Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast Narrator - ? 00:11 is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk, Episode 113 I'm your co host, Dr. Kane, and I'm Dr. Patel, and today's title is the top 10 clinical pearls for total parenteral nutrition, or TPN. So today we're going through not a comprehensive review of TPN and giving IV nutrition to patients, but kind of the top 10 pearls that are kind of our subjective what we think are key elements that every pharmacist really should know about TPN administration and dosing and things like that. Speaker 1 01:00 And this was actually one of our listener requested subject. So we thank you for that request, and I'm actually really excited to learn or refresh my memory, because this is not the practice setting that I, you know, encounter tpns on a regular basis. So with that, let's get started. Dr. Sean Kane 01:16 Yeah, so Pearl number one is going to be, if the gut works, use it. And really knowing about TPN is important, but knowing when to not use TPN is also really important. So basically, patients are indicated for TPN if they are malnourished, and we think that they're going to be NPO for a while, or if they are not malnourished, we literally wait seven days before we would initiate TPN for a patient. And that's really important, that if someone comes in who's not malnourished, and we know that we're not going to be able to feed them, we will literally wait seven days before starting that TPN in that patient, and that sounds like a really long time, but they're getting IV hydration and things like that. They're just not getting protein fats and dextrose and IV formulation for that first seven days. Speaker 1 01:59 So it may sound extreme that while we are kind of, quote, unquote, starving them for seven days, but there must be a reason why we can't give tpns earlier than seven days, right? Dr. Kane, yeah. Dr. Sean Kane 02:10 And you know what? What's interesting about this is that this was a classic argument between Europe and the US. So historically, Europe loved to give TPN early on and in America, we typically did not. We would wait that full seven days. It turns out that we've done some studies on this. And generally speaking, if you had to take all the studies and kind of condense it down to a sound bite, giving TPN can be harmful, so you have to have a central line, and that is an invasive device for a patient. You know, bacteria love the same stuff that is in TPN, which is nutrition, right? So TPN is associated with the risk of infection, hyperglycemia, liver damage. There are other complications of TPN. It's expensive, so if by day seven a patient doesn't need TPN, you've saved a lot of money. And then, most importantly, and as it relates to the the randomized, controlled trials that are out there that really kind of settled the argument for more or less between Europe and the US. Clinical outcomes are not different if you wait seven days versus if you initiate early TPN. The main primary endpoints in most of the trials have been 3060, or 90 day mortality rates, and they have not been different. So then you look at secondary endpoints, and things like infectious risk is higher, cost is higher, clinical outcomes are not really that different, so there is no reason to give an invasive, costly therapy if it doesn't change any outcomes and it may be associated with harm, which is why we're going to wait seven days to initiate TPN in someone who can't have adequate oral nutrition. Speaker 1 03:39 And that makes absolute sense. So now, just like nutrition concept in general, you know, I feel like the component of the tpns have the macronutrients, which is like the carbs, the fat, the protein, and then the micronutrients. So let's talk about some of the macronutrients, especially fat. What is the composition of fat and how much of the cholesterol versus fatty acids that we're going to need? Dr. Sean Kane 04:05 Yeah, so clinical Pearl number two is that everyone needs just a little bit of fat. So typically, when we do the TPN, the way that we figure out how much fat A patient should get is we figure out the number of calories they need, how much protein they need, and then based on that, would figure out how many non protein calories a patient needs, and among the non protein calories, about a third of that is going to be from fat, and about the remainder, about two thirds, or up to 70% is going to be from dextrose. So that's our typical calculation. But turns out that everyone needs some amount of fat. There's a syndrome called essential fatty acid deficiency, or efad. And this can actually happen in patients that get no fat at all. So if someone gets zero fat within about two to four weeks, they can actually develop the syndrome just because they don't have a sufficient number of lipids. So the way that you prevent efad from happening is that you give at least the minimum. Amount of lipids to a patient, the minimum is 100 grams a week of lipids. So to put it into context, it's about 500 mls of a 20% lipid emulsion, which is what many institutions use for their fat emulsion, or about a liter of propofol per week. Just to give it context, like most patients on propofol will use at least 250 MLS a day. So it's pretty easy to get to that threshold. Speaker 1 05:23 So we're talking about, let's say, for example, somebody who is on tpns and on propofol on top of that, you're probably covering some of the fat related nutrition out of the propofol solution. So may not need to add that into TPN, but this was just the context example. So if they're not on propofol, obviously we're going to have to add this in the TPN, yeah. Dr. Sean Kane 05:46 So I guess 2.1 absolutely propofol matters, and we have to account for that when figuring out how many calories patients are getting, but also if they even need IV fat in addition to their propofol, and usually the answer to that is no. And then number two, you know, it's not okay to just have a patient getting, you know, 5% dextrose for a long amount of time, maybe adding some protein to it. That's not going to be enough. Patients do need fat, so it's not that much, but patients still need some amount of fat. Otherwise they could potentially have this essential fatty acid deficiency syndrome. So you need a little bit, and you don't need to kind of overdo it, but there's some minimum amount that all patients will need. And I think it's worth also mentioning the reason that we use fat is that it's a very calorically dense macronutrient. So in some patients, we increase the amount of fat that we give them simply to give them less dextrose. For example, if hyperglycemia is an issue, but we want to maintain the same number of calories, we can play around with the ratio between fat and dextrose for those patients, depending on patient specific factors. Clinical Pearl number three still relates to the macronutrients, looking at lipids. So as I mentioned, typically, the way that we dose lipids is about 30% or about a third of your non protein calories are going to be made up of fat. Now that's like the very like type a way to dose lipids for a patient. My preferred method that we use at my institution, that I really like actually is kind of a lazier way of doing it, which is basically giving a bottle a day, so a bottle of intral lipid, which is IV fat emulsion. It's a 20% fat emulsion, 250 MLS. If I give a patient one bottle, 250 MLS a day of that, it's more than enough to prevent the essential fatty acid deficiency. And for most patients, that actually ends up being roughly about a third of their non protein calories. So this way, when you hang that bottle, especially if you're doing a two in one TPN, where the lipids are separate from the rest of the TPN, all the nurse has to do is hang the bottle till it's empty, and then she's done with it. As opposed to, you know, if I wanted to give 300 mls, that means that they're going to have to, you know, only use a portion of a bottle. It's more time. It's more waste things like that. And the other benefit here is, if a patient has, let's say, hyper triglyceridemia from our lipid we can now just do a bottle every other day or every Monday, Wednesday, Friday, but still more than enough to prevent the essential fatty acid deficiency. Because, again, you really only need 500 mls per week of this stuff. And if you're doing every other day or Monday, Wednesday, Friday, you're going to be well above that. And that would be a way to deal with the high triglycerides, but still giving the patient adequate calories and not having to deal with like portions of bottles that the patients need and stuff like that. The game is a little bit different. For a three in one TPN, where you just put the fat inside the bag. Nobody cares how much of the bottle you use. But especially for a two in one TPN, this is a really nice way to do it, Speaker 1 08:36 and it seems like we're here talking about just ease of administration, and I guess ease of TPN calculations, because those could be complicated. Dr. Sean Kane 08:44 Oh, yeah, absolutely. And TPN is one of those things that there's so many calculations that are involved, you really want to find opportunities to make it as simple as you can. Simple is better for this. And as you add complexity, that's where error happens, where you can make critical calculation errors where you end up potentially harming the patient, because you kind of lost the forest and the trees. So I'm all about for tpns, keeping it simple, keeping it straightforward, and I think this is one way to do that. Speaker 1 09:12 That's a good mantra to follow. And so now the other macronutrients that we talk about is glucose or dextrose, right? And it's, it's not at the same level, right? I think dextrose is a little bit different than glucose. And it's, that's the key, number four, the point number four that we want to emphasize Dr. Sean Kane 09:29 here, yeah. So if you think about it, like deck Patel for your diabetic patients, they don't check serum dextrose, they check a serum glucose. We give oral glucose, right? But then we give IV dextrose. So at face value, it almost seemed like dextrose is a different sugar molecule than glucose, but that's actually not the case at all, and that's really interesting, that by convention, we have different nomenclature, even though they're effectively the same molecule. Speaker 1 09:54 And so they're basically, we're talking about two different isomers, right? We have the D glucose that. Is what we use for energy and what's produced in nature. And then there's the L glucose, which is the synthetic form and can't really use for the energy. So when we are talking about tpns, the D isomer of the glucose is essentially what our dextrose Dr. Sean Kane 10:16 is, yeah. So when we say dextrose, we mean glucose, and when we mean glucose, we mean dextrose. However, in TPN, when we give dextrose, we're actually giving D glucose monohydrate. Now that monohydrate is important because when we give parenteral glucose in the form of D glucose monohydrate, the monohydrate decreases our caloric density. So normally, glucose, or glucose has a caloric density of four kilo calories per gram. But when you have that monohydrate in there now, because you have some water with every gram of sugar, now your IV dextrose caloric density goes from four down to 3.4 kilo calories per gram. So there is a slight difference in the caloric density. Even though the chemical structures are identical, that monohydrate makes a difference, Speaker 1 11:03 and we have to just then make up for that point six kilo calorie per gram difference, basically here, yeah, Dr. Sean Kane 11:08 you just didn't include it in your calculation. But it matters a little bit, because, especially when I was a student, I didn't really appreciate the difference between glucose versus dextrose and just understanding that they're effectively the same thing, except when you give it IV, it has a monohydrate associated with it, and that monohydrate changes the caloric density a little bit. Speaker 1 11:30 That makes a lot of sense, and now I appreciate the difference here too. The point number five we want to make is about some of the micronutrients. So, you know, we add things such as magnesium and phosphate and calcium into the TPN. And we want to emphasize that we can't put too much of the phosphate and calcium into the TPN, and that we're going to talk about the risk associated with that. Yeah. Dr. Sean Kane 11:55 So like typically in a TPN, we do add phosphate, because if we don't, eventually the patient will have a low phosphate level. So typical amounts of phosphate are going to be around like 20 to 40 millimoles per day of phosphate. Typical amounts of calcium that we put in, it's going to be around 10 to 15 milliequivalents per day, which is about two grams of calcium gluconate. So neither of these are like high doses of phosphate or calcium. This would be like a typical, normal amount that you'd give IV to a patient that had a low level and you're doing this essentially so that if a patient is in po for a long enough time period that they have these electrolytes and they don't have to leach them from their bones and stuff like that. And that's great. The problem, though, is that phosphate and calcium love to bind to each other. So actually, when you prepare a TPN, you're always going to start with one or the other as your first ingredient, and then you're going to use the other one as your very last ingredient. So for example, when making a TPN, TPN compounder, might start with the calcium as its first electrolyte, and then add phosphate at the very end as its very last electrolyte. So by doing that, you can reduce the risk of a calcium phosphate precipitate forming in the TPN during compounding. And really one of the reasons that we don't add that much is that the risk of precipitation goes up with the higher concentrations in TPN of phosphate or calcium. So you're kind of limited in terms of how much of either one you can put into a TPN. Speaker 1 13:15 Yeah, I do remember making sure that, you know, we want to use the right amount for this. This is where the TPN calculation would come in handy. Want to make sure that we're not using more than what's needed, otherwise precipitation can happen. And again, goes back to the technique of how we mix these two together. But something tells me that this may be a non issue, because most patients don't need more than the usual dose of the calcium. Correct? Dr. Kane, absolutely. Dr. Sean Kane 13:42 And this is probably one of the most common errors that I see when students evaluate a TPN, when we get our Chem seven plus mag, phos and calcium, almost every ICU patient and most hospitalized patients will have low albumin levels. Albumin is a negative acute phase reactant, which means that when you get sick, your albumin levels naturally drop as part of your stress response and your inflammatory response, and that matters because calcium is highly bound to albumin. So as your albumin drops, your calcium will also falsely become low. So normal calcium is about eight to 10, we'll say so having calciums in the sixes and sevens is not uncommon, but it's a falsely low calcium level. So you actually have to correct for hypoalbuminemia with calcium. And when you do that corrected calcium, correcting for that low albumin, almost all patients will end up in a normal range between roughly eight to 10. So at face value, you see a calcium level of six and a half, and you're like, Oh man, I got to go hog wild and add as much calcium as possible to get that calcium level where it needs to be. But in reality, the calcium levels fine when you account for their albumin. So most of these patients don't need extra calcium, and in fact, they have plenty of calcium temporarily in their bones if they really needed it. And again, we add it so that they don't have to leach from their bones. But. Most patients can just have the effectively, two grams of calcium gluconate per day and do perfectly fine with that. You don't need to keep going up and up and up on that unless there's something else going on for the patient. Speaker 1 15:10 So adding one more step into the calculation we're emphasizing here that we should really look for that corrected calcium when coming up with the dose Dr. Sean Kane 15:19 absolutely and this is probably, like, one of the most common pearls that comes up with respect to TPN, because it's such an easy mistake to make when evaluating a patient's electrolytes. Speaker 1 15:30 So point number seven is interesting too. You're talking about sodium content, and it's important because, you know, we're looking at milliequivalents, you know, the ranges and the doses, and the comparison with what's normal in the human blood versus normal saline that, you know patient is we're compounding the tpns with. So let's, let's talk about that. Dr. Kane, Dr. Sean Kane 15:55 yeah, you know, I think one thing that makes TPN hard, especially dosing it is, as pharmacists, were very familiar with like, how much sodium is in normal saline, 154, mil equivalents per liter. But when it comes to TPN, one issue is that tpns are often described in different ways of describing the dose. So for example, some institutions will dose sodium and tpns as mil equivalents per liter. Others will do milliequivalents per day. Others will do milliequivalents per kilogram per liter, and there's all sorts of other variants out there. So what ends up happening is that, you know, as pharmacists, we end up losing sight and clinical context of the drugs that we're putting into the TPN. So my number one tip when it comes to sodium is always convert your sodium in your TPN to milliequivalents per liter, and then contrast that with milliequivalents per liter of sodium with other fluids that you're more familiar with. So for example, normal saline has 154 milliequivalents per liter of sodium, which is actually hypernatremic. That's like more sodium than your blood, which is 135 to 145 so it'd be a big red flag if you have a TPN with more than 154 milliequivalents per liter of sodium, because effectively, you're giving them a very hypernatremic solution that probably the patient doesn't need that much sodium, unless, again, there's something really goofy going on with them. And again, we have other IV solutions that also have sodium in them, so like lactated ringers, has 130 milliequivalents per liter, half normal saline, which is considered basically a maintenance IV infusion, has 77 milliequivalents per liter. And of course, D 5w has no sodium in it, zero milliequivalents per liter. So probably your TPN should have some number in terms of amount of sodium, between zero the equivalent of D 5w all the way up to 154, milk equivalents per liter, the equivalent of normal saline. And if you're not in that range, you probably need to really closely evaluate what is going on. And why are you going outside of that range? Why does the patient need that much sodium in their TPN, for example? Yeah. Speaker 1 17:53 And then a lot of the time, when it comes to, you know, your calculations for the sodium, if it's off, you probably want to look at the the water amount, right? It's, if you're looking at the hyponatremia or hypernatremia, it's probably because either we're getting too much, the patient's getting too much fluid or too little fluid. And when I say fluid, it's water, absolutely. Dr. Sean Kane 18:13 And that's another key component of this number seven, Dr. Patel, is when you see, let's say, hypernatremia, usually it's not because the patient has ingested too much sodium, it's that they don't have enough water, or if they're hyponatremic, they have too much free water. They've been chugging down water, and we have to get rid of some of that free water. So most of the time, changing the sodium in your TPN is doing absolutely nothing in terms of altering the patient's serum sodium. Most of the time you're actually needing to alter the amount of water that they get, not the sodium, and that's actually true with most hyper and hyponatremias. Anyway, it's usually not a salt problem or sodium problem. It's usually a problem of water. Unknown Speaker 18:53 I 100% agree with you, yes. Dr. Sean Kane 18:56 Number eight deals with how we give the other electrolytes. So Dr. Patel, if you think about it, when you add sodium to a TPN, we can't take, like, a stick of sodium and throw it in the TPN, pure sodium, right? We have to have a salt form of it. Speaker 1 19:09 So yeah. So we're thinking about, like sodium chloride, or when we're talking about potassium, perhaps potassium chloride, Dr. Sean Kane 19:16 exactly, and basically, for sodium potassium, which are the main electrolytes that you're adding to that TPN, your options are sodium or potassium phosphate, sodium or potassium chloride, and sodium or potassium acetate. So you know, when we give sodium phosphate, we're really giving it for the phosphate component, not the sodium component. So effectively, when we're trying to give extra sodium or extra potassium to a patient, we have to decide we want to add the chloride salt or the acetate salt to the patient. You know, the balance of those two is actually dictated by the acid base balance of the patient. Speaker 1 19:51 So when you're saying the balance, let's say we have a patient with no acid base issues, so meaning their acids and bases are fine, then we're going. Aim in the TPN, maybe a 5050 mix when it comes to a chloride versus acetate, exactly. Dr. Sean Kane 20:05 So let's say that for that normal patient, no acid base problems, you wanted to give them 40 milliequivalents of potassium. That 5050 mix would mean that you would be giving of that 40 milliequivalents of potassium, 20 milliequivalents would come from potassium chloride, 20 would come from potassium acetate. Therefore you're giving a 5050, mix, right? Speaker 1 20:25 And the reason is, like we said, you know, we're really accounting for any kind of acid base imbalances. So if there is too much chloride, it's going to act as an acid. It's going to decrease the pH, right? So becomes more acidic, and decrease the bicarb, and it's going to increase, obviously the chloride, the serum chloride itself, and this could ultimately result into acidemia, yeah. Dr. Sean Kane 20:50 So you know, more common is, especially in the ICU, we see lots of lactic acidosis. We see plenty of acidic patients, so alkalosis is a little bit less common. So the more common scenario is that you have that patient with a low bicarb. Lower phlorid is higher because they got three liters of normal saline, which is an acidic solution. So more commonly, what we actually have to do is give a little bit more acetate. So for acetate, it eventually turns into bicarb, effectively in the patient. So by giving an acetate based salt, you can make their bicarb go up and help correct for an acid base balance or imbalance that the patient has. Potentially, you could go as far as giving all of your salt as the acetate. So you could potentially give 100% of your sodium as sodium acetate. 100% of your potassium is potassium acetate depending on how severe that patient's acid base balance is, and how they're responding to the TPN that you made yesterday, and how you're adjusting it today. Speaker 1 21:49 So in a nutshell, look at the patient's acid base status. If it's normal, do 5050, if it's not normal, then you can actually adjust the amount of chloride and acetate Dr. Sean Kane 21:59 salt Exactly. Yeah. Now, Dr. Patel number nine is right up your alley. So my clinical Pearl number nine is, in most circumstances, we should not be adding insulin inside the TPN to treat hyperglycemia. And if you think about it, this is like something that seems so intuitive, right? So you have all this sugar in a bag that you're giving IV to a patient, and if they're getting hyperglycemic, why would you not add insulin into the bag so that while they're getting the sugar water, they also get insulin to help with that hyperglycemia? Speaker 1 22:30 Yeah, it's very interesting, and really the reasons are a couple fold here. Insulin actually gets absorbed into the TPN bag or the tubing. So let's say we have 10 units of insulin in the TPN, for example, and we don't, don't really know how much is going to be absorbed in that bag or the tube and how much patient is going to ultimately get. So it gives us that unpredictability. And then secondly, let's say a patient has hypoglycemia because we added too much TPN, or they just had too much insulin running. Now there is insulin running, there is, you know, hypoglycemia, and now we've already added insulin in the TPN, so we can't really give that TPN anymore, because it's going to further aggravate the hypoglycemia. And we just made this expensive bag of TPN. It's just sitting there, so patient probably won't be able to receive the TPN that day. We want we don't want to do that either. And so the real approach here for the management of the hyperglycemia, rather than adding the insulin in the TPN bag, is to perhaps recalculate the amount of dextrose we're going to add in the TPN or on the separate side, just correct it with the sub q insulin therapy. Dr. Sean Kane 23:46 Yeah, and I mean in terms of the dextrose, like patients are going to need calories, right? So if you want to give them less dextrose, but still give them adequate calories, in many instances, you can just increase the amount of lipids that you're giving the patient and decrease that dextro so that that can be one strategy for the helping with hyperglycemia. And really, if you think about it, as annoying as it is, if you will, of giving subcutaneous insulin, people are really familiar with subcutaneous insulin. We give it all the time. People know about basal strategies and sliding scales and correction factors and all that stuff. So you have so much flexibility by giving it subcutaneously versus when you make a bag, that bag is a 24 hour bag. There's nothing you can do to adjust at that point, and you are in a lot of trouble if they do get hypoglycemic, because now that bag is going to make them more hypoglycemic because of that insulin that you put in it. So that predictability, the familiarity with subcutaneous insulin, makes us a pretty clear winner when making that TPN, Speaker 1 24:49 it makes sense. You know, we don't want to waste the TPN because we have to stop it or, you know, it's or not, have the patient get the other nutrients that were part of the TPN back. So Dr. K. I do remember, when practicing as a resident in the inpatient setting that there has to be a particular way the TPN gets administered when we are talking about the IV lines and stuff. So that's, that's where we are talking about a specialized IV filter, correct? Yeah. Dr. Sean Kane 25:17 And you know, as pharmacists, oftentimes these drugs are given by nurses, so we're not necessarily at the bedside to appreciate the nuances of how they're given to a patient. So this is an area that I think I'm I've always been a little bit less familiar with. But at the same time, when nurses don't know how a given drug should be administered, we're usually the first people that they call about that. So in terms of tpns, because of things like having calcium phosphate and the TPN, and other items that you're going to add to the TPN, tpns will have some amount of micro precipitates, so insoluble compounds that will never form into a full solution. And basically you don't want that to go into a patient's blood. Those micro precipitates, if they're big enough, can cause harm to the patient. So to avoid those from getting into the patient's blood, you must use a filter for all tpns before it gets to the patient. And the kind of filter you use is based on whether you have fat in the bag, or that would be called a three in one TPN, where your fat, dextrose and protein, are all in the same bag. Or if you're using a two in one bag, where you have fat separate from your protein index dose and electrolytes, and that fat is infused in its own dedicated line. Speaker 1 26:29 So then the that's where the size of the filter kind of separates, right? So when you're talking about three in one, where we have the fat in it, we're going to use a little bit of larger filter, we are talking about 1.2 micron because a smaller filter can be clogged by these fat globes or the emulsion and then the two in one, which is, you know, fat is separate. It's just protein, dextrose and other micronutrients. We could use a smaller filter at the point two two micron filter, yeah. Dr. Sean Kane 27:01 So those fat globs are about 0.5 microns in width, so the point two two micron is going to clog because the fat globs are just going to clog up that point two two micron filter. So for the three in one, you are kind of forced to use a larger 1.2 micron filter. But for the two in one, there's no reason to not use that really small filter to get rid of as many micro precipitates as you can. So in terms of some key concepts from these 10 clinical pearls, one big concept is fats. So essential fatty acid deficiency, or efat, you can prevent this just by giving 500 mls, which is typically two bottles of a 20% lipid emulsion once a week. And my preferred method of dosing lipids is kind of this lazier method, where you just give a bottle a day or a bottle every other day if a patient has hyper triglyceridemia. And that makes the lipid dosing incredibly straightforward and gives you less opportunity for error when making TPN based calculations. Speaker 1 28:00 And because, you know, we're considering TPN when patient, you know, it's my malnourished we're going to see lower level of albumin, so it's a Q phase reactant. And what it means is that when we are looking at calcium doses, we don't need to be giving escalating doses, because we need to account for that correction of the calcium. And the downside of giving escalated calcium doses is that, you know, along with the phosphate, it's going to cause compatibility issues and cause precipitates in the TPN solution. Yeah. Dr. Sean Kane 28:34 And the third point is, in terms of sodium, always think of sodium and milliequivalents per liter within your TPN, because that's how we describe sodium and all of the other IV fluids that we give to patients, from D 5w with no sodium, all the way up to normal saline with 154 milliequivalents per liter. And for the most part, you should stay within that range, unless there's some extenuating circumstance for your patient. Oftentimes, when you have hyponatremia or hypernatremia, it's actually not a sodium problem, but a water problem. So always be thinking about the amount of free water the patient is getting, or the amount of sterile water in your IV TPM, and maybe either increasing that or decreasing that, as opposed to making dramatic changes to the patient's sodium content of their TPN. Speaker 1 29:19 And another point to make is a balance between acetate versus chloride salt, right? So you want to use mostly acetate based electrolyte salts if you're looking at patients who have acidotic picture, metabolic acidosis, because that would, in turn increase the bicarb and decrease the chloride. And on the opposite side, if you're looking at alkalotic pictures of metabolic alkalosis. We want to use more chloride based solutions to get the opposite effect, basically. And last, but not the least, an important point to make is, let's just keep the insulin outside of the TPN. It causes compatibility issues. It causes hard time adjusting the blood glucose. The patient becomes hypoglycemic, it's just so much better to adjust the insulins on the subcutaneous level, or if you know there is a drip going on separately that fashion, rather than adding into the TPN and perhaps wasting that bag. Dr. Sean Kane 30:13 Well, hopefully this was a concise but helpful review for mostly the inpatient pharmacist or even the students who are going to start on your rotation soon, and maybe seeing tpns or being asked to dose tpns. This is one of those things that it's a very complicated topic, and I think just having a couple clinical pearls in your back pocket can really make a difference in terms of improving patient care. If you'd like to see some tips and tricks, we'll have some references available at our website, HelixTalk.com this is episode of 113 we also have just some key concepts from today's episode that you can view there. We're also on Twitter at HelixTalk. If you want to see previous episode, clinical pearls and tips of wisdom and things like that, feel free to follow us there. And finally, we love the iTunes five star reviews. So keep those coming. And again, this topic, the TPN topic was prompted by a listener email. So if you have topics that you'd like to hear about, let us know. You can find our contact information at HelixTalk.com so with that, I'm Dr. Kane and Unknown Speaker 31:13 I'm Dr. Patel, and as always, steady, hard. Narrator - Dr. Abel 31:16 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store, search for HelixTalk and place your review there Narrator - ? 31:28 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.