TPN and Lipids

Maybe she's thinking a PICC (since the P stands for peripheral)? Which, if that's what she's refering to, i'd wonder if she really knows what a PICC is.

Never heard of TPN and lipids going through a regular peripheral IV before either.

lipids can be run through at peripheral line, though they usually arn't.

tpn, on the other hand, really must go through at central line. the osmolarity is too high for it to be given peripherally. it will damage the veins. this is a national standard, set by ins, the intravenous nurses society. all nures who practice intravenous nurisng are held by these standards, no matter if they belong to ins or not.

there was a thread on this board recently about this very subject, and many posters stated that it was ok to give tpn peripherally, if necessary for a short time. this is not the case, as it violates national standards. even if your hospital policy states it is ok, that won't stand up should a lawsuit come about. if a pateint is receiving tpn and lose their central access, the proper procedure is to hang d10 until central access can be re-established.

now, ppn is different. ppn (partial parenteral nutrution), such as quick mix, is ok to put through a periperal line, though the line probably won't last very long. maybe this is what the educator was talking about? or, the educator could have been referring to picc lines, which many people consier to be peripheral lines. they are not. piccs are central lines. even though the line starts in the arm, it end in the vena cava, just like any other central line. so tpn can go through piccs.

the infusion therapy textbook put out by ins states:

"the low osmolarity of fat emulsions permits delivery by peripheral veins."

it later states:

"peripheral venous access for ppn ... , should be limited to short-term or supplemental therapy especially if ppn does not provide the patien't nutrient requirements. tpn solutions require access into a central vein to allow rapid dilution of the solution to prevent phlebitis, pain, and thrombosis."

Critter lover is right....NO TPN PERIPHERALLY...

I wouldn't want to even infuse lipids into an arm vein....it's just asking for phlebitis...

get a central line in....

Your instructor is wrong.

Hi,

Saw the post and thought I would respond. I am a NICU nurse. We OFTEN run TPN, lipids through a peripheral IV---you just have to make sure the dextrose content is not above 12.5%, and we don't run TPN with calcium in it into a PIV, we would give IV pushes of calcium. I will say PICC lines are very nice because you can give a higher dextrose content and have calcium in it---provided the line terminates centrally and isn't a "deep PICC"....hope this helps.....

THE KEY IS THE DEXTROSE PERCENTAGE, as SFRN points out. The rule at my old hospital was that if dextrose was >10%, then it must be given through a central line.

PPN keeps dextrose at 10% or lower, so it can be given peripherally (as Critter Lover mentions above).

THE MAIN PROBLEM IS WE USE THE TERM "TPN" FOR BOTH TPN & PPN. That's what causes the confusion, I think.

Thanks for this great conversation!

Hi, I wanted to add that Lipids need not to exceed recommended infusion rates under normal circumstances i.e. nutrition indications. In lipid rescue of anathesia toxicity this would not apply. Also lipids are lovely places for germs to grow in and anything seemingly chunky should NOT be used.

The EDUCATOR needs education. First of all, just because a PICC starts in the peripheral vascular system, doesn't mean that it is a Peripheral Access Device. So a PICC is a Central Catheter. As so appropriately said in other posts, TPN should never go into the veins that terminate in the peripheral vascular system. TPN is a solution that ALWAYS needs to infuse via Central Catheter. That is, via a catheter whose tip resides in the distal 1/3rd of the Superior Vena Cava, or the Inferior Vena Cava if it's a femerol catheter.

It's shocking for me to also see that NICU patients are getting TPN running into their small veins in the arms... CAN WE SAY OWWWWWWW!. It doesn't matter what your population is.. TPN is TPN, IS TPN and MUST GO CENTRALLY! TPN rarely has a dextrose concentration of less or equal to 10%. Usually the dextrose concentration is 50-70%. If your concentration of dextrose is 10% or less, you may have PPN infusing.

While it is true that PPN may have an osmolarity of less than 600, the final admixture of the solution still needs to be assessed and if it is > 600, place a central catheter.

Also, there should not be a catheter which is denoted as a "Deep Tip PICC."

INS, as critter lover pointed out, states that one can have a true PICC which terminates in the SVC, or you may have a Midline catheter, but to have a PICC terminate in the midclavicular area (Subclavian vein, innominate vein) is a NO-NO. Thrombus rates skyrocket when a tip stops here, and therefore should not be done.

Midline IV catheters are 3-8 inches in length and are not central catheters as they stop or terminate before the axillary vein at the shoulder. Medications that need to go centrally, should not be infused via this catheter just like they should not be infused via short term peripheral access catheters (

One on one, I'd kindly point out to your "educator" that you are aware of INS standards and they seem to differ from her views. Direct him or her to the INS web site www.ins1.org to obtain a copy of their standards.

IVRUS, without referencing this statement I will rely on my years as aRPh who has worked with TPN

a little. the stock concentrations of dextrose are either 50 or 70 but it gets diluted with the other main

Fluids the amino acids the sterile water and lytes. So a 200 gm dextrose load giving 680 calories from

Dextrose would use 140 ml of a70 percent solution at the compounding station.once the other

Ingredients are added 200 gm is in final volume for example 2liter which makes final concentration

10 percent. For the final concentration to be the 50 to 70 above stated would be pure stock concentration

.also ped tpn is a sub specialty and much thought goes into its preparation. Ped tpn usually is done with

Many considerations that the adult tpn formulator would not consider. Please excuse the copy

From my droid, cheers.hY

bisiegel,

Though I understand the 200gm/2L with a 10% osmolarity ~ 505... However, That is not the sum total of each and every admixture in the bag. The final admixture of the TPN is what has to be looked at.

IVRUS, let me take it from another angle. The final dextrose concentration in a TPN usually range 10%- 20 %. It is NEVER 50 to 70 %. It is compounded from a stock of 50% or 70 % and further diluted.

In my opinion anything more than than 20% cals coming from glucose should be examined to see if caloric intake could be shifted towards the aminos or the fats.

The final osmolarity is very high in the TPN due to the solute additive effects of all of the ingredients except for the sterile water. The amino acids and electrolytes and the dextrose toegether make the final osmolarity and yes it most always exceeds the 600s and more typically in the 1000 - 1100 range and hence the necessity of a central access device. Does that make sense ? ~ Barry

Agree with IVRUS. I do not see these mistakes that often where I work,however, we did see it last week. A patient pulled out their PICC and the nurse started a PIV and resumed the TPN. Luckily,our PICC nurse caught it the next day when she went to do the dressing change. I would have to approach this educator and provide them with the correct information. Do you feel that you can do this?

Abstract:

Out of 60 patients undergoing surgery for colo-nectal cancer, 30 were given total parenteral nutrition (TPN) via a peripheral venous catheter (PVC), and 30 via a central venous catheter (CVC). All Patients were treated for 10 days perioperatively.

There were no complications of the treatment by CVC. The treatment had to be interrupted in 11 (= 37%) of those receiving TPN via PVC, 4 because of general inconvenience, 7 because of transient pain in the infusion arm without any sign of phlebitis. 63% suffered no complications.

The study shows that, with most patients, it is possible to give TPN with an osmolality around 1100 mOsm/kg for up to 10 days via peripheral veins. For TPN of short duration, or where the duration of treatment is uncertain, it is recommended to give TPN initially via peripheral venous catheter, unless a central venous catheter is indicated for other reasons.

Reference

Hoffman, E. (1998). A randomised study of central versus peripheral intravenous nutrition in the perioperative period. Clinical Nutrition, (8)4, 179-180.