section name header

Information

Vascular Access

As previously discussed, the proper selection of vascular access (central vs. peripheral) depends on the type of PN formula. The hypertonic nature of PN requires the placement of a CVAD for administration. PN may be administered via any type of CVAD: nontunneled, PICC, subcutaneously tunneled, or vascular access port. The type of CVAD selected is based on a number of factors such as the anticipated duration of PN therapy and risk for thrombotic and infectious complications (Worthington et al., 2017). For patients who require long-term home PN, subcutaneously tunneled catheters are recommended (Kovacevich et al., 2019). The VAD should be the smallest gauge device with the fewest number of lumens necessary to meet the patient's needs (Ukleja et al., 2018; Gorski et al., 2021, p. S51; Worthington et al., 2017). PPN is administered via a short PIVC.

Care of PIVCs is addressed in Chapter 6, and care of CVADs is discussed in Chapter 8.

Parenteral Nutrition Administration

Multilumen VADs

When a patient has a multilumen VAD, ASPEN recommends dedicating one of the lumens exclusively to PN administration. While acknowledging that the research supporting this practice is based on a single study, the frequency of manipulation (i.e., accessing the lumen) is limited, which reduces the risk for intraluminal entry of microorganisms. Furthermore, the risk of infusing potentially incompatible medications with the PN is eliminated with this practice (Ayers et al., 2020).

Filtration

Filtration of PN solutions is critically important. While filters were initially developed for infection control purposes, the primary purpose for their use in infusion therapy is to protect patients from the harmful effects of particulate matter. The main consequence of particulate matter is to the lungs (Worthington et al., 2021). Symptoms may include fever, dyspnea, cough, respiratory failure, and even sudden death. When medications are coinfused with PN, there is an even greater increase in particulate matter. In 1994, the U.S. Food and Drug Administration (FDA, 1994) issued a safety alert regarding patient deaths related to calcium-phosphate precipitation in PN solutions that led to microvascular pulmonary emboli. This led to ASPEN's work in collaboration with the FDA to develop filtration recommendations over the years. In February 2021, ASPEN published new recommendations for filtration that states: Use a 1.2-micron filter for all PN solutions including PN solutions with lipids [“total nutrient admixtures” (TNA)], dextrose-amino acid admixtures, and lipid injectable emulsions (Worthington et al., 2021) (Fig. 12-5). Previous recommendations included filtration with a 0.2-micron filter for nonlipid solutions. Recommendations for setting up filtration for PN solutions are found in Table 12-4.

Table 12-4 Key Recommendations in Setting Up Filtration for Parenteral Nutrition Solutions

    1.Always use a 1.2-micron filter for all PN and ILE solutions.

    2.Locate the 1.2-micron filter as close to the VAD hub as possible.

    3.Do not coadminister medications with PN. If this must be done:

    • Consult with pharmacist to verify medication compatibility with the PN and if medication can be filtered; attach medication infusion at a Y-site above the filter.

    4.Prime the dextrose-amino acid solution through the tubing and filter, following the manufacturer's directions for use in priming the filter.

    • Do not invert the filter during priming; this allows the vented side of the filter to fill before flowing to the patient side.

    5.Attach the filter below the Y-site when the ILE and PN are administered as separate infusions.

Source: ASPEN, 2021.

NURSING FAST FACT!

Occluded filters are not uncommon and will result in electronic infusion pump occlusion alarms. After ruling out that the occlusion is not due to kinks or closed clamps on the administration set, that the CVAD is patent, and that the correct filter is in place (i.e., 1.2 micron), particulate matter is the likely cause. Replace the filter. Never allow PN to infuse unfiltered! Communicate with the pharmacy so that the PN formulation can be reviewed for potential causes for frequent clogged filters (ASPEN, 2021).

NURSING FAST FACT!

PN formulations are considered high-risk admixtures and can become contaminated during compounding or during the administration process.

Catheter Locking

For patients with long-term CVADs who have a history of multiple episodes of central line-associated bloodstream infection (CLABSI), antiseptic or antimicrobial drug locking may be considered for both therapeutic (i.e., to treat infection) and prophylactic reasons. A number of antimicrobial solutions have been used, such as ethanol, sodium citrate, taurolidine, and ethylenediaminetetraacetate (EDTA) (Gorski et al., 2021). Guidelines from the European Society for Parenteral and Enteral Nutrition (ESPEN) recommend taurolidine catheter locking in home PN as an infection prevention strategy (Pironi et al., 2020). ASPEN reports that ethanol is more widely used than antibiotic solutions due to concern about antimicrobial resistance (Ayers et al., 2020). Such solutions must be made by a compounding pharmacy because they are not commercially available at this time in single-dose syringes. Because there are conflicting data about the effect ethanol may have on polyurethane CVADs, recommendations are for use with silicone catheters (Ayers et al., 2020). There is a need for continued research relative to the efficacy, optimal concentration, optimal dwell time, and risks associated with antimicrobial locks (Ayers et al, 2020; Gorski et al., 2021, p. S116). In accordance with recommendations by the INS, such locking solutions should be aspirated at the end of the locking period, rather than flushed into the patient's bloodstream (Gorski et al., 2021, p. S116).

Administration Sets and Infusion Pumps

Specific recommendations guide the use of administration sets for PN. If any add-on devices (e.g., extension sets) are used, they are changed with each administration set change. Recommendations from ASPEN for administration set changes are as follows and are also cited in the INS Standards of Practice:

PN is always administered using an electronic infusion pump with free-flow protection (Gorski et al., 2021). For patients receiving HPN, a portable, ambulatory pump is used to provide the patient mobility and improve quality of life (Pironi et al., 2020). Infusion pumps are addressed in Chapter 5.

Blood Sampling for Laboratory Testing

The patient receiving PN requires frequent and ongoing blood sampling. Studies have reported the risk of CLABSI associated with blood sampling via the patient's CVAD (Ayers et al., 2020). With each CVAD access, there is risk for microbial contamination of the catheter hub. There is also risk of inaccurate laboratory values. Discouragement of catheter blood sampling should be considered, especially in situations in which the CLABSI rate is high despite adherence to basic infection prevention measures (Ayers et al., 2020). For HPN, routine laboratory sampling from the CVAD should be avoided whenever possible (Pironi et al., 2020). Laboratory sampling via venipuncture is then implemented. Refer to Chapter 7 for more information about blood sampling via a vascular access device.

Practice Criteria for Administration of Parenteral Nutrition

Establish Goals

Once it is determined that the individual will receive PN, goals for nutritional support should be set with specific markers and outcomes to be measured (Ukleja et al., 2018). Goals should address energy and nutrient requirements and intake goals, route for nutritional support, and short- and long-term measurable goals.

Examples of patient goals include:

Monitoring

The monitoring of patients receiving PN consists of assessment of the clinical and therapeutic response to the PN regimen. Assessment focuses on nutritional status, progress toward nutritional goals as discussed earlier, and anticipating and monitoring for potential complications as discussed in the next section. Areas for monitoring include physical assessment, functional status, vital signs, actual intake (oral, IV, enteral) and changes in GI function, weight, and the general response to PN such as wound healing. Monitoring of laboratory data such as blood glucose and serum levels of vitamins and minerals is important when abnormalities are suspected. Also, regular assessment and meticulous care of the VAD and infusion system are essential aspects of care.

ASPEN provides a PN administration checklist that addresses aseptic technique, PN container inspection, confirmation of patient identity and correct formula, and key steps in administration and monitoring. This is a helpful tool for nurses who administer PN in any health-care setting (see Table 12-5).

Table 12-5 PN Administration Checklist. Part of the A.S.P.E.N. Parenteral Care Pathway
PN Administration CHECKLIST ✔
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) champions the best evidence-based practices that support parenteral nutrition therapy in varying age populations and disease states. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events.
The purpose of this checklist is to promote safe practices by nurses administering parenteral nutrition.
  • Perform hand hygiene
  • Use sterile technique when manipulating vascular access device
  • Inspect PN container, check for:
    • Integrity of container: no defects or leaks present
    • No visible particles or precipitates
    • No oiling, streaking, clumping, or separation
  • Confirm correct formulation, check for:
    • Patient's name on label
    • Match all components listed on the label against the PN order
    • Route of administration (central vs peripheral)
    • Documentation of proper VAD tip placement
    • Start time
    • Infusion rate with taper if appropriate
    • Beyond use date and time
  • Verify patient identification
    • Confirm patient identity using two identifiers
    • Inspect armband (not applicable in home care)
  • Initiate PN infusion
    • Use appropriate size filter on distal end of tubing
    • Spike container
    • Prime tubing
    • Set infusion pump settings using double check
    • Trace catheter system to point of origin
    • Disinfect needleless adapter on VAD hub
    • Connect PN to patient
    • Initiate PN infusion at prescribed rate
  • Initiate monitoring protocol which includes:
    • Patient response
    • Glucose monitoring
    • Serial weights
    • Intake and Output
    • Bloodwork
    • Vital signs

Source: https://www.nutritioncare.org/SmartPN_Pathway.aspx. Reprinted with permission of the American Society of Parenteral and Enteral Nutrition.

NURSING POINTS OF CARE
ADMINISTRATION OF PARENTERAL NUTRITION

Nursing Assessment

  • History of weight changes
  • Dietary intake
  • History of diseases/surgeries
  • Identification of allergies
  • Medications, including over-the-counter and herbal products
  • Vital signs
  • Neurological status, including level of consciousness
  • Assessment of skin, hair, nails, and oral cavity
  • Intake and output
  • Baseline laboratory findings: Serum glucose, albumin, total protein, electrolyte, and chemistry profile
  • Appropriate VAD based on PN formula

Key Nursing Interventions

    1. Assist with insertion of CVAD, or insert if competent, as appropriate for therapy.

    2. Insert short PIVC per agency protocol for PPN.

    3. Verify correct tip placement of CVAD and patency of PIVC/CVAD before beginning PN.

    4. Check the label of the PN solution and ensure that it matches the orders before hanging each solution container.

    5. Use an electronic infusion pump to administer PN solution.

    6. Use a 1.2-micron filter for all PN solutions and ILE.

    7. Follow key steps in PN administration (see Table 12-5).

    8. Maintain VAD patency. Provide site care/dressing changes per agency protocol (at least every 7 days when using a transparent dressing; every 2 days when using gauze dressings) and prn if dressing loosened/dislodged or if drainage is present.

    9. Monitor

      a.Patient response

      b.VAD-related complications: Pay particular attention to phlebitis/infiltration with peripheral IV catheters; risk for bloodstream infection with all VADs

      c.Serial weights

      d.Intake and output

      e.Laboratory results: Serum albumin, total protein, electrolyte, glucose, and chemistry profile

      f.Vital signs

      g.Blood glucose

      • Adult hospitalized patients: Serum glucose should be maintained between 140 and 180 mg/dL (Ayers et al., 2020).

    10. The hang time of a PN solution container should never exceed 24 hours.

    11. Change the PN solution container and administration sets/filters every 24 hours. For ILE administered separately, the time limit for the container of ILE and the administration set is limited to 12 hours.

    12. Administer insulin as ordered to maintain blood glucose in the ordered range.

    13. Report abnormal signs and symptoms associated with PN to the provider and modify care accordingly.

    14. Observe for signs and symptoms of electrolyte imbalance (see Chapter 3 for a review of signs and symptoms).