TPN Guidelines

BluegrassRN · Sep 24, 2009

To answer some of your questions, a PICC is a central line. If the PICC has multiple lumens, then it is not an issue...the electrolytes go in one lumen, the TPN goes in another. Continuous TPN has a dedicated line. I have had patients who have had TPN intermittently (usually only at night). When TPN is not running, other meds can run through that line/lumen.

I have never seen electrolytes piggybacked into TPN. That doesn't seem right at all.

Blueorchid, ASN, RN · Sep 24, 2009

But is there any reason why you couldn't administer both electrolytes and TPN through the same line? Particularly if patients get TPN with electrolytes as is. Not that you would want to but I would think its just like adding more to the TPN solution...or am I totally off kilter there?

If its a factor of sheer volume going through the line I understand, but I was just wondering the rationale is only TPN through one line and nothing else and if there was something I was missing.

Thanks for the reply though

BluegrassRN · Sep 24, 2009

Off the top of my head, the main reason I wouldn't do it is compatibility issues. Certain concentrations of additives can cause precipitation in the TPN, for example. Also, TPN is formulated each day (in the hospital anyhow) based on a patient's labwork. Any changes that need to be made to the electrolyte solution in the TPN should be addressed within the TPN itself, not by adding another line of lytes. If you are piggybacking into the TPN, you are actually suspending the running of the TPN. If you y-site it in, you aren't, but you are still running into concentration/compatibility/acid-base issues.

Unless I were specifically directed to do so by IV therapy AND pharmacy, I would not EVER run anything into a TPN line. The exception to this, of course, is lipids, which we routinely y-site into TPN. If something was VERY off on the labs and needed to be addressed immediately through the IV, I would expect pharmacy to adjust the TPN and send me a new bag, or I would put the needed infusion through another lumen on the PICC or start a new peripheral site.

I'm curious, is this a hypothetical situation, or did you actually experience this in clinicals or at work? I have never seen a patient need any additional electrolytes with TPN that this situation would even come up, though it's not like I am giving TPN on a daily basis at work, so that may just be my own inexperience.

I'm posting a link to a thread that addresses IV questions in general, and TPN in particular. The 5th comment has several links with information about TPN.

https://allnurses.com/nursing-student-assistance/any-good-iv-127657.html

Hope that helps!

BabyLady, BSN, RN · Sep 24, 2009

According to the good ol nursing "rules of the road," TPN is given through a virgin IV line (never used) and only that line. Or at least that's what hospital protocol is telling me. When I looked online I also noticed that most TPN is placed through a central line and that line has a high rate of infection, hence I can understand why you would only administer TPN through said line.
However in clinicals my patient has TPN through a PICC line and I was wondering if this same principle applies with a PICC. Particularly if the patient is getting secondary infusions of electrolytes. Could you infuse the electrolytes through the same line? If not, why not? What are the other risks with TPN through a PICC line?
Any help would be great. Thanks!

TPN contains levels of Dextrose, which is the food needed to harbor bacteria.

It's not that the line itself gets infected, it's every time the line is accessed.

At our hospital, PICC dressings are NEVER changed unless there is a reason to...if the dressing is visible, with no s/sx of redness, infiltration or drainage/bleeding, it is left alone.

TPN is changed daily. The access port is swabbed with Chloroprep for 15 seconds and allowed to dry for 30 seconds (per vendor instructions) which is necessary for it to work propertly...then you spike your access port.

If you need to administer compatible drugs, you use the secondary line to the PICC using Chloroprep the same way.

Blueorchid, ASN, RN · Sep 24, 2009

To answer your question Bluegrass it was a mistake I witnessed by another nurse. I do apologize if I confused anyone, the electrolytes were not piggybacked directly off the TPN- both were indeed running at the same time. However it was run through the y-site, same as the lipids were and it was still going in through the same lumen as the TPN (it was a dual lumen PICC).

As to why electrolytes were administered that day, he was having frequent bouts of vomiting and had NG irrigation with 5 other drains coming out of him (his history takes a while I'll leave it at that). Its safe to say he was definitely losing fluids and with PRN magnesium available the nurse wanted to keep everything in top form. His TPN was actually cyclic so he had it running with an order registered from the day before (it usually is started at night) for so many hours with lipids and then its discontinued the next morning (when I was on the floor and saw it happen.)

Morning labs just happened to show his mag was the highest level of the low PRN electrolytes so they were done during the last part of his TPN.

They floated the magnesium in with 250 mLs of Normal saline and the mag was piggybacked off of that saline...which is why I kept saying piggyback. They were both running at the same time though.

I think the issue has to do with the risk of precipitate and I can see why you wouldn't want to run anything through the TPN. I imagine if it was something like an antibiotic that would cause havoc and I realized that what was done was considered wrong. It was just me pausing and saying..."wait...could this technically be right?"

As a student though I'd rather be safe than sorry though so I just wanted to clarify and make sure there wasn't something secret I'd missed. Apparently nothing happened to him and the next day the PICC was still clear *knock on wood* so I don't think there were any long term complications. And that's that!

rinne · Jan 17, 2010

Hi,

Just ran into similar question yesterday evening when I went to pull down a completed KCl line and was surprised to see it running into the TPN line. It had been running at y-site on its own pump rate but I was concerned nonetheless. Was taught that nothing is run into TPN line. We called pharmacy and were told it's compatible, with no mention of the "golden TPN rule." Yes, TPN already has K in mix so that makes sense, but still was hesitant. Checked with my manager and she asked about rate of TPN (70 ml/hr), pt with no fluid overload issues, so combined rate of 170 ml/hr seemed reasonable.

Home this morning, checked online and ended up here and then to site recommended by one of previous responders. Copied below for reference. Hope it helps.

Learning experience and didn't have to consider whether incident report was necessary :-)

rinne

From

http://healthlinks.washington.edu/nutrition/section6.html

D. Medications and Parenteral Nutrition

Administration of medications via PN may be beneficial when there is limited venous access and/or the patient is fluid restricted. The major problem associated with the addition of medications to PN is the potential for incompatibilities. The following issues should be considered if a medication is to be added to PN.

Certain medications should not be mixed with any PN if intermittent infusion is necessary to achieve therapeutic serum levels (i.e. antibiotics).

Medications that require a precise rate of infusion (i.e. cardiovascular agents) are not recommended to be added to PN solution.

Doses of a medication cannot be readily adjusted once combined with the PN.

Adding alkaline medications to PN admixtures may increase the potential for calcium-phosphate incompatibilities.

Medication must be chemically stable in PN solution for over 24 hours.

Medications routinely added to PN solutions include: H-2 antagonists (e.g. ranitidine) and insulin.

The use of Y-site or piggyback drug delivery has helped prevent or avoid drug compatibility problems. The contact time of multiple solutions being administered via Y-site is short, often in the range of 15-20 minutes. There are many studies documenting the compatibility of PN and medications when administered via Y-site injection. Call the IV pharmacy for a complete list of medications that are compatible with PN and lipids.

kkd683 · Mar 1, 2010

I have separate TPN and Lipids. Lipids are to run at 64.5cc/hr and TPN is to run at 50cc/hr. I'm assuming that I'll need 2 pumps and can then piggy back the 2 together. Is this correct? The pharmacy only sent filtered tubing but I thought the Lipids didn't need a filter?