TPN and Lipids - page 2

Do not base your practice on a lone outdated research study.check your policies and make certain they meet the current standard of care....tpn...give it centrally....ppn and lipids can be given peripherally...but you will often struggle to maintain a peripheral acess

Here are more recent studies that elucidate that TPN can be given peripherally. Latest article in 2008, would this be reason enough to challenge the status quo? I have more....


51 consecutive gastroenterological patients who required total parenteral nutrition (TPN) were entered into this study. Two patients were withdrawn because of specific nutritional requirements, leaving 49 patients for randomisation. 23 patients were allocated to receive peripheral parenteral nutrition (PPN) and 26 to receive feeding through a central venous line (CPN). There was no significant difference between the groups with respect to the median duration of feeding (9.4 ± 3.6 days; 12.0 ± 7.8 days) but significant morbidity occurred more frequently in the CPN group (11%) compared to the PPN group (0%).

TPN by the designated route was not possible in 4 patients in the PPN group and in 3 of the CPN group. Of the 19 patients commenced on PPN, 13 continued without complication until resumption of oral feeding (median 10.7 ± 3.2 days); 6 of these patients had to be converted to central venous feeding for completion of their nutritional requirements.

Of the 23 patients commenced on CPN, 21 completed their nutritional course (median 11.8 ± 5.3 days), 2 patients in the CPN group required conversion to PPN to complete their nutritional course.

This study shows that PPN is a feasible, safe alternative to CPN in many patients. It is not necessary to subject all patients who require TPN to the risks and expense of central venous cannulation.

Couse, N., Pickford, L., Mitchell, C., & Macfie, J. (1993). Total parenteral nutrition by peripheral vein -- Substitute or supplement to the central venous route? A prospective trial. Clinical Nutrition, 12(4), 213-216. doi:10.1016/0261-5614(93)90017-X
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IN 2008 STUDY:

Historically, TPN has been administered by the
central venous route because of the rapid development
of thrombophlebitis when TPN solutions are
administered into peripheral veins. Current awareness
about the pathophysiology of peripheral vein
thrombophlebitis and the use of a number of techniques
that prevent or delay its onset mean that it is now
possible to administer TPN via peripheral route. These
techniques and the changes in the practice of TPN in
recent years (e.g. reduction of caloric loads and use of
lipid emulsions) mean peripheral parenteral nutrition is
a technique that is now applicable to the majority of
hospitalized, nutritionally compromised patients for whom
intravenous feeding is anticipated for less than 10-14
days.

Gupta, K & Chopra, S. C.Total Parenteral Nutrition, Journal of Anaesthesia and Clinical Pharmacology 2008; 24(2): 137-146

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Normally, infusion sets are changed every 24 h and infusion pump sets and flow meters, used to adjust infusion rates, are changed every 72 h. In the General Surgery Inpatient Unit, infusion fluids with osmolarity up to 900 mOsm/L are given through peripheral veins, whereas fluids with higher osmolarity are given through central veins. Some total parenteral nutrition products have a low level of osmolarity and are administered peripherally, in which case Abbott pump sets are used and changed every 24 h. Infusion fluids, drugs given, dates of catheterization, removals, and dressings are recorded.

Uslusoy, E., & Mete, S. (2008). Predisposing factors to phlebitis in patients with peripheral intravenous catheters: A descriptive study. Journal of the American Academy of Nurse Practitioners, 20(4), 172-180. doi:10.1111/j.1745-7599.2008.00305.x

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Peripheral versus central venous access
PN is delivered by peripheral or central vein
access, depending on the concentration of
dextrose and consequent osmolarity of the
solution. The maximum concentration of
dextrose for peripheral venous access is 12.5%.
A dextrose concentration greater than 12.5%
has an acidic pH and can be irritating to the
peripheral veins. In addition to dextrose,
electrolytes and minerals added to the solution
increase the osmolarity of the solution. Short
term TPN for less than 3 days can be given via
the peripheral line.

Chaudhari, S., & Kadam, S. (2006). Total parenteral nutrition in neonates. Indian Pediatrics, 43(11), 953-964.

I would never deviate from the recommended standards. I have to say if INS and NAVAN ever changed their position on this I think that most would find it challenging to maintain a suitable access. When we used to give PPN peripherally we had to change those lines approximately daily d/t to thrombophlebits. Patients requiring TPN usually have many comorbitities which subject them to increased complications. Frankly,even on our PPN patients we place a PICC. Even 10 days of PPN or TPN could trash the veins. Venous preservation is what you need to think about here. If and when the recommendation is changed I can only see that at best given that way for a few days.

Dear all,
The TPN is a very critical mixture of various nutrients in varying concentration so it is hard to predict how will the body respond to it.
Citing this point the early manifestation of the reaction is must, so it must be given peripherally but if given at peripheral site it may damage the vessels so it must reach the central blood flow.
For this the TPN must be given through the PICC lines which start peripherally and give the indication of any adverse reaction before it is too late which is the chance that can happen with Central Line. and since it delivers the solution in high blood flow it gets diluted and causes no harm to blood vessels.

So TPN must be given through PICC
VYGON has a variety of PICC lines, even for the Preterm babies which is a 28 G catheter

Apart from this it is said that the lipids must be given in dark as they are sensitive to light.


but I don't know whether a ambercoloured extension line can help or not. please help me to find out whether the amber colored line helps in controlling the degradation of Lipids.

Regards
Santoshkumar,
Mumbai, Maharashtra
India.
00-92-9209003392