TPN questions

PedsRNBSN · Jan 23, 2006

I work in peds...so ours may be different than yours...

I'm doing a little research on TPN policies and have some questions:

1. Do you give TPN via a peripheral line ever? (PPN)

NO!!!! There have been TONS of incidences where there were HORRIBLE infiltrates-this is why we never do this.

2. Do you always stop the TPN for lab draws (even if the TPN is in a central line and the draw is peripheral?)

We always stop if we are drawing from central line, not usually if draw is periph.

3. Do you add insulin to the TPN for elevated blood sugars or do you run a seperate insulin drip?

NEVER add insulin, always start drip.

4. Do you infuse other meds into a line that has TPN running in it?

It depends if it is compatible or not (if it is, we run it), and (since we always run thru a central) if we have a double or triple lumen or not..etc..

cathlabnurse1972 · Jan 23, 2006

1. There is a different concentration of parenteral nutrition which can be given peripherally. This is PPN. It is different from TPN. TPN can only be administered via a central IV line.

2. You do not have to stop TPN to draw blood peripherally. TPN should not be stopped abruptly as this can cause hypoglycemic reactions. Labs should never be drawn from a central line through which TPN has been infusing.

3. Elevated serum glucose levels may need to be treated by adding insulin to the TPN, using SQ insuling and supplementing with an insulin gtt if needed. If you are using an insulin gtt, you can piggyback the gtt in at the port below the filter that is in your TPN line and run it on a separate pump.

4. There are some medications that are compatible with TPN, insulin, lipids, and some antibiotics--I just always call pharmacy first and make sure that I piggyback everything below the filter.

Hope this helps

gwenith, BSN, RN · Jan 23, 2006

I'm doing a little research on TPN policies and have some questions:
1. Do you give TPN via a peripheral line ever? (PPN)
2. Do you always stop the TPN for lab draws (even if the TPN is in a central line and the draw is peripheral?)
3. Do you add insulin to the TPN for elevated blood sugars or do you run a seperate insulin drip?
4. Do you infuse other meds into a line that has TPN running in it?
Thanks for your help.
Celia:)

1) NEVER, ever ever ever

Why? Because it has 50% Dextrose and that will cause a 3rd degree burn if it is put peripherally

2) I have never stopped TPN for lab draws because you should not stop TPN abruptly for any reason unless you are monitoring the BSL very closely.

3) We always have a separate insulin infusion but then I work ICU and our patients are not exactly stable when it comes to glocose levels

4) Unless it is insulin - NOTHING gets mixed with TPN. This is for 2 main reasons - firstly incompatability - not a lot of drugs are compatable with TPN and second is infection. TPN is an ideal bacterial culture medium the less you access the line the less chance of infection and contamination.

hrtprncss · Jan 24, 2006

I'm doing a little research on TPN policies and have some questions:
1. Do you give TPN via a peripheral line ever? (PPN)
2. Do you always stop the TPN for lab draws (even if the TPN is in a central line and the draw is peripheral?)
3. Do you add insulin to the TPN for elevated blood sugars or do you run a seperate insulin drip?
4. Do you infuse other meds into a line that has TPN running in it?
Thanks for your help.
Celia:)

1. Yes, depends on the dextrose conc.

2. If peripheral, then no. If central, then stop and draw.

3. Insulin is sometimes added usually. If pt has increased Blood sugar, sliding

scale is also started.

4. Depends on the meds, Pepcid, K, Mg, as riders. If they're compatible why

not

pvjerrys · Jan 24, 2006

10% dextrose (PPN) may be infused in peripheral vein.

20% or greater dextrose (TPN) must be infused via central venous line.

Usually pt has more than one lumen for TPN so that lab draws or other meds can be given via other lumen.

Blee O'Myacin, BSN, RN · Jan 24, 2006

Originally Posted by Celia M

I'm doing a little research on TPN policies and have some questions:

1. Do you give TPN via a peripheral line ever? (PPN)

2. Do you always stop the TPN for lab draws (even if the TPN is in a central line and the draw is peripheral?)

3. Do you add insulin to the TPN for elevated blood sugars or do you run a seperate insulin drip?

4. Do you infuse other meds into a line that has TPN running in it?

Thanks for your help.

Celia

1. TPN only through central lines. In the unusual event that a patient does not have a central line on my unit (Bone Marrow Transplant), we have one placed before TPN is started.

2. Yes. Unless they are peripheral blood cultures, all labs are drawn through a central access device. Having TPN run through the other lumen can alter results such as the CBC as well as the chemistry. It is off for less than 5 minutes. I flush the line, waste 10cc's and draw my labs.

3. Our pharmacy will add insulin to the TPN and if it isn't sufficient, we cover patients with Regular Insulin QID - or if that isn't sufficient, we start an insulin gtt.

4. I will Y in compatible meds below the filter. Tacrolimus and Cyclosporin are TPN compatible and is a lifesaver when you have a double lumen PICC, TPN running through one lumen and a pile of IV meds that are timed to go in over 2 hours.

Hope this helps!

Blee

Gompers, BSN, RN · Jan 24, 2006

Well, I work in the NICU, and our babies usually have pretty limited IV access. Most of the time we have peripheral IVs, PICC lines, and umbilical catheters. Once in a great while, we'll have an older baby with a Broviac line. But we do give TPN daily to about 50% of our patients, so I'll join in...

1. Yes, we give it peripherally. The dextrose has to be 12% or less, and the protein levels are lower as well. Usually this is a case where it's a new baby who hasn't had a PICC line placed yet, or a baby who did have a PICC line that got infected, and we won't typically place a new PICC until blood cultures are clear.

2. In the rare case that we have a Broviac, we'll stop the TPN, flush the Broviac, draw off 3cc of blood and then draw the labs. However, we never draw glucose or electrolytes off a line that had any dextrose/electrolyte solution running throough it. Otherwise, we'll draw the blood elsewhere while the TPN continues through the PIV, PICC, or UVC.

3. We always start a separate line for insulin drips and run it by itself.

4. We infuse whatever we can with the TPN! Again, limited IV access. According to pharmacy, NOTHING is compatible with TPN, but we have published charts that show what is actually compatible at the Y-site. If it's okay there, better believe we're going to use that line! We never have double lumen lines if it's a PICC, only if it's a UVC.

fergus51 · Jan 24, 2006

Same as Gompers, except we do put insulin in TPN. Do you know why your facility doesn't Gompers? Just curious.

Daytonite, BSN, RN · Jan 24, 2006

I'm doing a little research on TPN policies and have some questions:
1. Do you give TPN via a peripheral line ever? (PPN)
2. Do you always stop the TPN for lab draws (even if the TPN is in a central line and the draw is peripheral?)
3. Do you add insulin to the TPN for elevated blood sugars or do you run a seperate insulin drip?
4. Do you infuse other meds into a line that has TPN running in it?
Thanks for your help.
Celia:)

We gave TPN via peripheral line, especially if something happened to the central line and it wasn't working. You really shouldn't be cutting off TPN without tapering it. Then, we also had patients getting PPN because the doctors either couldn't make up their mind about going with a central line, or the patient was balking. You want to make sure you never run more than 15% dextrose through a PPN line. We had a situation when I was on an IV team where somebody hung a central line formula on a peripheral line. That was 40 or 50% dextrose infusing peripherally. Needless the say, the guy's IV was restarted 2 or 3 times in a 24 hour period before someone actually took the time to look at what was infusing. Turned out the pharmacy was never informed that the central line had been pulled and the nurse who hung that bag hadn't checked very carefully what she was hanging. Note: we often used two nurses to check TPN solutions against the actual written doctor's order (just like checking blood before a transfusion) to make sure we were hanging the right stuff. You'd be surprised how often we found mistakes in the formulas.

Yes, the TPN is totally stopped for a few minutes when you are going to draw blood from the central lines, but not if the blood is being drawn from a peripheral vein. If the TPN is infusing into a central vein it is hitting the heart within seconds where the turbulence and blood coming into the heart is diluting and mixing it with blood. If you're drawing blood on someone with PPN running, you want to try to draw out of the opposite extremity rather than going below the point of IV insertion.

Insulin was often added into the TPN solution itself. The brains over in pharmacy had mixture guidelines on this. The insulin is added to help the body process the high dextrose content.

The only other thing that was piggybacked directly into a running TPN solution was lipids. Most of the time the lipids are now mixed into the actual TPN solution although there are still some docs that will want to infuse a one time dose of 500cc of it over, say, 8 hours. Otherwise, things like antibiotics and other IV piggybacked meds are strictly run through separate IV lines. This is why it's ideal to have a central line that has 3 separate lumens, or a dual lumen PICC line. That gives you at least one lumen that you can use exclusively for the piggybacked meds. In those cases you can run the piggybacks at the same time as the TPN as long as they are all infusing through separate lumens of the catheter. There is enough turbulence and blood in the vena cava entrance to the atrium of the heart where the tip of the central catheter should be positioned to prevent these solutions from coming into direct contact each other and causing a physical incompatability.

It is important for nursing to know where the tip of the central line lies within the patient's anatomy. If the catheter tip is in the subclavian vein, there will not be the turbulence and larger amount of blood flowing there as there is in the vena cava. Also, in the last hospital where I was an IV therapist, there was a TPN team that consisted of physicians, pharmacists and dieticians. No TPN solution was allowed to be mixed and hung unless someone from the Hyperal Team reviewed the orders the doctor had written. If they thought there was something about the orders that they felt were wrong, the hyperal pharmacist would contact the doctor and discuss it with him.

suzanne4, RN · Jan 24, 2006

10% dextrose (PPN) may be infused in peripheral vein.
20% or greater dextrose (TPN) must be infused via central venous line.
Usually pt has more than one lumen for TPN so that lab draws or other meds can be given via other lumen.

Up to 10% Dextrose may be given via a peripheral line, anything greater than that mist be a central line. Many times you will see 12.5% dextrose, and that is always via a central line. Once it contains greater than 10%, it automatically becomes TPN, and no longer can be considered a PPN.

Gompers, BSN, RN · Jan 24, 2006

Same as Gompers, except we do put insulin in TPN. Do you know why your facility doesn't Gompers? Just curious.

The main reason is that we usually only have the one PICC/PCVC running plus peripheral IVs. We'd prefer to run the insulin through a PIV in a slow drip, and save the central line for all the antibiotics, etc. That way the PIV lasts longer than if we ran the insulin through the main line and had to use the PIV for all our meds. Also it's the fact that we like to be able to flush all our meds through our central lines without accidentally "pushing" an insulin bolus, kinda like when we're running pressors through the line - have to rely on PIVs for everything else. And I hate that!!!