemia may be 2 to Mg deficiency
CRP
Weekly
Assess the presence of acute phase response
LFTs, Bilirubin
Daily, weekly if stable
Liver function
INR
Daily
Assess coagulation
FBE
Daily, weekly if stable
Blood loss, anaemia
Serum Triglyceride
Baseline, then weekly
Assess for hyperlipidaemia
Copper, Selenium, Zinc
Week 4, then monthly
Assess for deficiency
Iron, B12, Folate
Week 4, then 3 monthly
Assess for deficiency
Clinical
bowels/ stoma
Biochemistry
o
Vitamins A,D,E
Cited from: NICE – Nutrition Support in Adults (2006),
Nutrition manual for adults in health care facilities (2009)
Prompt Doc No: AHG0001525 v6.0
Thomas and Bishop, 2007 DAA – Parenteral
Approval Date: October 2016
Review & Update by: October 2020
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GUIDELINE
Title: PARENTERAL NUTRITION FOR INPATIENTS
APPENDIX 3: ALGORITHM FOR CEASING PN
Is there adequate carbohydrate input from another
source? (i.e. oral or enteral nutrition)
Yes
No
Has the patient been
given insulin?
Has the patient been
given insulin?
Yes
Contact
Endocrinology/unit
Registrar to request
review of insulin dosage
prior to weaning PN
Yes
No
Cease PN
Advise medical team to
prescribe 1L IV 5% dextrose
over 12 hours to prevent
hypoglycaemia
Halve rate of PN for 4 hrs
Cease PN
Monitor BGL 1 hour post. If
within normal limits, cease
monitoring.
Contact Endocrinology team
for advice regarding
ongoing glucose provision
and review of insulin
regimen
Upon ceasing PN monitor BGL as per Endocrinology/unit Registrar or 30min, 90min and 4hr post
Prompt Doc No: AHG0001525 v6.0
Approval Date: October 2016
Review & Update by: October 2020
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