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Chapter 13

Total Parenteral

Nutrition

2012 Paradigm Publishing slides reprinted with

permission of ParadigmPublishing, Inc., St. Paul, MN

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Introduction

Nutritional therapy is administeredto patients who have a conditionthat prevents proper absorption ofnutrients from food and/or medicalconditions that render them unableto swallow or move food along the

gastrointestinal (GI) tractthe feeding tube may be a nasogastric(NG) tube , a gastric (G) tube , or a

jejunum (J) tube

2012 Paradigm Publishing

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Types of Parenteral Nutrition

Peripheral Parenteral Nutrition

Also known as partial parenteral nutrition or PPN,this type of parenteral solution provides a portion ofthe daily calories, electrolytes, and hydration to apatient in need of nutritional supplementation

the long-term administration of PPN is rarely done due to

the risk of extravasation


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Types of Parenteral Nutrition/2

Total Parenteral NutritionTPNs are administered into alarge vein in the neck, the chest,

the groin, or the abdomena CVC is placed into the veinthere are a number of differentmethods of inserting a CVC,

including tunneled catheter andnontunneled catheter insertion and peripherally inserted centralcatheters (PICCs)


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Indications for Prescribing TPNSome medical conditions that may lead to theprescription of TPN include:

diseases of the stomach, bowel, or GI tract, such as Crohnsdisease , short-bowel syndrome , ischemic bowel disease , orulcerative colitisany GI trauma or disease that results in gastrectomy orcolectomycongenital disorders of the GI tract


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Indications for Prescribing TPN/2 Some medical conditions that may lead to theprescription of TPN includecontinued:

diseases such as cancer, stroke, or acquired immunedeficiency syndrome (AIDS)severe cachexia , a type of malnutrition created by conditionssuch as marasmus or anorexiaany type of trauma, treatment, or disease that impairs thepatients ability to intake nutrition


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Formulation of TPN Solutions

A 2-in-1 TPN solution provides a 24-hour supply ofall nutrients except fatty acids

The most common TPN formula is the 3-in-1 TPNsolution which provides all of the nutrients neededfor a 24-hour period, including fatty acids in the formof Liposyn


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Formulation of TPN Solutions/2

Regardless of the formula, most TPNs are comprisedof the same basic ingredients:

sterile water, which provides hydration

dextrose, which supplies the primary source ofcarbohydrates for calories and energyAminosyn (amino acids or AA), which provides themolecular building blocks for protein synthesisLiposyn, which supplies essential fatty acidselectrolytes, vitamins, and minerals, which provide thebody with the nutrients needed for a myriad of chemicalprocesses (considered additives )


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Guidelines for Ordering TPN

When ordering sterile TPN components, prescribersconsider several factors, including the patients age,diagnosis, kidney function, liver function, andelectrolyte levels

Medications other than the typical TPN componentsare usually not added to a TPN solution due to the

potential for incompatibilityexceptions to this guideline are insulin, an H2 antagonistsuch as ranitidine, and heparin


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Guidelines for Ordering TPN/2

TPN Medication Order

The prescriber ordersthe components of theTPN solution by filling ina TPN order form

the TPN label should

match the information onthe order form exactly


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Compounding of TPN Solutions

Manual Compounding

Compounding continues to be a common practiceamong IV technicians

requires an IV technician to run the various base solutioncomponents through IV tubing and into an EEC or IV bag(often referred to as the final container )another popular term for this procedure is the gravitydraining method

the underfill method is another frequently used procedure


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Compounding of TPN Solutions.../2

In partially automated TPNcompounding , the TPN basesolution is prepared using an

automated compoundingdevice (ACD)comprised of up to eight differentpump stations

provides a separate source-tubing lineand color-coded IV tubing spike foreach of the TPN base components(often called source solutions and areheld within source containers )


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Fully automated TPN compoundingis a common procedure in facilitiesthat prepare large numbers of TPN

solutions each daythe TPN base solution is formulatedusing a TPN compounding device, suchas an automix compounder, and theTPN electrolytes and most otheradditives are prepared by a specialautomated device called a micromixcompounder


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Benefits and Drawbacks of Manual and AutomatedCompounding Methods

Manual TPN preparation is generally the most cost-

effective methodis also very time-consuming and labor-intensivethe tasks carry a greater risk for human error

Partially automated TPN preparation is considerably

faster and more accurateFully automated TPN preparation is by far the fastestand most accurate method


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Cleaning and Calibration of the ACD

USP Chapter requires that an ACD becleaned and calibrateddaily prior to TPNpreparation

record these tasks on anACD Cleaning andVerification Log Sheet


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Premixed TPN Solutions

Premixed TPN solutions areprimarily used in homehealthcare situations in whichthe patient requires long-termTPN therapy and hasconsistently stable lab values

called multiple-channel TPNsolutions


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Preparation Risks of ParenteralFluids

Every time a needle pierces a vials rubber top or theinjection port of an IV bag, there is a risk ofcontamination of the CSP

because TPN solutions are comprised of multiple solutioncomponents mixed with multiple additive components,the risk of contamination is greater with TPNs than it iswith other CSPs


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Preparation Risks of ParenteralFluids/2

In addition to the risks associated with the procedureitself, the chemical makeup of TPN solutions makesthem especially susceptible to incompatibility

complications, including:therapeutic incompatibilitychemical incompatibility physical incompatibility

In general, therapeutic and chemical incompatibilitiesare not visible to healthcare personnel and may onlybe identified by end-product testing


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Standard Mixing Protocols for TPNPreparation

Protocols should specify appropriate ingredients anddoses to ensure that all TPN components are boththerapeutically and chemically compatible

in general, the ingredient mixing order for TPNs is asfollows: the base solution dextrose, amino acids, sterilewater, and then fatty acids followed by the additives


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The Final Container

The glass EEC used in TPN preparation may have aspecial type of aluminum cap that must be removed

it is important to remove the cap very carefully

An empty bag constructed of plastic or polyvinylchloride (PVC) is more commonly used among sterilecompounding personnel

although more costly than an EEC, a TPN bag is easier to

handle during the sterile compounding processThe final container must be inspected for evidence ofparticulate matter or incompatibility


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Storage of the Final Container

Prepared TPN solutions should be refrigeratedremoved approximately 30 minutes before administration

It is very common to set the maximum storage

period for medium-risk CSPs as follows:not more than 24 hours at controlled room temperature

not more than 7 days at controlled cold temperature

not more than 30 days in a solid frozen state

All TPN solutions prepared using strict aseptictechnique have a beyond-use CSP date (BUD) clearlymarked on the CSP label2012 Paradigm Publishing

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Administration of TPN Solutions

TPN solutions are typically infused through a CVCand are administered continuously at a rate orderedby the prescriber

because the catheter is placed directly into a major bloodvessel and may remain in place for a week or longer,nursing personnel must exercise proper care of thecatheter

patients must also be closely monitored to ensure thatthey receive adequate nutrition, maintain balancedelectrolyte levels, and remain free of infection


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Administration Risks of ParenteralFluids

All patients receiving parenteral fluids should bemonitored for the following complications:

nosocomial infection

allergic reaction (including anaphylaxis)phlebitistissuingembolism

extravasationcellulitisStevens-Johnson syndromenephrotoxicity


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Administration Risks of ParenteralFluids/2

The primary risk associatedwith TPN administration isnosocomial infection

It is advisable for nursingpersonnel to filter the TPNsolution for possible

particulate mattermost facilities employ an in-line filter


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Special Considerations forPreparing TPNs

Training for Sterile CompoundingPersonnel

Must pass both a written exam andhands-on process validation test

as well as successfully complete anegative-growth ATTACK kit (or similartype of basic media-fill testprocedure ) upon completion oftraining, prior to preparing IVs forpatient use, and upon observance of abreak in aseptic technique


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Special Considerations forPreparing TPNs/2

Training for Sterile Compounding Personnel continued Advanced training includes the completion of anegative-growth, media-fill test procedure that ismore difficult than the basic media-fill test procedure

the advanced media-fill test procedure requires thetechnician to aseptically perform manipulations frommultiple containers

Those who prepare TPN solutions must also receivespecial training


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