1. Lab tests:

a. Before starting TPN: CBC w/diff, plts, PT, lytes, CHEM-12, Mg, triglycerides, prealbumin, 24 hour urine for UUN, weight.

b. When starting TPN: Accu-chek q4h before rate change until maximum glucose conc is reached, then q8h. CBC and lytes daily until stable.

c. When TPN is stable: Urine dextrostix q8h

Every Monday: CBC w/diff, plts, lytes, CHEM-12, Mg, prealbumin (until increasing or normal), triglycerides (if on daily lipids), 24 hour urine for UUN.

Every Thursday: CBC, lytes.

d. Others: Weigh 3 times per week. Record I's and O's daily. Vitamin K 10 mg Sq weekly.

2. Prealbumin (Transthyretin) - Thyroxine-binding protein. Preferred visceral protein to evaluate nutritional status/monitor progress of patient. Half-life of 2-3 days. Normal range 10-40 mg/dl.

3. Transferrin- Iron transport protein. Visceral protein of value in assessing the severity of malnutrition and progress of patient. Half-life of 8 days. Iron deficiency, pregnancy, and hypoxia stimulate transferrin synthesis. Pernicious anemia, chronic infection and iron overload are associated with low transferrin levels. Preferred level is > 200 mg/dl.

4. Nitrogen balance - Use to assess if an anabolic state has been achieved.

Nitrogen intake (gms) = Protein intake (gm)/6.25

Nitrogen balance (gms) = 24 hr N intake - (24 hr UUN + 4)

1. After central venous catheter is placed, obtain portable chest X-ray.

2. Verify catheter position prior to initiating central parenteral nutrition.

3. Only infuse TPN and lipids through TPN port.

4. If TPN is interrupted for any reason, administer D10W at current rate.

5. Refer to TPN guidelines for infusion rates.

6. LIPIDS

IF lipids are given separately; check for egg allergy, if none then run at 0.5 ml/min x 15-20 minutes. If no adverse effects, increase the rate to a maximum of 500 ml over 12 hours.

7. MAINTENANCE ORDERS:

a. Weigh patient 3 times per week.

b. Record all I & O's.

c. Fingerstick glucose monitoring q4h until maximum glucose concentration is reached, then q8h until stable.

d. Urine clinitest QSHIFT once stable and report glucose > 2+.

e. CHOOSE ALL THAT APPLY

____Daily CBC, lytes until stable

____QMON CBC w/diff, platelets

____QMON lytes, SMA-12, Mg

____QMON prealbumin (until increasing or normal)

____QMON fasting triglycerides

____QTHUR CBC,lytes