HAF & Lipid mixing

TiffyRN, BSN, PhD · Apr 28, 2005

Our unit infuses them separately but then they are y'd together before going into the patient. We haven't been given a rationale for it. I do know from previous experience that most adult patients the TPN and Lipids are mixed together most everywhere except . . . On oncology. There it depends on the IV access the patient has, If they have a single lumen cath then often the lipids are given as a bolus over 4 hrs the reasoning being that many meds are compatible with the TPN but not the lipids so separating them keeps us from having to start another line. I used to float to an oncology unit and they kept a chart there on common meds and whether they were compatible with TPN with lipids, TPN only or neither.

Anyway, I think that's probably why we do it routinely in NICU, because we so often have limited IV access.

Gompers, BSN, RN · Apr 28, 2005

ETA: I assume you meant if we mix them together in the same IV bag, rather than if we infuse them together or into seperate IVs. Was that the question?

Our rationale for infusing them separately (as in different IV bags, but placed together at the Y-port with a double T-connector):

In the NICU, we go up and done on the maintenance fluid (HAL) rate all the time depending on what other IVs are being hung on that baby - we'll be going up and down on the HAL as dopamine is increased or weaned, fentanyl drips are started or discontinued, etc. Meanwhile, the lipids are run on their own pump over 24 hours, and we don't mess with that because we want the baby to get the whole dose of lipids. So in the end, the amount of HAL varies each day, but they lipids are always given in full. If we had the two mixed, and started a lot of drips on the baby that day, he/she wouldn't get the full dose of lipids because we'd have turned down the HAL/IL rate so much. Does that make sense?

As far as just giving the lipids over a shorter time, I think the reason for that is so that the baby doesn't have to metabolize it all at once. Their triglycerides tend to skyrocket sometimes, so over 24 hour is really much better for them. If a baby is on amphoteracin and we're shutting off the TPN for the daily infusions, we'll give the lipids over 20 hours. Or if a chronic baby is on cycled TPN, we'll give them over 16 hours because we aim to shut off the TPN for 8 hours a day.

The babies we send home on TPN, on the other hand, DO have the HAL and IL mixed in their bags. It gets mixed at the last minute as the moms are about to connect their new daily bag. This is because they only have the one compact infusion pump, and also because these kids are on such a stable amount of TPN that we know they'll get the whole dose because their mom isn't increasing or decreasing the rate like we are.

sparkyRN · Apr 30, 2005

TPN and IL are run seperately and connected into the IV below the filter for peripheral, PICC and CVLs. No lipids in the UAC. Lipids are notorious for clogging the air filter in the IV line.

dawngloves, BSN, RN · Apr 30, 2005

We run seperate so we can adjust the fluids to meet the baby's TFL according to their status, (NPO, d/c drips and meds) When weaning from fluids, the lipids are the first thing we shut off.

KRVRN, BSN, RN · Apr 30, 2005

We mix ours. I believe it is because our pharmacists feel that mixing them decreases the infection rates by decreasing the number of drips and tubings and such connected to the baby. It runs for 24 hours. Unfortuneately we end up having to switch the baby to clear fluids without the protein and IL if blood sugar or electrolyte issues force us to change IVF's in the middle of the night. We run our mixed fluids via UAC's as well if that's the only central access we have.

Hannahrn · Apr 30, 2005

Gompers, why would you cycle TPN? I have never heard of that practice. THen, on the hours that the TPN is off, what do you infuse?

Gompers, BSN, RN · May 1, 2005

Gompers, why would you cycle TPN? I have never heard of that practice. THen, on the hours that the TPN is off, what do you infuse?

We do this with the older, chronic gut babies. Since these kids have never tolerated full feedings, their livers have been exposed to TPN since birth and they will eventually go into liver failure. Of course we try to push enteral feeds, but it's not always possible. So for these kids, we aim to get them off TPN for 8 hours a day to give their livers a rest. Our GI docs believe that it slows liver failure. We start out with two hours off, then four, then six, then eight. It takes a few weeks to get them up to a full eight hours' off, and some kids don't tolerate it as their glucose levels drop.

During the "off" time, if they have a Broviac we just give them heparinized saline flushes so that the tubing is full of that while it's clamped off. If it's a PICC line, we keep the hyperal infusing but only at 0.5cc or 1 ml an hour to keep it from clotting off.

The kids who go home on TPN really benefit from cycling. For one thing, it gives them up to 8 hours a day to be free from the IV pump, and it makes going to doctor's appointments and such easier for the parents. Plus, if a kid is going home on TPN, it's usually a pretty severe intestinal problem and they are heading towards liver damage. Anything we can do to slow that down is worth a try.

prmenrs, RN · May 1, 2005

We 'Y' them in. If the bag comes up different from the order, at least you wouldn't have the kid charged for both when you sent it back to Pharmacy.