Central lines and TPN vs PPN - page 2
First of all, hi! I've been reading these forums for a long time, but this is my first post. I am relatively new to nursing, and I have a few questions. I recently started working as a unit... Read More
Feb 21, '08Quote from Emmanuel GoldsteinTOOK THE WORDS RIGHT OUT OF MY MOUTH!!If you'll look at the order sheet at the ingredients of TPN vs PPN, you'll notice that PPN (peripheral parenteral nutrition) has a dextrose of 12.5% or less. Any IVF with a higher dextrose concentration must be given through a central line. (at some hospitals I've worked, the limit was 10%)
A PICC is a central line that is placed peripherally. A midline is a peripheral line. The difference is where the catheter tip lies; a PICC is threaded into the central circulation while a midline ends in the upper arm near the axilla. Because it is a peripheral line, you don't run TPN through a midline.
Feb 21, '08Quote from nbnurse95Recently we've starting adm TPN through reg IV's. It's not as convenient since you only have the one line to work with so we usually have to start a second line for meds etc.
I'm with CAREBEAR on this one. The dextrose concent. has to be less than 10%, otherwise, it will thrombose vein and cause BIG problems. You can run lipids through a peripheral line without problems since it has a low dextrose content. I am interested in learning more about your TPN in Canada...could you please fill me in. Thanks.
Feb 21, '08The Travasol is definitely a different recipe than the one we use with Central lines and we're NEVER to run the Travasol alone peripherally. We always MUST run it with lipids.
Feb 22, '08we had an incident on the last iv team i worked on where we had been called to restart one patient's iv 3 times in one day. when i was the one who went up to do the 4th restart within a 24 hour period i looked at the iv fluid that was infusing. it was tpn with a 50% concentration of glucose. it was never meant to be given peripherally. who made the mistake of hanging it, never knew. but, 50% glucose given over time in an iv infusion is caustic to the peripheral veins. no doubt, this patient will probably have 3 sclerosed and unusable veins forever due to this error. if only people had looked at the label of what was hanging, the outcome would have been much different for the patient.
as i mentioned, with central lines that terminate in the vena cava, the large amount of blood as well as the turbulence of the blood avoids the problem of mechanical phlebitis due to the caustic nature of the tpn solutions. the more solutes they put in these solutions, the higher the osmolality of the solution becomes and that means they are more hypertonic. peripheral veins cannot tolerate the constant flow of very hypertonic iv solutions.
there is good pathophysiology surrounding the theory of the use of these devices.
Feb 26, '08Hi siggie13, I checked the policies and order forms at my hospital.
Our TPN for Central lines is as follows:
Amino Acids 5%, Dextrose 16.6% and Lipids 10 or 20%.
and for IV lives:
Amino Acids 2.7%, Dextrose 9% and Lipids 20%. There are also a few differences with the electrloytes.
"The lipids should be administered at the same time as the solution for peripheral parenteral nutrition. This simultaneous infusion diminishes osmolarity in the primary solution which favours prolonged usage of the peripheral vein".
I haven't seen a problem with the vein yet. It seems to work fine.
Mar 22, '10Hi! I'm inright now and we are covering the whole central line thing right now. So for starters I don't know exactly what a midline is or what it is used for because we don't really see those, in fact the hospitals around us require the line to be in the SVC or they cannot be used (as far as I know so far at least) Second, TPN can't go through a peripheral line simply because it is what they call hyperosmolar (or >500) so it's viscous and the small veins in your periphery cannot handle it. Our teacher even mentioned that although PPN can go through a peripheral line, you still need to monitor it because it still carries some risks.
The vanco. answer is that vancomycin actually has a pH of 2.4-4.0 depending on how it was diluted. The veins of your periphery can really only handle pH's of about 5-9, so vanco. has a very high risk of extravasation, it's super acidic (like putting battery acid into your veins was the way it was explained to us). With that said a lot of hospitals near us have put policies into place just in the past year stating that the first dose of vanco. can go through a peripheral line, but after that the doses must be administered through a central line. Mostly because people have started noticing and requesting central lines for their patients to avoid those complications... Hope this helped and good luck with everything!!
Mar 22, '10Is it a problem when you push amps of dextrose in hypoglycemia pts or codes? Is it okay because it's a quidk thing instead of a long term infusion?
We do vanco all the time in peripheral lines......I've never had a problem with it. We do run it very slow.
Mar 22, '10I know, I think a lot of facilities still do, because I feel like it's just recently been noticed that vanco has a high rate of extravasation. And you have to run vanco slow because fast infusions can cause something called red man's syndrome.... It's pretty interesting though!!
May 20, '10Interesting thread.
At the facility I work at we give a TON of Vanco (SNF that specializes in vents and dialysis 160-170 pts, 75-100 with regular infusions).
We routinely run vanco pretty fast...1g over 30 min or so and mostly in PIVs and mostly in hands (8/10 PIVs are in hands). We see Red Man's Syndrome every once in a blue moon, maybe once or twice a year.
Have yet to see Vanco do anything when a PIV infiltrates. Dumb luck I guess.
May 21, '10A midline is a venous catheter inserted at or near the ACF with its tip terminating in the upper third of the upper arm at the axillary level. ONLY isotonic and near iso- tonic IV solutions and medications with a Ph ranging between 5-9 should be administered through a PICC line. So NO Vancomycin should not be given through a ML as the Ph runs between 2-4
May 21, '10Quote from iluvivtSee thats strange to me. Here in AZ I have yet to see a facility mandate that Vanco be given centrally. Everyone I ask and everywhere I have seen all infuse Vanco peripherally unless they have some other type of access.A midline is a venous catheter inserted at or near the ACF with its tip terminating in the upper third of the upper arm at the axillary level. ONLY isotonic and near iso- tonic IV solutions and medications with a Ph ranging between 5-9 should be administered through a PICC line. So NO Vancomycin should not be given through a ML as the Ph runs between 2-4
May 21, '10In Australia we have an injectables guidelines bible and Vanco can ve given through PICC and CVC.