| Study PN Protocol A: all early PN patients except malnourished |
| Feeding day 1 (first 24 hours of PN) |
| • Commence Kabiven G19% at 60 mL/hr (or goal rate, whichever is lower). |
| • Consider trace element, mineral and vitamin needs as clinically appropriate. Feeding day 2 (second 24 hours of PN) |
| • Increase Kabiven G19% to 80 mL/hr (or goal rate, whichever is lower). |
| • Consider trace element, mineral and vitamin needs as clinically appropriate. Feeding day 3 (next 24 hours) |
| • Increase Kabiven G19% to goal rate, as appropriate. |
| • Consider trace element, mineral and vitamin needs, as clinically appropriate. |
| • Recommend trialing enteral/oral nutrition, if clinically appropriate. |
| • Once the patient tolerates ≥475 kcal/day EN, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| • If patient tolerates any oral caloric intake from food, complete remainder of 24 hour Kabiven infusion and do not hang another bag. Feeding day 4 (next 24 hours) plus all additional days after day 4 |
| • May switch to parenteral nutrition solution tailored to patient’s specific clinical needs. Goals not to exceed 25–35 kcal/kg and 1.0–1.5 g protein/kg. |
| • Consider long term needs regarding trace element, mineral and vitamins as clinically appropriate. |
| • Recommend trialing enteral/oral nutrition, if clinically appropriate. |
| • Once the patient tolerates ≥ 475 kcal/day EN, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| • If patient tolerates any oral caloric intake from food, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| Insulin/glucose protocol: early PN patients |
| If glucose levels exceed 10 mmol/L an insulin infusion should be commenced and titrated to achieve peak serum glucose levels of <10 mmol/L. |
| Frequent monitoring of the patient’s blood glucose should be initiated as per your ICU’s usual practice for patients receiving an insulin infusion. |
| If insulin infusion is required at ≥6 units/hr to maintain glucose target: |
| • Reduce Kabiven G19% to 40 mL/hr for 24 hours. |
| • At the end of 24 hours, if insulin needs are reduced below 6 units/hr, increase Kabiven G19% to 80 mLs (or original goal rate, whichever is lower) for 24 hours. |
| • At the end of this second 24 hour period, if insulin needs remain below 6 units/hr, increase Kabiven G19% to goal rate. |
| • If insulin requirements exceed 6 units/hr at any time during the above process, reduce PN to previously tolerated rate, or 40 mLs/hr (whichever is higher), for 24 hours. Begin increasing rate every 24 hours as above, if tolerated. |
| Study PN Protocol B: malnourished early PN patients (ex BMI ≤ 17) |
| Feeding day 1 (first 24 hr of PN) |
| • Commence Kabiven G19% at 40 mL/hr (or goal rate, whichever lower). |
| • Strongly recommend administering 100 mg thiamine, commencing at least 30 minutes prior to initiation of Kabiven G19% infusion, as clinically indicated as per product licensing indications. |
| • Recommend daily administration of other vitamins, minerals and trace elements, as clinically appropriate. Feeding day 2 (second 24 hours of PN) |
| • Increase Kabiven G19% to 60 mL/hr (or goal rate, whichever is lower). |
| • Recommend daily administration of vitamins, minerals and trace elements, as clinically appropriate. Feeding day 3 (next 24 hours) |
| • Increase Kabiven G19% to goal rate, as appropriate. |
| • Recommend daily administration of vitamins, minerals and trace elements, as clinically appropriate. |
| • Recommend trialing enteral/oral nutrition, if clinically appropriate. |
| • Once the patient tolerates ≥475 kcal/day EN, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| • If patient tolerates any oral caloric intake from food, complete remainder of 24 hour Kabiven infusion and do not hang another bag. Feeding day 4 (next 24 hours) plus all additional days after day 4 |
| • May switch to parenteral nutrition solution tailored to patient’s specific clinical needs. Goals not to exceed 25–35 kcal/kg and 1.0–1.5 g protein/kg. |
| • Strongly recommend addressing long term needs regarding trace elements, minerals and vitamins as clinically appropriate. |
| • Recommend trialing enteral/oral nutrition, if clinically appropriate. |
| • Once the patient tolerates ≥475 kcal/day EN, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| • If patient tolerates any oral caloric intake from food, complete remainder of 24 hour Kabiven infusion and do not hang another bag. |
| Insulin/glucose protocol: early PN patients |
| If glucose levels exceed 10 mmol/L an insulin infusion should be commenced and titrated to achieve peak serum glucose levels of <10 mmol/L. |
| Frequent monitoring of the patient’s blood glucose should be initiated as per your ICU’s usual practice for patients receiving an insulin infusion. |
| If insulin infusion is required at ≥6 units/hr to maintain glucose target: |
| • Reduce Kabiven G19% to 40 mL/hr for 24 hours. |
| • At the end of 24 hours, if insulin needs are reduced below 6 units/hr, increase Kabiven G19% to 80 mLs (or original goal rate, whichever is lower) for 24 hours. |
| • At the end of this second 24 hour period, if insulin needs remain below 6 units/hr, increase Kabiven G19% to goal rate. |
| • If insulin requirements exceed 6 units/hr at any time during the above process, reduce PN to previously tolerated rate, or 40 mLs/hr (whichever is higher), for 24 hours. Begin increasing rate every 24 hours as above, if tolerated. |
Abbreviations: kcals, kilocalories; EN, enteral; ICU, intensive care unit; BMI, body mass index.