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Obtain appropriate IV access (Seres, 2021a)
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PN may be administered through a peripherally inserted central catheter (PICC), subclavian, internal jugular, or femoral central venous catheter. Tunneled catheters (i.e. Hickman, Groshong, or implanted infusion port) may be preferred if recurrent infection.
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When possible, infuse PN into a dedicated single lumen central venous catheter; multiple-lumen central venous catheters should have one port dedicated to the infusion of PN.
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Peripheral parenteral nutrition (PPN) solutions contain a lower concentration of dextrose (10%) and the osmolality is typically below 900 mOsm/L, less hypertonic compared to total parenteral nutrition (TPN). PPN can be administered through a larger peripheral vein while TPN solutions must be infused through a central venous access device.
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Use a 1.2-micron filter for the lipid emulsion if administering as a separate solution. Piggyback the lipid emulsion solution below the parenteral nutrition filter. Ensure that any administration set to be used for lipids is di(2-ethylhexyl)phthalate (DEHP)-free (Lippincott Procedures, 2020).
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Add certain additives to the bag just before administering as some may not be stable in the solution for more than 24 hours (i.e. multivitamins, trace elements, medications such as insulin). Add clearest additives first.
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Remove PN solution bag from refrigerator at least 1 hour before hanging, allowing solution to warm up to room temperature to reduce the risk of hypothermia, venospasm, and pain. Do not place in hot water, a warmer or microwave.
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Verify PN orders including patient identifiers and weight, administration date/time, route (central or peripheral), dextrose concentration, and component names and dosages (amount per day), total volume and infusion rate, duration of infusion (continuous or cycled) and appropriate filter size (Lippincott Procedures, 2020). Check expiration date and ensure the solution will not expire while it is infusing.
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PN solutions containing dextrose and amino acids alone or with IV lipid emulsion added as a 3-in-1 formulation may hang for a maximum of 24 hours.
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IV lipid emulsion alone shouldn’t hang for more than 12 hours.
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Observe bag for leaks, color, cloudiness, separation, and precipitate formation. If signs of separation (“oiling out”), immediately return the solution to the pharmacy.
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Always administer PN using an electronic infusion pump and initiate slowly.
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Set the infusion rate, concentration, and volume to be infused.
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Set alarm limits appropriately.
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Label the container and IV administration set with the date of initiation or the date when change is required as directed by your facility.
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If PN must be stopped unexpectedly, administer 10% dextrose in water (as ordered) at same rate as nutrition solution to prevent blood glucose fluctuations and hypoglycemia.
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Provide line care using infection control techniques including hand hygiene, aseptic technique to change dressings and caps; never use a stopcock to administer PN solution.
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Avoid piggybacking other medications into the same line as PN solution.
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Change tubing every 24 hours. For lipids, change the administration set with each new container and at least every 12 hours. Change dressings as directed by your facility or if soiled, wet, or loose.
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Refeeding syndrome: In patients with significant weight loss or long-term malnutrition, starting PN can induce “refeeding syndrome,” manifested by electrolyte disturbances and fluid shifts or overload. Severe hypophosphatemia (including respiratory failure, cardiovascular collapse, rhabdomyolysis, seizures, and delirium), hypokalemia, low magnesium and any electrolyte imbalance should be corrected before PN is started.
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Central line-associated bloodstream infection (CLABSI): Patients may be at high risk due to malnourishment, immunocompromised state, and long-term IV therapy.
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Adhere to your facility’s central line bundle protocol; use proper hand hygiene and maximal barrier precautions during insertion.
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A dedicated single-lumen subclavian catheter for PN administration may decrease the risk of CLABSI.
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PN-associated liver disease (PNALD): Symptoms can range from transient elevations in liver function tests (LFTs) to fibrosis, cirrhosis, steatosis, hypertriglyceridemia, and irreversible hepatic failure.
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Metabolic complications may include hyperglycemia, hypoglycemia, serum electrolyte changes, macro- or micro-nutrient excess or deficiency, and Wernicke’s encephalopathy.
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Metabolic bone disease (MB) may be caused by abnormal bone metabolism resulting in decreased bone density and increased fracture risk; monitor serum calcium, phosphorus, and magnesium.
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Destabilization of formula may lead to emboli; monitor PN solution for faint cream layer, separation of oil and water.
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Hypercapnea may result from oxidation of glucose to carbon dioxide.
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Venous access complications include bleeding, vascular injury, pneumothorax, venous thrombosis, arrhythmia, and air embolism.
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Extravasation of PN solution can lead to tissue necrosis.
If the central venous access device or peripheral IV catheter used for PN is discontinued, document the following:
In patients stabilized on PN, periodic efforts should be made to initiate EN.