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Unformatted text preview: SCANNED TO PHARMACY
Date ___________________ Time ___________________
Nursing will hang a 24-hour bag daily at 2100. New orders or changes received after 12:30 pm will take effect the following day.
NUTRITION (>7.5 Kg) 1. Specify Route of Administration:
Note: Maximum dextrose concentration in Central PN = 35%
Maximum dextrose concentration in Peripheral PN = 12.5%
2. Today's Weight ___________ Kg
3. Final Dextrose Concentration = ________%
Note: Usually initiated with D10 and advanced by 2.5-5%/day, as tolerated.
4. Amino Acid = _________ gm/kg/day
Note: Usually initiated at 1gm/kg/day and increased by 0.5-1gm/kg/day until goal achieved. Max = 3.5gm/kg/day.
5. PN Infusion Rate = ________ mL/hour over ________ hours = ________mL Total
Note: Pharmacy will prepare a 24-hour supply, plus 50mL overfill, based on infusion rate ordered.
6. Fat Emulsion 20% ______ mL/hour over _____ hours = ________mL Total
Note: 20% lipid supplies 2 kcal/mL. Up to 50% of daily calories may be administered as lipid.
Initiate at 2.5-5 mL/kg/day Advance by 2.5 mL/kg/day, as tolerated, up to a maximum of
15 mL/kg/day (3gm/kg/day). Suggest infusing lipids over 20 hours.
Select standard additives based on patient weight, or select and order tailored additives. Tailored 7.5 - 25 kg Over 25 kg Na (mEq/kg/day)
PO4 (mM/kg/day) 3
0.5 Chloride:Acetate ratio 1:1 1:1 Pediatric Recommendations
1.5mEq Acetate is provided
with each gm Amino Acid
See note below. 5 (Pediatric)
0.2 mL/kg/day up
to 5 mL/day
(Adult MTE-5) See note below.
max 30 mcg/day
200 mcg/day 200mcg/day only if on MVI-12 MVI (mL/day)
Pediatric Trace Metals
Selenium Vitamin K (mcg/day)
0.5units/mL, if needed
10mg/kg/day if on TPN over 10 days
Note: 5mL of Pediatric MVI contains: Vitamin A - 2331units, Vitamin B1 - 1.2mg, Vitamin B6 - 1mg, Vitamin B12 1mcg, Vitamin C - 80mg, Vitamin D - 400units, Vitamin E - 15.54units, Vitamin K - 200mcg, Biotin - 20mcg,
Dexpanthenol - 5mg, Folic Acid - 140mcg, Niacinamide - 17mg, Riboflavin - 1.4mg.
10mL of MVI Adult contains: Vitamin A - 3300units, Vitamin B1- 6mg, Vitamin B6 - 6mg, Vitamin B12 - 5mcg, Vitamin
C - 200mg, Vitamin D - 200units, Vitamin E - 10units, Biotin - 60mcg, Dexpanthenol - 15mg, Folic Acid - 600mcg,
Niacinamide - 40mg, Riboflavin - 3.6mg, B2 - 3.6mg, Vitamin K - 150mcg.
0.1mL of Pediatric Trace Elements contains: Cr - 0.1mcg, Cu - 10mcg, Mn - 2.5mcg, Zn - 100mcg.
1mL of Adult Trace Elements contains: Cr - 10mcg, Cu - 1mg, Mn - 0.5mg, Zn - 5mg. SE - 60mcg.
Caloric Profile: Dextrose: (_______%)x(________mL infused)x(0.034kcal/mg) = ______ Kcal Dextrose
20% Lipid:(______mL infused)x(2kcal/mL) = ______ Kcal Lipid
______ Total NonProtein Calories Protein: (______gm infused)x(4kcal/gm) = ________ Kcal Protein
Total Kcal/Kg: (_____Kcal Dextrose) + (_____ Kcal Lipid) + (_____ Kcal Protein) ÷Kg = ______ Total Kcal/Kg Authorization for therapeutic substitution is given unless checked here
Patient Identification Sutter Medical Center, Sacramento
A Sutter Health Affiliate Parenteral Nutrition TPN Orders
01296 (10/22/09) ORDERS ...
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- Spring '09