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Journal of Parenteral and Enteral

Nutrition http://pen.sagepub.com/

Home Parenteral Nutrition Tutorial

Donald F. Kirby, Mandy L. Corrigan, Rex A. Speerhas and Dorothy M. Emery
JPEN J Parenter Enteral Nutr 2012 36: 632 originally published online 24 September 2012
DOI: 10.1177/0148607112460397

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460397 PENXXX10.1177/014
8607112460397Journal of Parenteral and Enteral Nutrition / Vol. XX, No. X, Month XXXXHome
Parenteral Nutrition Tutorial / Kirby et al


Home Parenteral Nutrition Tutorial Journal of Parenteral and Enteral

Volume 36 Number 6
November 2012 632-644
© 2012 American Society
for Parenteral and Enteral Nutrition
Donald F. Kirby, MD, FACP, FACN, FACG, AGAF, CNSC, CPNS; DOI: 10.1177/0148607112460397
Mandy L. Corrigan, MPH, RD, LD, CNSC; Rex A. Speerhas, RPh, BCNSP; http://jpen.sagepub.com
hosted at
and Dorothy M. Emery, RN http://online.sagepub.com

The nutrition support practitioner may be called upon to help coordinate care at home for a patient who requires prolonged intravenous
nutrition after he or she becomes stable enough to leave the hospital. This tutorial reviews the many concepts that must be considered to
manage this type of care successfully. (JPEN J Parenter Enteral Nutr. 2012;36:632-644)

home parenteral nutrition; vascular access; adults

Introduction nutrients to sustain themselves. Surgical and medical teams

refer patients to NST physicians for determining the appropri-
Dudrick and colleagues1 developed and established the tech- ateness of HPN therapy in patients with intestinal failure (IF).
niques for administering parenteral nutrition (PN) in the IF is defined as a loss of absorptive capacity secondary to
1960s. Since then, home parenteral nutrition (HPN) has come obstruction, dysmotility, surgical resection, congenital defect,
to be used for patients who require an extension of intravenous or mucosal disease, resulting in chronic diarrhea, dehydration,
(IV) nutrition beyond the hospital. HPN is not without risk, but electrolyte abnormalities, micronutrient imbalances, and mal-
techniques of PN administration in the hospital have been nutrition.2 These patients may require HPN for several weeks
adapted for use in the home setting. As challenging as it can be or months or indefinitely. Table 1 lists the common etiologies
for the patient and additional potential caregivers to administer for HPN. Patients with cancer who cannot maintain fluids and
this type of therapy at home, it has become much easier with electrolytes and could be candidates for hospice care will not
the availability and evolution of many home care services that be discussed further here.
were not available when the first patients went home from our
program in the 1970s. Over the years, infusion devices have
become smaller in size and more portable, thereby reducing Table 1. Common Indications for Home Parenteral
restrictions to allow more freedom of movement so that Nutrition in Adults
patients are not homebound. Short bowel syndrome
Nutrition support teams (NSTs) are commonly composed Radiation enteritis
of physicians, dietitians, pharmacists, nurses, and social work- Severe pancreatitis refractory to enteral nutrition trial
ers, but few hospitals in the United States have home NSTs Gastrointestinal motility disorders
managing these complex patients. Proper delivery of HPN High-output gastrointestinal or pancreatic fistulae
Bowel ischemia
therapy requires an interdisciplinary approach as well as a
Bowel obstruction
clear understanding of the pathophysiology of the underlying
Inflammatory bowel disease with malabsorption
condition, safe solution ordering, fluid and electrolyte manage-
Selected oncology patients
ment, management of short- and long-term infectious and non-
infectious complications, and selection and maintenance of
vascular access devices (VADs). The purpose of this article is
to provide a thorough review of transitioning patients from
From the Cleveland Clinic, Cleveland, Ohio.
hospital to home and management of HPN therapy.
Received for publication July 9, 2012; accepted for publication August 10,
Patient Selection
Financial disclosure: none declared
Patients who have been receiving PN in the hospital
Corresponding Author: Mandy L. Corrigan, MPH, RD, LD, CNSC,
may become stable enough to consider leaving the hospital, but
Nutrition Support, Clinician, Home Parenteral Nutrition, Cleveland
for a number or reasons, they may not be able to either main- Clinic, 9500 Euclid Ave/TT2, Cleveland, OH 44195, USA;
tain their fluids and electrolytes normally or ingest sufficient e-mail: corrigm5@ccf.org.

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Home Parenteral Nutrition Tutorial / Kirby et al 633

Table 2. Medicare Criteria for HPN (www.cms.gov)

Massive small bowel resection (leaving ≤5 feet of small bowel Complete mechanical small bowel obstruction (inoperable)
distal to the ligament of Treitz)
Short bowel syndrome (enteral losses exceed 50% of enteral Bowel rest for at least 3 months (severe exacerbation of regional
intake) enteritis or proximal enterocutaneous fistula and tube feeding
distal is not possible, symptomatic pancreatitis)
Weight loss 10% in ≤3 months
(serum albumin below 3.4 g/dL, fecal fat tests demonstrating malabsorption)
(serum albumin below 3.4 g/dL, gastrointestinal motility disorder refractory to maximum
prokinetic medication, diagnostic test showing dysmotility)

After HPN is deemed necessary, a care plan should be devel- will provide some of the HPN and/or related supplies as char-
oped by the interdisciplinary team with patient involvement, ity care, and the patient is required to pay a set cost out of
and the patient should understand the risks and benefits of HPN pocket.
therapy. The care plan should include the indication for HPN,
the approximate length of HPN therapy, end point (surgery,
spontaneous healing of fistula, resolution of obstruction, transi-
IV Access
tion to enteral nutrition [EN], etc), and the goals of HPN (weight One of the most critical decisions that must be made prior to
gain, weight maintenance, weight loss). After determining the hospital discharge is how long the intended HPN therapy may
plan of care, selection of the proper VAD should follow along be needed, short vs long term. The answer to this will help in
with patient education, identification of the HPN caregiver, selecting the most appropriate VAD for each individual
insurance review by a nurse case manager, selection of a patient. To avoid multiple needless catheterizations, the deci-
homecare agency and infusion pharmacy, evaluation of the sion should be made by collaborating with the primary service,
home setting (for safety), and stabilization and cycling of the Infectious Disease Service (if antibiotics are necessary), the
HPN solution. For centers providing HPN without management NST physician, and the patient. Advantages/disadvantages for
by a physician lead NST, case managers assist in identifying a each VAD include the following: patient/caregiver ability to
physician to prescribe HPN and coordinating the many differ- care for the VAD, activity level, body image concerns, previ-
ent skilled therapies that patients may require. ous history of VADs, additional therapies needed, and patient
preference.5 Figure 1 shows the potential sites for IV access.
Choices for vascular access include tunneled VADs with an
Reimbursement anchoring cuff (Hickman/Leonard, Broviac, and Groshong),
The case manager or discharge planner plays a critical role in implantable ports, and peripherally inserted central catheters
determining the patient’s insurance benefits and reimburse- (PICCs). For “short-term” therapy, defined as short to moder-
ment for HPN. Costs associated with HPN were estimated at ate duration (usually weeks), a PICC is often used.6 This can
$140,000 annually in 1992 and are probably higher now.3 For be placed at the bedside by a specialty team or in interven-
patients with Medicare, the Centers for Medicare & Medicaid tional radiology. Some advantages of the PICC are the cost-
Services (CMS) criteria must be met for reimbursement of effectiveness of bedside placement, decreased risk of catheter
HPN. Criteria for HPN coverage include the following: HPN insertion complications, and ease of removal upon completion
therapy is required for at least 90 days (CMS defines the con- of HPN therapy. Disadvantages include the following: patient
dition causing the need for HPN therapy to be 90 days or is less independent with the care of the PICC, dressing must
lifetime as judged to the best of the attending physician’s remain dry, tip migration if the PICC is not secured, and a
knowledge) and weight maintenance cannot be possible using greater risk of thrombosis due to the small intraluminal diam-
other methods (enteral feeding or pharmacological interven- eter of the catheter.7
tions). Diagnoses covered by CMS for HPN therapy (see Table For longer term therapy, months to years, tunneled cathe-
2) include bowel obstruction, pancreatitis, small bowel fistula ters are the mainstay. Advantages of tunneled catheters are
(not able to be bypassed with a feeding tube), or intestinal ease of self-care, they can be used for an extended timeframe,
malabsorption or dysmotility.4 Documentation such as opera- the cuff aids in the prevention of bacteria migrating into tunnel,
tive reports, laboratory values, and imaging studies are and the ability to repair holes or breaks. However, there is a
required by CMS to support the diagnosis of intestinal failure lower risk of thrombosis8 with tunneled catheters compared
requiring HPN. Medicaid benefits and private insurances cov- with PICCs. Implanted ports are another option for long-term
erage vary, and benefits should be reviewed by the case man- continuous therapy or intermittent therapy. An advantage of a
ager or discharge planner to ascertain individual benefits. port is minimal alteration in body image, no concern for acci-
Patients without insurance coverage provide additional chal- dental pulling or cutting of the device, and patients may go
lenges for the discharge planner. Often, homecare providers swimming when the port is not cannulated. A disadvantage is

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634 Journal of Parenteral and Enteral Nutrition 36(6)

Figure 1. Common intravenous access sites for home parenteral nutrition.

the needle stick to access the port, and with severe infections, antibiotics are ordered every 12 hours, this could be given
a surgical procedure is needed for removal. before and after the HPN 12-hour cycle. For antibiotics given
Another consideration when selecting a VAD is the number more often than every 12 hours, a double lumen would be
of lumens that will be needed. It is very important for patients required. Selecting the optimal double lumen may help in
to receive the fewest number of lumens required. Unneeded decreasing chances of withdrawal or total occlusion complica-
lumens require unnecessary manipulation of the catheter, tions (unpublished observation). One option is the Hickman 9
which increases the chance of infection. Also taken into con- Fr., with the white lumen having the intraluminal size of 0.7
sideration is the cycle of the HPN solution and if other IV mm and the red lumen 1.3 mm. Another option, the Leonard 10
therapies are required. For instance, with a single lumen, if Fr., is more desirable as both lumens are 1.3 mm. Otherwise,

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Home Parenteral Nutrition Tutorial / Kirby et al 635

Table 3. Central Vascular Access Device Complications

Central Vascular Access Device Complications Symptoms

Exit/insertion site infection Erythema, drainage, swelling, or tenderness
Tunnel infection Pain, swelling, erythema, or induration along the subcutaneous tract of a tunneled
(eg, Hickman or Broviac) catheter
Port pocket infection Tenderness, purulent drainage, and erythema in the subcutaneous pocket of totally
implanted port
Withdrawal/total occlusion Inability to aspirate blood and/or flush the catheter
Pinch-off syndrome Complication of subclavian tunneled central catheter with intermittent/permanent
occlusion related to postural changes
Thrombosis Chest pain; earache; jaw pain; swelling of arm, shoulder, neck, or face on ipsilateral
catheter side; leaking at exit/insertion site
Superior vena cava syndrome Shortness of breath; dyspnea; cough; cyanosis of face neck, shoulder, and arms;
distended chest/neck veins
Air embolus Coughing, shortness of breath, and chest pain
Skin erosion Erythema, skin abrasions, or tears over central venous access device

the Leonard catheter is identical to the Hickman catheter; the needleless connector before clamping can cause reflux of
difference between the two is simply the diameter of the blood back into the catheter. It is recommended when flushing
lumens. to leave a small amount of saline in the syringe and while
Not only is selecting the appropriate VAD of utmost impor- actively flushing close the clamp. Positive pressure will pre-
tance, but also the vessel where the catheter is placed can help vent retrograde of blood into the catheter. With the neutral dis-
in decreasing possible complications. Figure 1 shows the placement connector, there is no fluid movement in either
potential sites for IV access. The choice of the insertion site is direction when tubing or syringe is disconnected. Flushing
dependent on many factors such as patient anatomy, chest wall with a positive displacement connector means that when dis-
disease, previous catheters, radiation therapy, implanted defi- connecting, a small amount of fluid is forced from the reser-
brillator/pacemaker, and previous thrombosis. According to voir of the connector into the catheter to prevent the reflux of
the Centers for Disease Control and Prevention (CDC), “No blood. In this case, clamping after disconnecting is required.
recommendation can be made for a preferred site of insertion Helping the patient maintain the VAD for the duration of
to minimize infection risk for a tunneled central vascular cath- HPN therapy should be the goal, and measures to help meet
eter.” However, the CDC does recommend the avoidance of this goal include hand hygiene, access site disinfection, and
the femoral site.9 providing education to the patient on caring for the VAD.
Many preventive strategies and new technologies are avail-
able to help prevent some VAD-related complications (Table
3). Thrombotic catheter occlusion and catheter-related infec-
Solution Basics (Adapted From
tions are the most commonly reported catheter complications Speerhas and Rhoda13)
for all types of VADs in the healthcare setting. One preventive Components of HPN solutions include protein in the form of
strategy to help in decreasing thrombosis is ensuring that the amino acids (AAs), carbohydrate in the form of dextrose, elec-
tip of the VAD is positioned in the right atrium/superior vena trolytes, minerals, vitamins, trace elements, medications, and
cava (SVC) junction.10 The tip of the catheter should be aligned sterile water for injection. Fat may be added daily to HPN or
with the vessel walls and free floating. According to administered separately.
Kusminsky,11 malpositioned VADs have been associated with
problems of local toxicity, SVC perforation, and venous
thrombosis. Previously, VADs were placed within the right
Amino Acids
atrium, but the current practice opposes this because of the Synthetic crystalline amino acids, which provide 4 kcal/g, are
increased risk of perforation. Other preventive strategies to used in PN as a source of protein. AA solutions are made by a
help decrease the incidence of thrombotic occlusions and pos- number of manufacturers, range in concentration from 3%
sible infection would be using proper flushing technique and (30 g/L) to 20% (200 g/L), and are available in standard or
correct clamping sequence when disconnecting the syringe disease-specific formulations.
from a needleless connector. It is important to know what type Standard AA solutions contain 8 essential AAs plus cysteine
of fluid displacement the connector has—negative, positive, or and 6 nonessential AAs. Some standard AA solutions (specifi-
neutral—to prevent blood reflux into the tip of the catheter.12 cally, FreAmine III [B. Braun, Bethlehem, PA]) also contain an
With negative fluid displacement, disconnecting from the appreciable amount of phosphate, which must be considered for

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636 Journal of Parenteral and Enteral Nutrition 36(6)

compatibility and when dosing electrolytes. A 10% solution is Table 4. Multivitamin Injection Formulations, 2000
used in PN formulas that do not require concentrated or dis- Ingredient Amount/Unit
ease-specific AAs. Concentrated AA solutions, 15% or 20%,
are available when minimizing fluid intake is required. Fat-soluble vitamins
  A (retinol) 1 mg
Choline is a nonessential AA that is found in many foods,
  D (ergocalciferol or cholecalciferol) 5 mcg
and consequently, deficiencies are rare. Approximately 80% of
  E (α-tocopherol) 10 mg
patients who rely on HPN for their full source of nutrition have
  K (phylloquinone) 150 mcg
been found to have low levels of choline circulating in the
Water-soluble vitamins
blood.14 Some investigators think that choline deficiency may
  C (ascorbic acid) 200 mg
contribute to the development of PN-associated liver disease  B1 (thiamine) 6 mg
(PNALD). Choline is not routinely added to HPN formulas  B2 (riboflavin) 3.6 mg
since it can be synthesized endogenously from methionine and  B6 (pyridoxine) 6 mg
therefore is not an essential AA. In contrast, studies have  B12 (cyanocobalamin) 5 mcg
shown that this pathway may be altered when patients are on   Folic acid 600 mcg
HPN. Buchman et al15 showed that patients receiving HPN  Niacin 40 mg
with choline deficiency and hepatic abnormalities had a rever-   Pantothenic acid 15 mg
sal in these hepatic abnormalities once choline supplementa-  Biotin 60 mcg
tion was started. Further clinical trials are still needed to fully
understand the effect of choline supplementation intravenously
on PNALD, and development of an injectable choline prepara- mL, 20% provides 2 kcal/mL, and 30% provides 3 kcal/mL. A
tion is still needed. minimum of 100 grams of IVFE is required weekly to prevent
EFA deficiency. Other fat emulsions formulations are available
outside the United States but will not be discussed here.
Carbohydrate is provided as dextrose and is usually the pri-
mary calorie source in PN. IV dextrose has 3.4 kcal/g and is an
inexpensive, readily available energy source that can be Some electrolytes and minerals are inherent in AA mixtures.
admixed with any AA solution. Commercially available dex- Additional electrolytes and minerals are added to PN in the
trose solutions range in concentration from 5%–70%. amounts based on the individual needs of the patient. Sodium
and potassium are available in salt forms as chloride, acetate,
and phosphate. The gluconate salt of calcium is the preferred
Fat form of this mineral (over calcium chloride) since it is less
Fat is available for IV use as an oil-in-water emulsion. The likely to cause incompatibilities in PN.5 Multichambered PN
emulsified lipid particle ranges from 0.1–0.5 microns in diam- bags are also commercially available with a standard mixture
eter, which is slightly smaller than endogenous chylomicrons. of electrolytes. National shortages of many ingredients con-
All IV fat emulsions (IVFEs) available in the United States tained in PN formulas have occurred, making patient-specific
contain egg phospholipids as an emulsifier, water, and soybean PN very difficult to order.
or safflower oil as a source of polyunsaturated fatty acids.
Glycerol is added to make the emulsion isotonic. Lipid parti-
cles break down and release triglycerides when administered
intravenously. Triglycerides are then hydrolyzed by lipopro- IV vitamin preparations should be added to HPN solutions
tein lipase forming glycerol, free fatty acids, and mono- and daily. Vitamins are commercially available as injectable mul-
diglycerides. The free fatty acids are usually taken up by the tivitamin infusions or single-entity products (with the excep-
tissues and either oxidized for energy or used for resynthesis tion of biotin, pantothenic acid, riboflavin, and vitamins A, D,
of triglycerides and deposition into adipose tissue. and E) (Table 4). There is also an adult multivitamin injection
The primary role of IVFE is to prevent essential fatty acid available without vitamin K. Since this has short-term stability
(EFA) deficiency. Since IVFE contains egg phospholipids, it is in PN solutions, it cannot be compounded by pharmacy for
contraindicated in the (rare) instance of a documented egg HPN, and the patient or caregiver must add this to each PN
allergy. If so, as a last resort, safflower or sunflower oil can be prior to infusion. During times of multivitamin shortages,
administered topically or enterally.16 American Society for Parenteral and Enteral Nutrition
IVFEs containing 10% or 20% fat are isotonic and are the (A.S.P.E.N.) recommends IV vitamin preparations be given 3
source of EFAs when a patient is receiving a dextrose-based times weekly. Chewable vitamin supplements twice daily can
PN solution. The 30% solution is used for compounding total be used for patients with IF on days multivitamin infusion
nutrient admixtures (TNAs). A 10% IVFE provides 1.1 kcal/ (MVI) is not infused.

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Home Parenteral Nutrition Tutorial / Kirby et al 637

Table 5. Adult Multiple Trace Element Injections (Concentration/mL)5

MTE-4 MTE-4 Concentrate MTE-5 MTE-5 Concentrate
Chromium, mcg 4 10 4 10
Copper, mcg 0.4 1 0.4 1
Manganese, mg 0.1 0.5 0.1 0.5
Zinc, mg 1 5 1 5
Selenium, mcg 0 0 20 60

Multiple trace element injections are from American Regent, Inc (Shirley, NY). Single trace element injections are also available for chromium, copper,
manganese, zinc, and selenium.

Table 6. Indications for Adding Histamine-2 Receptor Antagonists to Parenteral Nutrition

Peptic ulcer disease
Gastroesophageal reflux disease (GERD)
Recent extensive small bowel resection with resultant hypergastrinemia
GERD-type symptoms due to ileus or bowel obstruction
Gastrointestinal stress ulcer prophylaxis in high-risk patients (eg, critically ill postoperation)

Trace Elements
Heparin is not used in HPN patients routinely as it can
Chromium (Cr), copper (Cu), manganese (Mn), selenium (Se), cause heparin-induced thrombocytopenia, and if it is used, it
and zinc (Zn) are the trace elements most commonly added to should be withheld in patients actively bleeding.
HPN. These are commercially available in various combina- Regular human insulin is chemically stable in HPN and is
tions or as single-element products (Table 5). effective in controlling blood glucose when added in appropri-
Iron (as iron dextran) may also be added to dextrose-based ate amounts. Insulin should not be routinely added to HPN
PN solutions, but a test dose must first be administered to rule unless the patient has a history of diabetes or is demonstrating
out an anaphylactic reaction. The addition of iron dextran to glucose intolerance for any reason. Only regular human insulin
PN solutions should only be considered in cases of docu- should be added to HPN. Insulin has short-term stability in PN
mented iron deficiency anemia when enteral iron supplementa- solutions, and the patient or caregiver must add it to each PN
tion has failed. Iron cannot be added to a lipid-based PN prior to infusion.
formula because it destabilizes the IVFE.17,18 Since iron has Histamine-2 receptor antagonists such as famotidine, raniti-
short-term stability in 2-in-1 PN solutions, the patient or care- dine, and cimetidine are used to decrease gastric acid secre-
giver must add to each lipid-free PN prior to infusion. tions, particularly in patients with massive small bowel
Aluminum. Aluminum is a contaminant in all ingredients resection or to prevent stress-induced gastropathy. Once added
used to make PN. Aluminum toxicity has been noted in to HPN, oral and other IV doses of this class of drugs should be
patients receiving PN, especially neonates and adults with discontinued. The therapeutic dose of famotidine is 40 mg/d.
renal insufficiency.19 The dose of these agents must be reduced by half in patients
with renal impairment (creatinine clearance <30 mL/min).
Because histamine-2 receptor antagonists can potentially cause
Medications mental status changes, particularly in the elderly, their use
should be limited to certain conditions. See Table 6 for indica-
PN is a complex formulation primarily designed to deliver tions on adding these agents to PN solutions.
nutrients and fluids but can also be used to deliver medica- Octreotide is a somatostatin analogue used to decrease gas-
tions. Administering medications via HPN is generally not tric, pancreatic, and intestinal secretions; intestinal motility;
recommended due to potential drug-nutrient interactions, and the time needed for gastrointestinal (GI) fistula closure.20
compatibility limitations, and the inability to adjust or discon- It is also used in graft vs host–induced diarrhea following allo-
tinue the medication without discontinuing HPN. However, geneic bone marrow transplantation.21 The usual starting dose
delivering medications via HPN can reduce nursing time and of octreotide in HPN is 300 mcg/d. There may be a risk of
risk of contamination due to decreased manipulation of IV developing gallstones due to cholestasis (see Table 7).
lines associated with administering medications separately. Octreotide can be safely added to PN solutions, but due to its
Medications commonly added to HPN are discussed below. A short-term stability, it must be added by the patient or care-
pharmacist should be consulted before adding any other medi- giver just prior to infusion of each PN.22 Some pharmacies
cation to HPN. may not allow addition of octreotide directly into the PN bag.

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638 Journal of Parenteral and Enteral Nutrition 36(6)

Table 7. Suggested Management of Hepatobiliary Abnormalities

Assess ongoing need for PN and ability to start •  Discontinue/wean PN if able
enteral nutrition •  Start enteral nutrition (oral diet, enteral tube feeding)
Assess for overfeeding of macronutrients •  Decrease dextrose or lipid calories if overfeeding present
• Limit IV fat emulsion to lowest dose to prevent EFAD (500 mL of 20% lipid once
weekly) or
• Limit lipid to less than 1 g/kg/d23 if patient requires 3-in-1 PN solutions to achieve
adequate glycemic control (caution needs to be taken to adhere to manufacturing
stability guidelines to ensure a stable 3-in-1 solution)
Assess clinical indication for discontinuation of • Discontinue IV fat emulsion if patient is tolerating adequate amount of fat from
IV lipids enteral nutrition47 and does not demonstrate signs of malabsorption
Rule out EFAD • EFAD is associated with steatosis because of inhibition of fatty acids released
from stored fat in the presence of EFAD26
Cycle PN solution • Ensure that the patient is not receiving continuous infusion of PN and provide
  cycled PN infusion if medically possible48
• Assess for ability to decrease frequently of PN infusion (eg, 6 days per week,
every other day)
Monitor for trace element toxicities • If whole-blood manganese or serum copper values are elevated on laboratory
studies, omit manganese and copper from PN solution49,50
Assess medications or herbal supplements •  Review current medications
(promoting cholestasis or hepatotoxicity) • Discontinue antisecretory agents (octreotide) and histamine-2 blockers in PN
solutions that can cause cholestasis51
•  Review any herbal supplements
Rule out any infectious causes/sepsis •  Review for signs of sepsis, including catheter-related sepsis47
Assess for bacterial overgrowth • Assess for signs of small bowel bacterial overgrowth in patients with short
bowel syndrome or blind loops and treat with a trial of oral cyclic antibiotics
because released endotoxin reduces bile flow51,52
Review medical history for underlying liver • Hepatologist referral can initiate necessary diagnostic tests and imaging
disease and refer to hepatology (for medical (eg, ultrasonography of the right upper quadrant, magnetic resonance
evaluation) cholangiopancreatography, liver biopsy to describe the full extent and
type of damage) and/or initiate medications (such as ursodiol)
EFAD, essential fatty acid deficiency; IV, intravenous; PN, parenteral nutrition. Source: Corrigan.53 ©2011 Support Line, Dietitians in Nutrition Support,
a dietetic practice group of the Academy of Nutrition and Dietetics. Used with permission.

For these patients, octreotide may be injected subcutaneously short-term stability in PN solutions, metoclopramide cannot
or provided as the long acting depot formulation is adminis- be compounded by the pharmacy for HPN, and the patient or
tered every 28 days. caregiver must add this to each PN prior to infusion.
Corticosteroids such as IV methylprednisolone or hydro-
cortisone can be added to HPN for those patients who
need long-term corticosteroid therapy and cannot take oral
PN Formula Selection
corticosteroids. Drawbacks to adding corticosteroids to HPN PN can be compounded as 2-in-1 (dextrose-based) or 3-in-1
solutions include full dose of steroids not being delivered if (lipid-based) formulations. A 3-in-1, also known as a total
there are pump malfunctions or if the HPN solution is nutrient admixture (TNA), may be administered centrally or
abruptly stopped for any reason. Since steroids have short- peripherally (home PN therapy does not use the peripheral
term stability in PN solutions, they cannot be compounded by route) depending on osmolarity, whereas a 2-in-1 is typically
the pharmacy for HPN, and the patient or caregiver must add administered centrally. The patient’s clinical and nutrition
this to each PN prior to infusion. status, estimated duration of therapy, and current IV access
Metoclopramide is compatible in PN solutions. Meto- are considerations when determining the type of PN solution.
clopramide is a prokinetic gastrointestinal agent commonly Osmolarity of PN solutions can be estimated using the for-
used for chronic nausea. If chronic IV use is necessary, 20–40 mula in Appendix A.
mg/d can be added to PN. However, this is rarely done due to Central PN can be provided as a 2-in-1 solution since there
the high incidence of neurological side effects. Since this has are no limits on osmolarity when infusing into a central vein.

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Home Parenteral Nutrition Tutorial / Kirby et al 639

The decision to add IV fat emulsions to PN or administer it

separately is based on clinical, physiochemical, and economic
TNAs may be advantageous when limiting carbohydrate is
warranted due to glucose intolerance. However, IVFEs are
more expensive than dextrose, and adding it to PN creates
issues regarding the stability of the formula and compatibility
with other additives.

Compatibility of a TNA involves the stability of the IVFE.
IVFEs are stable by virtue of a phospholipid coating and
negative electrical charges surrounding each lipid particle,
causing a repellent effect and preventing coalescence. TNAs
have stability problems if improperly compounded (see
Appendix B). Incompatibility can also result from the addition
of inappropriate concentrations of highly positively charged
particles to the TNA. Iron cations, for example, can cause
significant interference with IVFE stability and should not be
added to a TNA. In addition, the total mEq of calcium and
magnesium in a TNA should be restricted (see Appendix B).
If IVFE stability is compromised, creaming or “oiling out”
will occur (see Figure 2). Creaming presents as a skim milk
lower layer with a creamy white layer on the surface of
Figure 2. Cracking or oiling out of intravenous fat emulsion.
the solution. This represents the beginning of emulsion destabi-
lization. At this stage, sufficient shaking will reemulsify the
mixture. “Oiling out” or “cracking” represents a drastic stabil- and trace elements need to be added prior to dispensing from
ity change and is identified when free oil floats on top of the the pharmacy. These commercial solutions of PN are not
TNA solution. When this occurs, the TNA should not be patient specific as they all have the same concentration of
infused. electrolytes or no electrolytes at all. In general, a patient on
The relative solubility of calcium and phosphate is of con- HPN can travel. For short trips, the PN bags can be taken in
cern in all PN solutions. Precipitation of calcium phosphate in cold-storage containers. For longer trips, it is reasonable to ask
PN can occur if the solution is not prepared correctly or the the infusion pharmacy to ship HPN bags and supplies to the
concentrations of calcium and phosphate are too high. If PN is destination. A letter from the prescribing physician may be
compounded with an AA solution containing phosphates necessary for airline travel.
(FreAmine III 10%; B. Braun), this amount of phosphates
should be included in the calculation. See Appendix C for an
equation to calculate calcium and phosphate limits to maintain
solubility of these components in the PN solution. PN may be cycled or administered continuously. In a hospital
setting, PN is usually infused continuously over a 24-hour
period because it requires less nursing time, effort, and manip-
PN Solution Preparation and Delivery ulation of IV lines. Continuous infusion also generally results
The goal of specialized nutrition support is to provide nutri- in fewer metabolic complications, such as hyperglycemia and
ents in adequate quantities to meet metabolic demands. electrolyte disturbances. PN can be cycled over 8–20 hours to
Individualized PN prescriptions, rather than standard solu- allow time away from the infusion pump when a patient is
tions, are the best way to meet these needs while remaining discharged to an extended-care facility or home. It is recom-
within daily fluid allowances. Standard commercial solutions mended that the PN be cycled and stable (euglycemia) prior to
of PN with or without electrolytes and containing different discharge home from the hospital. One goal is to cycle PN
amino acid and dextrose concentrations are currently avail- over 12 hours each day. This allows the pancreas and liver to
able. These are supplied as dual-chamber bags (none available readapt from the stress of the PN infusion and also provides
in the United States with fat emulsion) and have extended for some enhanced quality of life for the patient. Infusion
stability and a lower aluminum content, and they have poten- pumps can be programmed to taper up 1, 2, or 3 hours and/or
tially less chance of error in compounding as only vitamins taper down 1, 2, or 3 hours to maintain glycemic control

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640 Journal of Parenteral and Enteral Nutrition 36(6)

during and after the PN infusion. Only minor infusion cycle Table 8. Recommendations for Long-term Parenteral
alterations should be required in the home setting. Nutrition Solutions for Prevention and Treatment of
Metabolic Bone Disease
Weaning of HPN Solutions Component Recommendations
Weaning of HPN solutions differs from weaning hospital PN Calcium At least 15 mEq/d
solutions. Rather than decreasing the energy or fluid of the Phosphorus Calcium-phosphorus ratio of 1:2 (example: 15
daily solution, calories and fluid are usually reduced by omit- mEq/d calcium and 30 mEq/d phosphorus)
ting days of the HPN infusion. Once the patient has achieved Magnesium Adequate amount to maintain normal serum
his or her goal weight and/or the condition requiring PN ther- magnesium value
apy has been resolved (ie, malabsorption medically treated, Acetate Adequate acetate salts to prevent acidosis and
surgical intervention, etc), typically 7 days of HPN infusions maintain a normal serum bicarbonate value
are reduced to 5 or 6 days if the patient can maintain adequate Protein 0.8 to 1 g/kg/d protein once stable
hydration. When infusion schedules are changed, laboratory Sodium Adequate amount of sodium to maintain normal
serum sodium values, accounting for losses of
studies are checked the following week to evaluate fluid and sodium via gastric, stool, or urinary routes
electrolyte stability. Once intake and output records are
reviewed for fluid balance, weight status is evaluated, and labs Source: Corrigan.53 ©2011 Support Line, Dietitians in Nutrition Support,
a dietetic practice group of the American Dietetic Association. Used with
are acceptable, the patient is assessed for ability to wean fur- permission.
ther from PN.
After HPN solutions are reduced to the minimum, 3 days
weekly, the patient’s PN is placed on hold for 1 week. After
laboratory studies are reviewed and found to be normal and the clearly show that the incidence of IFALD increased with the
patient’s weight and enteral intake is assessed to be adequate, duration of HPN. When liver enzymes suddenly increase or
the patient’s VAD is removed and HPN formally discontinued. remain persistently elevated, investigating the cause is war-
Some HPN programs will keep the VAD for several weeks to ranted (see Table 7 for the suggested management of hepato-
months to verify that the patient can be independent of HPN and billiary complications). Our institution avoids use of IVFE
does not need to restart and require another invasive catheter daily, but if required based on specific patient comorbidities to
placement, especially if access has been an issue in the past. achieve glycemic control, IVFE is be limited to less than 1 g/
kg daily23 (see Table 7).
MBD is used to describe the complex abnormalities of bone
HPN Monitoring and Complications metabolism, density, and strength, such as osteopenia, osteo-
There is a lack of controlled trials with HPN patients and porosis, and osteomalacia.24 Long-term HPN patients are at
therefore a lack of evidence-based guidelines for monitoring risk for developing MBD. MBD is estimated at 84% preva-
and treating potential complications. Long-term complications lence of osteopenia and 67% prevalence of osteoporosis in
may include intes-tinal failure–associated liver disease HPN patients.24,25 Patients should be screened for MBD after 1
(IFALD), metabolic bone disease (MBD), and infectious year of HPN therapy and referred to an endocrinologist if bone
(catheter-related bloodstream infections [CRBSIs], site infec- densitometry scan is abnormal. Causes of MBD are poorly
tions, port-pocket infections, tunnel infections, etc) or nonin- understood. Contributing factors to MBD include medications
fectious catheter complications (catheter-related thrombosis, and underlying medical conditions, but the contribution of PN
SVC syndrome, air embolism, occlusions, etc). Other meta- is unknown.26 See Table 8 for HPN solution prevention and
bolic (fluid and/or electrolyte abnormalities) or mechanical treatment options.
catheter complications may also occur. CRBSI is the most common infectious complication of
Currently, there are no professional society guidelines for HPN therapy and is a significant contributor to healthcare
monitoring HPN patients. Our practice at the Cleveland Clinic costs, with the average cost of CRBSI ranging from $33,000 to
is to obtain labs monthly once the patient is stable. Our lab $65,000 per occurrence.27,28 Tunneled catheters or implanted
monitoring includes a basic metabolic panel, hepatic panel, ports with the fewest number of lumens necessary should be
phosphorus, magnesium, and complete blood count. used because they have been associated with a decreased inci-
Prealbumin, C-reactive protein, and prothrombin time (PT)/ dence of infection.29 The typical presentation of CRBSI
international normalized ratio (INR) are monitored monthly. includes fever, rigors, and chills with infusion through the
Trace elements (copper, chromium, selenium, zinc, and whole- catheter.30,31 Laboratory findings suggestive of CRBSI can
blood manganese) are monitored biannually. include positive blood cultures, increased white blood cell
Cavicchi et al23 reported the prevalence of liver disease in count, and possible elevation of liver enzymes (nonspecific to
HPN patients with permanent IF, noting that 26% of patients CRBSI; elevation may occur with sepsis), but quantitative
had liver disease after 2 years and 50% after 3 years. The data blood cultures are the gold standard for diagnosis.

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Home Parenteral Nutrition Tutorial / Kirby et al 641

Decreasing HPN Complications longest number of hours the patient is disconnected from HPN.
Before starting the next HPN infusion, ETL is flushed through
One of the main goals of HPN therapy is to maintain the the line with normal saline (in adult patients). ETL is com-
patient’s nutrition status while concurrently making all efforts monly only used in catheters made from silicone as alcohol has
to minimize complications associated with HPN. CRBSI is the potential to act as a solvent with polyurethane materials.
one of the most serious infectious complications of HPN. Crinch et al38 examined the mechanical properties of polyure-
Methods to prevent CRBSI have included selecting the VAD thane and silicon catheters after exposure to 70% ethanol for
with the fewest number of lumens, institutional hand hygiene 10 weeks in the lab to investigate the effect on the integrity of
policies, staff and patient training on proper catheter care tech- the catheters. The authors report that there was a negligible
niques, maximal barrier precautions during catheter insertion, impact on the mechanical properties of polyurethane and
aseptic technique during catheter insertion, and removing silicon catheters and suggest that concerns about the use of
catheters no longer in use.9 Instructing the patient on infection ethanol in these catheter types are less of a concern.
prevention is one of the most critical steps in preventing Some literature in the pediatric population shows there may
catheter-related infections. It is imperative for patients to be increased risk of thrombosis with ETL use, but this has yet
receive education on aseptic technique for HPN procedures to be documented in the adult population.39,40 More studies are
and catheter care. Patients should be provided detailed written warranted in this area to define many unanswered questions
instructions, visual demonstration, and the opportunity to repeat regarding the optimal ethanol concentration, optimal dwell
back the procedures. Homecare nursing plays a vital role in time in the catheter, and studies for cost-savings analysis and if
reinforcing the teaching provided to patients while hospitalized quality of life is affected in HPN patients. Currently, 70% ETL
on catheter care, monitoring compliance with procedures, and locks must be compounded in the pharmacy into a prefilled
monitoring the catheter site. Other techniques have included use syringe. Stability of the compounded ethanol within the
of antibiotic or ethanol lock therapies to prevent CRBSI. syringe has been studied and documented.41
Antibiotic locks have been used to treat CRBSI. Antibiotic For patients with hypercoagulable states or those at increased
locks consist of 100- to 1000-fold higher concentrations of risk of a catheter-related thrombus, some experts suggest use of
antibiotics that dwell within the lumen of the catheter when low-dose warfarin (1–2 mg of warfarin/d) to reduce thrombotic
cycled HPN is not infusing. Antibiotic locks are used with risk prior to insertion of a long-term VAD with continued ther-
systemic antibiotics for treatment of a CRBSI when the goal is apy as long as the VAD is in place. Boraks et al42 demonstrated
to salvage the VAD. Antibiotic locks should not be used alone decreased incidence of CVAD-related thrombosis in oncology
for treatment of CRBSI but in conjunction with systemic anti- patients with tunneled catheters given 1 mg/d warfarin upon
biotics for 7–14 days.32 CDC guidelines9 recommend not insertion until the line was removed. Bern et al43 showed
using antibiotic lock for the prevention of CRBSI in general reduced thrombus related to VAD in oncology patients given 1
but can be used prophylactically only in situations with long- mg/d warfarin 3 days prior to VAD placement and continued
term VADs in patients with a history of multiple cases of therapy for 90 days after placement. Ports were used and cor-
CRBSI. The use of antibiotic locks brings concerns for the rect placement for the study was defined as within the tip of the
development of resistance or the potential for selection of SVC or proximal innominate vein (these lines would currently
worse infectious organisms. The optimal duration of antibi- be considered malpositioned and at greater risk of thrombus
otic locks remains unknown.32 due to tip location).5,10,44 It is unclear if these results could
Ethanol lock (ETL) has emerged as a method to prevent transfer to the HPN patient population.
CRBSI and has been used in many patient populations, includ- Patients receiving HPN therapy via a VAD may also benefit
ing hemodialysis, oncology, and adult and pediatric HPN from low-dose warfarin therapy; however, past studies within
patients, but its use is not approved by the Food and Drug the PN population have been completed with heparin and not
Administration or the Infectious Disease Society of America warfarin. The decision to use this potentially beneficial therapy
due to insufficient data. Benefits of ETL over antibiotic lock in HPN patients is based on clinical judgment of the managing
include the following: there is no concern for the development physician until future studies are completed. Treatment with
of resistance (as ethanol acts to denature proteins), it is inexpen- anticoagulation prophylaxis in oncology patients receiving
sive, and it has both bactericidal and fungicidal properties. HPN should be strongly considered due to the underlying
Small studies among HPN patients have demonstrated a statis- increased risk of thrombosis.
tically significant reduction in CRBSI.33-37
Because of the limited number of studies, the optimal dwell
time and strength of ETL are unknown, but it is believed to be
Quality of Life
most effective immediately after the central venous access HPN has been a lifeline for patients with intestinal failure
device (CVAD) is placed, before biofilm has a significant over the years, but quality of life (QOL) can be challenging to
amount of time to form. Typically, 3 mL of 70% ethanol is measure. The difficulty in capturing and defining QOL is
administered after cycled HPN infusions are completed determining the impact on QOL from symptoms related to the
and allowed to dwell within the lumen of the catheter for the primary disease vs the impact from HPN. Tools to measure

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642 Journal of Parenteral and Enteral Nutrition 36(6)

Table 9. Intestinal Transplant Criteria4

1. Failure of home parenteral nutrition (HPN)
(a) Impending (total bilirubin above 3–6 mg/dL, progressive thrombocytopenia, and progressive splenomegaly) or overt liver failure
(portal hypertension, hepatosplenomegaly, hepatic fibrosis, or cirrhosis) because of parenteral nutrition liver injury
(b) Central venous catheter (CVC)–related thrombosis of 2 or more central veins
(c) Frequent central line sepsis: 2 or more episodes per year of systemic sepsis secondary to line infections requiring hospitalization,
a single episode of line-related fungemia, septic shock, and/or acute respiratory distress syndrome
(d) Frequent episodes of severe dehydration despite intravenous fluid in addition to HPN
2. High risk of death attributable to the underlying disease
(a) Desmoid tumors associated with familial adenomatous polyposis
(b) Congenital mucosal disorders (ie, microvillus inclusion disease, tufting enteropathy)
(c) Ultra short bowel syndrome (gastrostomy, duodenostomy, residual small bowel <10 cm in infants and <40 cm in older children)
3. Intestinal failure with high morbidity or low acceptance of HPN
(a) Intestinal failure with high morbidity (frequent hospitalization, narcotic dependency) or inability to function (ie, pseudo-
obstruction, high-output stoma)
(b) Patient’s unwillingness to accept long-term HPN (ie, young patients)

QOL that have been validated in the HPN population include and networking/peer support for patients receiving home nutri-
the HPN-QOL, a 48-item questionnaire.45 tion support therapies. Patients should be made aware of the
Due to the need for infusions that last many hours, many Oley Foundation when starting on HPN therapy so they are
patients talk about the difficulty in getting a good night’s sleep. aware of the educational, outreach, and networking benefits the
Clinicians can offer the patient an option to infuse HPN solu- foundation offers. Visit www.oley.org for more information.
tions during the daytime hours to allow for restful sleep during
the night hours. Over the years, equipment such as portable
pumps and backpacks has allowed for enhanced mobility in
Intestinal Transplant Considerations
the home setting. It is our practice, considering QOL, to assess Despite the general success in managing patients with HPN,
the ability to allow patients to infuse HPN solutions 6 nights there are instances when patients can and should be considered
weekly if they do not have excessive GI losses or problems for either an isolated small bowel transplant or a multivisceral
maintaining adequate hydration. transplant. Table 9 lists the current guidelines according to the
CMS. These indications will not be considered further in this
tutorial as intestinal transplant is a separate topic.
A.S.P.E.N.’s National Patient Registry for Nutrition Care,
called Sustain, has recently been launched. The overall mission
Additional Issues
of the prospective, longitudinal registry is to improve patient As this detailed discussion has shown, HPN is very labor
outcomes.46 The first phase of registry will help provide infor- intensive and uses many resources. Unfortunately, this man-
mation on the number of adult and pediatric patients receiving agement is either poorly or not reimbursed by insurers and
HPN in the United States, describe patient characteristics and government agencies alike. This can lead to breaks in manage-
diagnoses, and evaluate the effectiveness and outcomes of ment and responsibilities that could ultimately affect the
HPN therapy.46 The eventual goal of Sustain is to include patient. Furthermore, attempts at weaning could create a
patients receiving EN. The registry is open to all HPN provid- “Catch-22” where the patient is under the “minimum reim-
ers (physicians or homecare agencies) and is easy to use. bursable infusion amount,” which could then require the
Whether an HPN provider is following 1 or 100 HPN patients, patient to be responsible for the charges. Insurers and the
it is prudent to provide these data to contribute to improving government should work with physicians and appropriate
patient outcomes. For enrollment and additional information on societies to more fairly compensate those for their time and
Sustain, please visit www.nutritioncare.org/sustain. efforts to keep patients out of the hospital and give them hope
for an improved QOL.

Oley Foundation
The Oley Foundation is a nonprofit, national organization
founded in 1983 that assists patients who receive HPN and The provision of HPN requires a coordinated multimodality
home EN. The Oley Foundation provides a patient-focused approach to provide a costly, high-tech therapy at home.
educational newsletter, annual conference (for patients/clinicians), Although patients can do very well, vigilance to maximize

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Home Parenteral Nutrition Tutorial / Kirby et al 643

QOL and to minimize potential complications takes significant Appendix D

effort on both the patients’ and clinicians’ behalf to form a
beneficial symbiotic therapeutic partnership. Glossary

Appendix A CRBSI Catheter-related bloodstream infection: a sys-

temic infection involving the catheter.
Calculating the Osmolarity of PN Solutions
CVAD Central venous access device: a catheter whose
tip optimally lies in the lower third of the superior
A. Total grams of AA per liter of solution ____ × 10 = vena cava adjacent to the right atrium.
____ mOsm
B. Total grams of dextrose per liter of solution ____ × 5 HPN Home parenteral nutrition: the provision of intra-
= ____ mOsm venous nutrition at home.
C. Total grams of fat (30% emulsion) per liter of solu-
tion ____ × 0.67 =____ mOsm PICC Peripherally inserted central catheter: a catheter
D. Total mEq of calcium, magnesium, potassium, and inserted peripherally (usually in the basilic, brachial,
sodium per liter of solution ____ × 2 =____ mOsm or cephalic veins) and advanced centrally into the
superior vena cava.
Add A, B, C, and D to derive the osmolarity of the PN solution
= _____ mOsm/L. PN Parenteral nutrition (or central vein nutrition): refers
Example: PN solution containing 1800 kcal, 80 g amino to nutrition support that is delivered via a catheter tip
acids, and nonprotein calorie distribution of 70% dextrose and that optimally lies in the lower third of the superior
30% lipid in a 2400-mL volume plus 200 total mEq of calcium, vena cava adjacent to the right atrium. This allows
magnesium, potassium, and phosphorus: optimal mixing of highly osmolar solutions due to
turbulent blood flow and decreases the risk of venous
A. 80 g AA/2.4 L = 33 g AA/L × 10 = 333 mOsm thrombosis related to PN therapy.
B. 304.7 g dextrose/2.4 L = 127 g dextrose/L × 5 = 635
C. 148 g lipid/2.4 L = 61.7 g lipid/L × 0.67 = 41 mOsm References
D. 200 mEq lytes/2.4 L = 83 mEq/L × 2 = 167 mOsm   1. Dudrick SJ, Wilmore DW, Vars HM, Rhodes JE. Long-term total paren-
Total osmolarity = 1176 mOsm (must be infused with a teral nutrition with growth, development, and positive nitrogen balance.
central venous catheter if osmolarity is >900 mOsm) Surgery. 1968;64:134-142.
 2. O’Keefe S, Buchman A, Fishbein T, et al. Short bowel syndrome and
intestinal failure: consensus definitions and overview. Clin Gastroenterol
Appendix B Hepatol. 2006;4:6-10.
  3. Howard L. Home parenteral nutrition: survival, cost, and quality of life.
Compatibility Compounding Guidelines Used Gastroenterology. 2006;130:S52-S59.
  4. Center for Medicare and Medicaid Services, U.S. Department of Health
by Cleveland Clinic for 3-in-1 PN Solutions13 and Human Services. Meeting your Medicare needs. http://apps.ngsmedi-
51&ContentID=34464. Accessed April 2, 2012.
PN Component Compatibility Range   5. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutri-
tion. JPEN J Parenter Enteral Nutr. 2004;28:S39-S70.
Amino acid 20–60 g/L (80–240 kcal/L)
  6. Emery M, Stafford J, Pearson A, Steiger E. Venous access and catheter
Dextrose 40–250 g/L (138–850 kcal/L) care. In: Coughlin KL, DeChicco R, Hamilton C, eds. Cleveland Clinic
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Divalent cations ≤20 mEq/L 121-142.
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ated thrombosis with and without the use of prophylactic anticoagulants.
JPEN J Parenter Enteral Nutr. 2008;32:443-447.
  8. Moureau N, Poole S, Murdock MA, et al. Central venous catheters in home
Appendix C infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol.
Calculating Calcium and Phosphate Solubility13 2002;13:1009-1016.
  9. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the preven-
(Should Not Exceed 200) tion of intravascular catheter related infections. Am J Infect Control.
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devices. JPEN J Parenter Enteral Nutr. 2006;30:S70-S72.
Sodium phosphates, potassium phosphates, and FreAmine 11. Kusminsky RE. Complications of central venous catheterization. J Am
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