TPN additives

[Inquisitive one]

Have a subacute patient on TPN. Nurses need to add additives prior to hanging. One of the additives was 70/30 insulin along with regular insulin. I questioned the order because I learned that only Regular insulin is given IV. Would you have questioned the order? Can other insulins be given when mixed in TPN? The doctor d/c'd the 70/30 insulin and increased the regular insulin. What's your experience? Thanks

[RunningWithScissors]

My experience is that TPN additives are only done in the pharmacy under an airflow hood, NEVER on the floor.

70/30 insulin in TPN sounds kind of wacky, but who knows? I haven't been to a conference in a couple of years and things change. (Hints to the boss, how about a little continuing ed $$'s??)

[TiffyRN, BSN, PhD]

I'm pretty sure I've never heard of nurses adding products to TPN; changes are always done in the pharmacy (except maybe in homecare but I'm not sure about that). Also, 70/30 is not to be given IV, only Regular insulin and Humalog (or Novolog) is to be given IV.

Here is a link to the Eli Lilly pamphlet on 70/30 Humalog. It states it is never to be given IV or IM. This is the patient information section but it stands to reason as NPH is merely insulin with a product added to help it have a delayed release from SQ tissue.

http://pi.lilly.com/us/humulin-70-30-ppi.pdf

Please consult the pharmacist regarding this order.

[nursepearl]

IN the hospital setting we do not add anything to the TPN and if the TPn order changes then we send it back down to the pharmacy to be changed. As far as the 70/30....sounds fishy to me.

My boyfriend is on TPN at home and we add mulite vitamins and pepcid to the TPN ourselves...but of course this is at home.

[Zizka]

I'm pretty sure I've never heard of nurses adding products to TPN; changes are always done in the pharmacy (except maybe in homecare but I'm not sure about that). Also, 70/30 is not to be given IV, only Regular insulin and Humalog (or Novolog) is to be given IV.

Here is a link to the Eli Lilly pamphlet on 70/30 Humalog. It states it is never to be given IV or IM. This is the patient information section but it stands to reason as NPH is merely insulin with a product added to help it have a delayed release from SQ tissue.

http://pi.lilly.com/us/humulin-70-30-ppi.pdf

Please consult the pharmacist regarding this order.

I'm guessing the reasoning behind long acting substances not being given IV or IM is that they need to remain in the SC areas to be LONG acting.

[Inquisitive one]

Just to clarify; this patient is in LTC (SNF) setting and there isn't an inhouse pharmacy. Nurses need to add pepcid, vitamins, insulin, and vitamin C from an ampule to the clear dextrose solution before hanging. The TPN bag comes as a dual chamber with the lipids separate from the clear solution. Once the additives are in and mixed a dividing strip is removed and the lipids flow into the dextrose solution. This is done every 24 hours.

[rita359]

Just to clarify; this patient is in LTC (SNF) setting and there isn't an inhouse pharmacy. Nurses need to add pepcid, vitamins, insulin, and vitamin C from an ampule to the clear dextrose solution before hanging. The TPN bag comes as a dual chamber with the lipids separate from the clear solution. Once the additives are in and mixed a dividing strip is removed and the lipids flow into the dextrose solution. This is done every 24 hours.

I work in a hospital setting and know nursing homes run differently but tpn is supposed to be made in pharmacy under a hood that prevents contamination. Nursing homes get their meds from a pharmacy which should have provisions for making tpn. Possibility for contamination is high. Seems like your facility needs to update their practice.

[caroladybelle, BSN, RN]

I'm guessing the reasoning behind long acting substances not being given IV or IM is that they need to remain in the SC areas to be LONG acting.

My understanding is that the products in the longer-acting insulins that extend their action are not compatible with IV administration. That the molecular makeup of insulin other than regular is such that it might cause emboli, etc. That is also why, when mixing insulins, you draw up the longacting after the regular, so that no particulate med from long acting contaminates the regular.

[morte, LPN, LVN]

I work in a hospital setting and know nursing homes run differently but tpn is supposed to be made in pharmacy under a hood that prevents contamination. Nursing homes get their meds from a pharmacy which should have provisions for making tpn. Possibility for contamination is high. Seems like your facility needs to update their practice.

that is the way of long term care.....hopefully added in the med room with the door closed......it is delivered several days worth at a time....not daily..

how often do you change the tubing at your institution? how long does ea bag hang?

[Inquisitive one]

Each bag hangs for 24 hours. The tubing is changed when a new bag is hung. We also attach a 1.2 micron filter to the tubing. Having an inservice today at work about TPN by an infusion nurse employed by the pharmacy. She puts in our PICC's and midlines also.