Total Parenteral Nutrition (TPN)

2023
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 CarepathRx On Call
24 / 7 Access to the Clinical Pharmacy ​team​
Contact the pharmacy by calling
For after-hours, weekend and holiday the phone number at the top of
support, troubleshooting, and delivery the medication label.
needs:
• CarepathRx Pharmacist
• Local pharmacy support varies
by pharmacy.
• Dietitians
1-877-ENTERAL
• Nurses
• Delivery
 TOTAL PARENTERAL NUTRITION
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal
tract. It is a process in which the patient is given nutrients through veins when they do
not have other nutrition sources. The method is used when someone can't or shouldn't
receive feedings or fluids by mouth. Protein, carbohydrates, fat, minerals and
electrolytes, vitamins, and other trace elements are delivered intravenously so the
nutrients go directly into the bloodstream, bypassing the gut.
It is long-term therapy.
TPN can be given to a person who has a digestive disorder, accident, or has critical
surgery.
TPN is caustic as it has minerals, glucose, and electrolytes.
TPN can only be administered in larger veins near the chest or neck of the
patient. TPN must be administered through a Central Line.
The products are made by pharmaceutical compounding companies.
 Peripheral Parenteral Nutrition
It is a process of providing supplements with another source of obtaining/receiving
nutrients.
It is normally a fourteen day process. It is a short-term therapy.
It is not very caustic as compared to TPN
PPN can be administered in a short vein in a patient body.
PPN can be given to a person whose digestive system has been blocked or
unable to take a sufficient amount of nutrients from other sources .
 Total Parenteral Nutrition (TPN) is only appropriate when the gut does not work
enough to support adequate nutrition or extended bowel rest is clinically indicated

Mechanical Short Bowel Bowel Rest

Other
Obstruction Syndrome Indicated
Complete bowel Small bowel Enterocutaneous Severe
obstruction resection fistula Malabsorption

Partial bowel
Pancreatitis
obstruction
GI surgery with
Congenital short gut
anastomosis healing
Malignant GI mass Motility disturbance

Inflammatory bowel
Ileus GI Trauma Enteritis
disease
 Signs of
Nutritional
Deficiency
 CONTRAINDICATIONS
•Known hypersensitivity to egg, soybean proteins, peanut proteins, corn or corn products or
to any of the active substances or excipients

•Severe hyperlipidemia or severe disorders of lipid metabolism characterized by

hypertriglyceridemia (serum triglyceride concentration >1,000 g/dL)

•Inborn error of amino acid metabolism

•Cardiopulmonary instability (including pulmonary edema, cardiac insufficiency, myocardial

infarction, acidosis and hemodynamic instability requiring significant vasopressor support)

•Hemophagocytic syndrome (a life-threatening disease of severe hyperinflammation)

 Biochemical/
Laboratory Testing

Failure to achieve nutritional goals is often

because of inadequate monitoring.
General PN goals are to support lean body
mass, structure and function of the organs
and prevent nutrient deficiencies.
 Always stop the infusion prior to lab draw.​

Blood Flush line before and after lab draw.​

5-10ml flush before​

Sampling 10-20ml flush after​

Waste 10ml of blood prior to collecting specimen. ​

Tips
Hub to hub for best results. ​
Always remove extension sets when drawing labs. ​
Attach new sterile caps/extension sets after lab draws. ​
Microclave manufacture recommends:​
Draw labs through cap and flushing adequate. ​
• Caps should be changed no more than every 96 hours (use
clinical judgement).​
Helpful with sluggish or no blood return: ​
Positioning of line and limb.​
Syringe draw by pulling back 1-2 ml increments and allow to fill.​
Use the other line lumen.​
Flush briskly with 10mls using the push pause method to create turbulent flow.​
 Peripheral​ Catheter Non-tunneled Central​ Venous Catheter

TPN must be
administered
through a Central
Line.
Also, why high risk of
TPN is highly concentrated sepsis.
10% Dextrose (or more)
5% protein (or more)
Appropriate central lines for TPN: Click to add text
PICC
Non-tunneled central
Tunneled central Subcutaneous Needles PICC​ (Peripherally Tunneled Central​ Venous Catheter
Inserted Central Catheter)
Implanted Ports

PPN (partial parenteral nutrition with

dextrose concentration <10% and
protein conc<5%) is very rare and not
indicated for home infusion.

Midline Catheter Implanted Ports

 TPN Orders
Total Volume to be infused
Nutrients to be infused
Calories & lipids to be infused
Duration of infusion, and tapers

Total volume to be infused over ordered time.

Prevents Prevents
Hyperglycemia Hypoglycemia
 Dual
2:1 Solution Chamber 3:1 Solution 3
Bags
Chamber
SMOF
Bag
 Supplies
Review teaching guide to determine what supplies are required to administer therapy.
Review TPN additives and volume on Rx Orders in HCN and/or POT to determine
additional supplies.
Lipids are larger molecules and require the 1.2 - micron filter to be able to pass through.
• 2:1 (no lipids) require the 0.2-micron filter.
Adequate battery or battery charge.
• Typically, TPN is ran over 12-16 hours and is 1200-1600 ml per dose.
• Resulting in a Plateau greater than 100ml/hr.
Glass ampules require a filtered needle to draw up medication.
Tubing change
• Daily – with each dose.
 IV Line Filters​
An IV-line filter is a membrane in the tubing set designed to prevent
particulates and air bubbles from being administered.​
Filters Components: ​
• Inlet allows fluid to enter the filter compartment.​
• Fluid then fills the vented side, allowing air to be removed.​ Arrow to point up
• Filter membrane becomes wet and prevents air and during priming.
particulates to flow through the tubing. Works like a strainer. ​
• Fluid flow to patient side for administration.​
Proper priming techniques allow the fluid to fill the air-vent side first,
then saturating the membrane and before filling the patient side.​
Common filter membrane sizes:​
• Arrow should point up when priming to allow air bubbles to 0.2 micron ​
flow through membrane before fluid saturates it. ​ • For medications
compounded in the home.​
• Most frequently used to
filter particulates. ​
1.2 micron ​
• Usually for TPN lipids.​
• Allows larger molecules to
pass to the patient.​
 TPN Product Label
Product label to be reviewed with each dose or bag change.
Pump settings to be reviewed on the pump with each dose or bag
change.
Product label components to review:
• Patient name
• Ordering provider
• Medication name and dose in bag or cassette
• Administration instructions / Pump parameters
• TPN additives
• Storage & warming instructions
• Expiration date

32
TPN PLAN OF TREATMENT IS 3 PAGES
 Always
maintain
Patient Additives aseptic
technique.

Some medications are added to the PN solution at time of administration due to decreased
stability.
• The bag of TPN will expire 24 hours after the additives are placed in the TPN bag.
Examples of common additives include, but are not limited to:
❖ Insulin
❖ Famotidine
❖ Heparin
❖ Vitamins (exp. Multivitamin, folic acid & vitamin B12)

When introducing additives, use strict aseptic technique to avoid

antimicrobial contamination
 “Hub scrub” for 30
seconds using alcohol
and friction in a twisting
Preventing CABSI
motion. Scrub the Hub for 30
Allow to dry for 60 seconds!
seconds
The Catheter Hub is a known source of line
related bloodstream infections (CABSI).
The CDC recommendations are to “SCRUB”
rather than “WIPE” the hub with alcohol or
chlorhexadine before accessing.
SCRUB THE HUB before each use. S.A.S.H
requires cleaning the HUB 4 times with 4 new
TPN patients: anapestic wipes, one for each IV-line access.
30 second scrub Teach the patient scrupulous Hand Hygiene
x2 prior to TPN procedure and maintaining aseptic technique.
with a 60 second air dry
between scrubs
 START
Double Scrub the Hub Connect Scrub the
TPN to IV hub for 30
line seconds

Air dry for Air dry for

60 seconds 60 seconds

Steps to Flush
Scrub the
and connect Scrub the
hub for 30
seconds TPN to IV line hub for 30
seconds

Air dry for Air dry for

60 seconds 60 seconds

Scrub the
Flush with
hub for 30
saline
seconds
 START
Flush with
Double Scrub the Hub Heparin or
Disconnect
TPN Tubing
other locking
from IV
agent

Scrub the
Air dry for 60
hub for 30
seconds
seconds

Steps to
Scrub the
hub for 30
disconnect TPN Air dry for 60
seconds

and lock IV
seconds

Line
Scrub the
Air dry for 60
hub for 30
seconds
seconds

Scrub the
Air dry for 60
hub for 30
seconds
seconds
Flush with
saline
 Metabolic
Complications
Glucose Metabolism
Why we taper up and down.
Hypergl ycemia from rapid infusion of glucose & hypoglycemia wi th abruptly s topping.
 SASH Method

1 . Follow physician orders on

POT for flushing volumes.
 Line Locking
To prevent CABSI and maintain line patency. ​
Not to be administered systemically.​ Common locking solutions:
• Always withdrawal lock solution before flushing line with Saline. Vancomycin​
• If multiple caregivers, label the catheter: “DO NOT USE-LineLock” Gentamycin​
to prevent systemic administration (flushing of lock solution). ​ Ciprofloxin
Allow lock solution to dwell for a period specified by the physician High dose Heparin ​
order. ​
Antibiotic lock therapy:​
• Goal of sterilizing the catheter lumen​
• Instilling high concentrations of antibiotics into the catheter
lumen for extended periods of time​
Ethanol lock therapy: ​
• Goal of sterilizing of the catheter lumen​
• IV line must be made of silicone, other materials may
deteriorate.​
 Alcohol Caps​
Cap to cover the Microclave cap (hub/connector). ​
Cap with alcohol-soaked sponge to cleans hub. ​ Must scrub the hub​ for
30 seconds​ before
Cap is left in place between IV-line access. ​
EVERY IV hub access ​
Reduces risk of CLABSI from hub contamination ​
• Must continue to scrub the hub!​
• Single use only.
Failure to scrub the hub
will result in increased
infection risk! ​
Sapphire CADD Solis CADD Prizm

✓VOLUME TO BE INFUSED
✓RATE OF INFUSION
✓TAPER UP TIME
✓TAPER DOWN TIME
✓INFUSION PERIOD
Pump Batteries & Charging
 Pump Parameter Changes
The pharmacy will either:
• Send a new pump to the patient programmed with the new
parameters.
• Call the patient to talk through the pump changes, with a read back
process for confirming the pump settings.

The role of the home nurse is to confirm the pump the patient is using
is programmed with the correct settings.
 CarepathRx Contacts:
[email protected]

Christie Fisher MSN, MBA, RN, CRNI, IgCN

National Director, Nursing
Cell: 412-295-7849

Thank you for participating!

Please reach out with questions or for information on additional training opportunities.
 CADD Solis
Tubing change
• Daily
Allow medication to warm to room temperature for 4-6 hours, as noted on the
Plan of Treatment.
Always power up before attaching tubing cassette​
•Listen for series of beeps and self-check before attaching the tubing
cassette.
•This will prompt “Reset RES VOL?”
•Attaching tubing cassette before power up will result in pump not
prompting user with “Reset RES VOL?”
Powered by Battery​
•4 – AA Batteries​
•Remove batteries between infusions
•Replace batteries when:
•Low Battery
•Depleted battery
•Rechargeable Battery
•Plug in pump for a minimum of 4 hours each day, to maintain
battery charge.
Always prime on its side, with the lever side down to prevent “Air In Line” alarms​
47
 Sapphire Pump
Tubing change ​
• Daily
Allow medication to warm to room temperature for 4-6 hours, as noted on the Plan
of Treatment.​
Powered Internal Rechargeable Battery​
• Plug in pump for 6 hours each day to fully charge rechargeable battery ​
• External Power Pack with 6 – AA batteries for emergency use.
• Passcode: 8880
Click: Repeat Infusion
• Do not select: Start New Infusion
Click: Screen Lock
• Do not select: Patient Lock Out
 Pump will be delivered programed

49
with the patient’s orders.

Always confirm pump setting against

CADD Prizm orders prior to starting the pump

Tubing change
• Daily – with each dose.
Allow medication to warm to room temperature for 4-6 hours,
as noted on the Plan of Treatment.
Powered by 1 9-volt battery AND PowerPack
• External power pack is used with the 9-volt battery in
the pump
• Power pack should be charged 7 hours each day.
• Power pack requires monthly maintenance.
Always power up before attaching tubing cassette
• Listen for series of beeps and self check before
attaching the tubing cassette
• This will prompt “Reset RES VOL?”
 Video link to TPN training
TPN in the Home (RNs):
https://www.youtube.com/watch?v=YlgrCEtvlLw
 Eitan
Medical
Sapphire
Pump
 Sapphire Pump
Tubing change ​
• Intermittent – every 24 hours​
• Continuous – Mondays, Wednesdays and Fridays only​
Allow medication to warm to room temperature for 2-4 hours, as noted on the Plan of
Treatment.​
Powered Internal Rechargeable Battery​
• Plug in pump for 6 hours each day to fully charge rechargeable battery ​
• External Power Pack with 6 – AA batteries for emergency use.
Passcode: 8880
Click: Repeat Infusion
• Do not select: Start New Infusion
Click: Screen Lock
• Do not select: Patient Lock Out
Pump programming Code: 7770
 DELIVERY MODES

❖ PCA Delivery Mode

❖ Continuous Delivery Mode
❖ Intermittent Delivery Mode
❖ Multistep Delivery Mode
❖ TPN Delivery Mode
❖ Epidural Delivery Mode
➢ Open the safety door. Then, insert the
administration cassette at an angle, by
placing the saddle (Figure #1) on the round
metal anchor (#2) in the cassette's housing.
Make sure that the arrow on the cassette
(#3) is pointing toward the bottom of the
pump, and the bottom flange is inside the
cassette housing.

➢ Clip the upper end of the administration

cassette into the metal lock (Figure #4).

➢ Close the safety door over the administration

cassette. Ensure that the safety door clicks
upon closure.
 TO REMOVE CASSETTE

Disconnect administration
set from the patient, close
the clamps and remove
administration cassette by
raising the metal lock that
secures it to the pump
 Sapphire Pump
STOP THE PUMP TO REMOVE CASSETTE TURN OFF PUMP
Disconnect To turn pump off, press
Press STOP administration set from and hold ON/OFF
the patient, close the button for 5 seconds
clamps and remove
administration cassette
by raising the metal
lock that secures it to
the pump
 Sapphire Pump
Powered by an Internal Rechargeable
Battery​
• Plug in pump for 6 hours each day to fully
charge rechargeable battery

External Battery Pack with 6 – AA External

Battery
Pack
batteries for emergency use.
 Sapphire Pump Tubing

AVAILABLE SETS
Infusion set with non-vented spike,
1.2μ filter and needleless y-site
Vented/Non-vented
drip chamber Microbore with non-vented spike,
0.2μ filter and needleless y-site

Microbore with non-vented spike

Primary infusion set with

vented/non-vented drip chamber,
back check valve and 2 needleless y- Tubing may
contain some or
site all of these
components
➢ Open the safety door. Then, insert the
administration cassette at an angle, by
placing the saddle (Figure #1) on the round
metal anchor (#2) in the cassette's housing.
Make sure that the arrow on the cassette
(#3) is pointing toward the bottom of the
pump, and the bottom flange is inside the
cassette housing.

➢ Clip the upper end of the administration

cassette into the metal lock (Figure #4).

➢ Close the safety door over the administration

cassette. Ensure that the safety door clicks
upon closure.
Repeat Last Infusion

1. Select Repeat Last Infusion

2. Review and confirm the program
3. Prime the set
4. Press Start to start the infusion
PRIMING THE SAPPHIRE SET
 TO REMOVE CASSETTE

Disconnect administration
set from the patient, close
the clamps and remove
administration cassette by
raising the metal lock that
secures it to the pump