Guidance For Commencing
         Total Parenteral Nutrition (TPN)
         In the event patients are required to commence on total parenteral nutrition (TPN) without full 
         input from dietetics/pharmacy review, please ensure the following factors have been considered:
          1.  Patient IV access - central or peripheral
          2.  Risk of Refeeding
                                                           +2     +2
          3.  Biochemistry prior to start TPN including Ca , Mg , Po
                                                                       4-
          4.  Current weight
        TPN is administered via a dedicated central lumen or peripheral placed line.
        Ensure consideration is given to overall fluid balance when commencing TPN.
        Types of TPN available without dietetic review depending on patients IV access.
          Peripheral or Central access             Central Access 
          w Kabiven 5g bag 1440mls                 w Smofkabiven 12g bag 1477mls with
          w Kabiven 9g bag 2400mls                    electrolytes is available for central use only
         Other TPN bags are available including electrolyte and fat free bags - please discuss with your 
         dietitian or pharmacist
         Refeeding Syndrome (Refeeding guideline available on Firstport for further information)
          At risk:              High Risk:                                         Extremely high risk:
          Little to no          One or more of the following:                      BMI <14kg/m2 or 
          nutritional intake    BMI <16kg/m2 or Unintentional weight loss          Negligible intake for 
          for >5 days           >15% last 3-6 months, or low levels of K+,         more than 15 days
                                Mg+2 or Po4- prior to starting TPN
                                Or those with 2 or more of the following: 
                                BMI <18.5kg/m2, Unintentional weight loss 
                                >10% within the last 3-6 moths, little to no 
                                nutritional intake for >5 days, History of 
                                alcohol or drug abuse, chemotherapy
         Prescribe Pabrinex I&II once/day for 10 days for patients at high and extremely high risk 
         of refeeding
          Biochemistry
                                                           +2     +2
          Please ensure biochemistry including, U&E’s, Ca , Mg , PO  are checked and corrected          
          prior to starting TPN and checked daily thereafter.           4-
                                                                                      MPR.PARNUT.20_06800.H
                           Total Parenteral Nutrition (TPN)
                                                 GI tract is not functioning or accessible 
                                               Is patient likely to require TPN for >5 days
                             or is clinical condition likely to persist for >5 days before improvement noted
                                   No                                                             Yes
               Please discuss with medical team in charge/                        Dedicated access obtained for TPN
                dietitian or pharmacist re appropriateness 
                                   No                                                             Yes
                    Request cannula or central access
                                                            +2    +2
                   Check biochemistry including U&E’s, Ca , Mg , PO4 is satisfactory (refer to refeeding guidelines)
                                   No                                                             Yes
                   Replace prior to commencing TPN 
                                       Risk of refeeding syndrome (See page overleaf for factors)
                                                                                                         If patients weight is 
                                   No                                                     Yes           <50kg, please feed at 
                                                                                                        10kcal/kg for first 48 hrs
                                                                                                         and then commence 
             Wt >60kg commence on day 4 of plan below and increase to                  Prescribe         of day 1 of the above 
            day 5 depending thereafter on patient access and biochemistry            Pabrinex I&II      plan and titrate daily if 
                               within normal parameters                              once/day for         biochemistry allows
                                                                                        10 days
                                        Day 1 & 2: Weight >50kg commence on 50% Kabiven 5g bag @30mls/hr x 24hrs
                                                    Day 3: Increase to 75% Kabiven 5g bag@ 45mls/hr x 24hrs
                                                   Day 4: Increase to 100% Kabiven 5g bag @60mls/hr x 24hrs
                          Peripheral access only                                          Central access only
               Day 5: 80% Kabiven 9g @57mls/hr x 24hrs                      Day 5: 80% Smofkabiven 12g with electrolytes 
                                                                                           @50mls/hr x 24hrs
              Day 6: 100% Kabiven 9g @100mls/hr x 24hrs                     Day 6: 100% Smofkabiven 12g with electrolytes 
                                                                                           @62mls/hr x 24hrs