INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER TOTAL PARENTERAL NUTRITION (TPN):

ADMINISTRATION OF PARENTERAL NUTRITION AND LIPID EFFECTIVE REVIEW DUE REPLACES NUMBER NO. OF PAGES DATE APPROVED BY APPLIES TO

HOSPITAL NAME

PURPOSE DEFINITION TPN is a nutritionally hypertonic solution which provides glucose, amino acids, Lipid emulsion, vitamins, and trace minerals via a central / peripheral venous access. It is commonly ordered for patients in situations when oral /enteral feedings cannot meet the patient's nutritional needs due to malfunction of the GI tract Goal of TPN Therapy is to replenish depleted stores of protein, promote wound healing, weight maintenance, immunocompetence, and nitrogen balance. RESPONSIBILITY CROSS REFERENCES POLICY 1. A physician order to initiate TPN therapy. 2. Ready made TPN from Baxter or B Broun or prepared TN will be used for all TPN orders. 3. TPN orders written by pharmacist. Exception: Neonatologists write TPN orders for neonates in NICU. 4. In the patients chart, the TPN prescriptions, composition, infusions rates of TPN and IV lipids are written. 5. If the TPN will be prepared in the hospital IV section. The preparation should be done utilizing aseptic technique and laminar air flow hood in the presence of class 100 clean room with positive air pressure. TPN should be prepared by Aseptic technique certified pharmacist 6. Double-checking is a must during the preparation of any TPN solution. 7. TPN and lipids must be infused utilizing two separate pumps. TPN solutions requires a 0.22-micron in-line filter, which must be used for all patients. Lipids are not filtered, therefore ensure connection distal to the filter using an Y-connector with clamps. Use only filter sent from the pharmacy, common filters on the nursing floor may not meet the specifications for TPN solution.

JCI Standards

CBAHI Page 1 of 7

8. Tubing and Filter Changes: Change 0.22-micron filter & IV primary pump tubing (TPN) every 72 hours. Change IV primary pump tubing (Lipids) every 24 hours. 9. Y-connector with clamps and in-line filter is considered as part of the primary set and should be changes at the same time. 10. In-line filters will be supplied by the pharmacy and sent to the floor. 11. If TPN is on hold for longer than 12 hours i.e. cyclic TPN or a long procedure. The TPN tubing and the filter will be changed daily unless the TPN is replaced with a suitable IV infusion. Appropriate replacement fluid will be hung until the next TPN is due. 12. The lumen being used for TPN and Lipid administration must not be used for the concurrent administration of blood and blood products or for cardiopulmonary monitoring devices. As for single lumen Pot-a-Cath, the TPN must be on hold while blood product is transfused. The line must be well flushed with Normal Saline before and after Blood products. 13. No additives can be added to the TPN at any time after the TPN has been attached to the patient. 14. Established TPN and lipid tubing set up must never be reconnected to a new or rewired central/peripheral line. New tubing must be established. Administer D10W or Dextrose Saline solution with or without KCl through the new or rewired central line, until next TPN is available. 15. Two nurses (SNIs only) must check the bag against the Parenteral Nutrition Order Form to validate accuracy of contents, date and sign in designated area at the bottom of the form. 16. If TPN bag is damaged or is leaking, stop TPN, then contact the physician. An alternate solution must be ordered until the following day when a new TPN solution is prepared. 17. When infusing lipids for the first time, obtain baseline vital signs prior to initiation, then at 15 minutes and hourly for two hours. Monitor the patient for allergic reaction. If any of allergy occur, stop the lipid infusion immediately and notify the physician. 18. The maximum osmolarity must be taken into account for peripheral administration. Maximum osmolarity for Adult must not exceed 900 mOsmol/L for adult or patient over 12 years of age; 1000 mOsmol/ for pediatrics ( 2 years 12 years of age) , and 1100 mOsmol/L for infant and neonate. The maximum Dextrose concentration in peripheral TPN for infants is 12.5%, pediatrics 10% and adult 8%. 19. The TPN rate is never adjusted unless specifically ordered by the physician in Intensive Care areas 20. TPN should not be interrupted for more than one hour without an alternate solution, D5W/ D10W or Dextrose Saline solution with or without additive to be infused at previous TPN rate. This included emergency situations and codes. If the infusion is interrupted i.e. central catheter occlusion or line dislodged, immediately notify the physician. A peripheral access must be obtained and Dextrose solution or Dextrose-Saline solution infused at the previous TPN rate. The patient is at risk for an insulin rebound (hypoglycemia) when the TPN (particularly central TPN) is suddenly discontinued. 21. Intake and output must be measured and recorded on Daily basis. 22. Daily weights are to be done at the same time and on the same scale. 23. TPN Management during Ambulance Transport: For patients receiving TPN who are transferred by ambulance to other hospitals. TPN and lipids should be discontinued and suitable IV solution hung. JCI Standards CBAHI Page 2 of 7

24. TPN management for Patients Leaving the Unit for Procedure Surgery/OR Recovery Room TPN should never accompany a patient to the OR or the recovery room. Short Procedure Scheduled for : < 2 hours, TPN > and lipids may accompany patients. < 1 hour, TPN and lipids may accompany patient Long Procedure Scheduled for: MRI, CT Scan:

Adult Patients

> 2 hours, replace TPN with suitable IV solution.

No pump may accompany patient , replace TPN with suitable IV solution . Same procedure as for adult.

Pediatric Patients

Same as for adult

> 1 hour, replace TPN with suitable IV solution.

PROCEDURE 1. Infuse D5W/D10W or Dextrose Saline Solution with or without additive for emergency replacement of TPN. Ringers Lactate or normal saline (without dextrose) is never a suitable replacement for TPN solution. 2. Do not place TPN in direct sunlight. For patients ambulating outdoors, ensure TPN is protected from light. Otherwise TPN and lipids should be replaced with suitable IV fluids 3. TPN solutions should be assessed for particulate matter, turbidity, leakage and defects in the container before using. 4. Determines if peripheral access is suitable or not according to the calculated final osmolality of the TPN solution before initiating peripheral TPN. 5. Monitoring of the rate of infusion and amount must be checked hourly and recorded Daily Care Form 60111. Attempting to catch up TPN rate must not be done. The patient could suffer metabolic complications from increased or decreased rate. If a primary IV fluids is infusing concurrently with TPN/Lipids the rate of the IV fluid may need to be adjusted when the lipids are infusing. 6. The IV lipids are supplied in a glass bottle, bag or syringe.

PROCEDURE 1. Care for infusion site, observe for signs of inflammation and dressing is intact. Perform central line dressing changes per Central Venous Catheter (CVC) Dressing and Tubing Change procedure. Cover insertion site with occlusive dressing after confirmation of line placement and always take great care of the sterile dressing site. JCI Standards

EXPLANATION It is imperative to assess and inspect IV insertion site and dressing every shift for signs and symptoms of infection or drainage. Change dressing immediately if wet, soiled or no longer occlusive. See the procedure for CVC dressing and tubing change for further information. CBAHI Page 3 of 7

GENERAL OBSERVATION OF PATIENT AND IV ACCESS SITE

ORDER AND PRODUCT VERIFICATION AND PRE-INFUSION PREPARATION 2. Remove the TPN from the refrigerator one hour To allow solution to warm to room temperature. before spiking. 3. Verify TPN orders against the label on the TPN bag. When verifying compare with the TPN Order Form (Note TPN must be kept refrigerated, remove 1 hour prior to use ). 4. Check TPN solution for cloudiness or precipitates, leakage prior to infusing. Check lipid for oil separation. 5. Once verification is confirmed, initial, time and date both the TPN order form and TPN bag. Two SNs must compare the contents of the TPN label with the TPN orders, including the amounts of additives and infusion rate. These steps reduce risk of error. Any precipitation/ particle/ leakage observed, the TPN can not be used as it may not be safe to be used. Only SNs are allowed for the checking as TPN solution is a multiple ingredient solution.

6. Wash hands. Apply FULL aseptic technique in To prevent contamination and to reduce infection rate. handling TPN/Lipid for connecting to IV sets. Put on a face musk, wear sterile surgical glove, use adequate amount of sterile alcohol swabs. 7. Gather the equipment and take it to the patient room. Identify the patient and explain the procedure. Check the ID band for the correct name and medical record number (MRN) giving TPN to the wrong patient can be fetal.

8. Assemble primary pump tubing and connect to Be sure connections are secure with leur locks, do not the 0.22-micron inline filter for TPN solution, over tighten connections as filter may crack. ensure two or three way connector with clamps is in place. Avoid puncturing the TPN/ Lipid bag 9. Place the TPN bag on a horizontal surface, spike with a consistent twisting force. 10. Prepare TPN infusion tubing for priming. Prime tubing and then close clamp on IV set. Prime the tubing / filter with TPN solution. Hold filter in an inverted position during priming. Prepare Lipid infusion tubing for priming. Do not attach filter to the Lipid. Prime tubing and then close clamp on IV set. 11. Connect TPN tubing to infusion pump. Connect Lipid tubing to another infusion pump. Utilize aseptic technique to connect the TPN /Lipid tubing to the connector of the IV access. Ensure leur lock is secured. Lipid JCI Standards Per hospital policy an inline 0.22 micron filter (supplied by pharmacy) must be connected to the TPN IV administration set. This traps particulate matter, bacteria, endotoxins, and vents air from IV tubing. By positioning the filter upside down air is cleared from the membrane.

TPN / Lipid must be infused via an infusion pump only. The rate of the infusion must be constant (do not adjust to catch up). The prescribed nutrient amount and rate are calculated by the certified nurse. It is important to follow order/label instructions to ensure CBAHI Page 4 of 7

solutions must be infused as close as possible to the vein and below the 0.22 micron filter. 12. Secure tubing and set prescribed rate, have a second SN to double check the rate on the pump, open clamps. 13. Document the following hourly on the IV Fluid balance sheet: Time, Rate. 24 hour-fluid balance.

proper rate regulation.

TPN must be infused at a constant rate to prevent metabolic complications and the rate on the pump must match the rate prescribed. Use the Critical Care Nursing Record Form for neonatal intensive care unit.

INFUSION / MAINTENANCE OF TPN 14. Use only a Central Line to administer central line concentration TPN. Always check the osmolarity value on the label. Maximum osmolarity for peripheral line: Adult : 900 mOsmol/L Pediatric: 1000 mOsmol/L Infant: 1100 mOsmol/L 15. An inline 0.22 micron filter must be attached to the TPN infusion tubing prior to administration of TPN. Use only filter supplied from the pharmacy. Do not attach filter to the Lipid emulsion. 16. If a primary line has been previously used for another purpose, it cannot be used to administer TPN. Use a new IV primary line if you are not sure. 17. If the Central Line has multiple lumens, a single port must be selected and dedicated solely for TPN / Lipid use. Reserve the large lumen for blood product. 18. TPN orders must be renewed every 24 hours by physician 19.Ensure that the following is documented daily in the patient's record during the course of therapy: -Date and time each TPN bag is initiated. -Infusion rate/site JCI Standards TPN is highly concentrated solution, if the osmolarity exceeds the toleration of the peripheral vein, it will damage the vein and the surrounding tissue. A central line TPN may not be given via peripheral vein if the osmolarity exceeds the peripheral toleration. Always check the osmolarity of the solution.

Use of a micron filter will reduce micro-organism growth and will decrease the risk of infection to patient. Lipid emulsion is an emulsion of fat particle and will not pass a bacterial retention filter.

Do not use the TPN port for blood draws, Central Venous Pressure (CVP) monitoring, or administration of medications except under special circumstances. These measures will increase the risk of contamination. No other IV solutions or IVPB, including blood products will be administered via this IV line except Lipids.

This will allow adequate time to prepare solution and ensure timely delivery. Documenting all nursing care provided, expected outcomes, and any interventions. Documentation and monitoring is critical to minimize complications and ensure cost effective therapy.

CBAHI Page 5 of 7

-Volume infused -Intake and Output. -Results of glucose tests. -Daily weights. -Unexpected outcomes or interventions. 20. When physician orders to discontinue TPN , An order for tapering for a central line TPN should be ordered if the patient has no other source of glucose intake. Decreases glucose load, thus decreasing pancreatic secretion of insulin to prevent rebound hypoglycemia. Peripheral TPN may be discontinued at once with low dextrose %.

MONITORING 21. Upon initiation of TPN obtain baseline of renal / hepatic profile, triglyceride and prealbumin blood levels. 22. For Long term TPN patient and / or hypercatabolic patient, a 24-hour urine collection for UUN, Urine Creatinine and Total Volume may be required upon order. 23. Perform "Strict" Intake and Output and record. Compare with baseline and trends in changes will aide the formulation and therapy to achieve the purpose and to avoid complication of IV nutrition therapy. Analysis of a 24 hour urine specimen will provide clinical information about the patient's nutritional status by analyzing Nitrogen Balance and Catabolism.

Intake and Output amounts reflect fluid balance. Trends over a 2-3 day period may reveal a negative or positive fluid balance, indicating need for change in volume of TPN or other fluids. Weight changes are indicative of dehydration or fluid overload. Over hydration may occur in patients with cardiac, hepatic, or renal failure. High carbohydrate intake in TPN solution may lead to glucose intolerance. Notify the physician of results that are out of range. Deficiencies in vitamins and trace elements may cause abnormalities in metabolism and impairments in skin integrity. Elevated temperature and white cell count may indicate development of systemic infection. Central venous catheter and/or TPN solution should be considered as potential sources of infection until ruled out.

24. Perform Daily weights and record in addition to 24 hour-fluid balance.

25. Capillary Blood Glucose check every 6 hours or per order. Assess the patient for glucose intolerance and signs of sepsis. 26. Assess the patient for impaired wound healing,

27. Monitor the patient's temperature and vital signs at a minimum every 4 hours and record. Assess the patient for signs of sepsis. Monitor white cell count per CBC order.

JCI Standards

CBAHI Page 6 of 7

FORMS EQUIPMENT 1. Adult Parenteral Nutrition Order Form 2. Neonatal Parenteral Nutrition Order Form 3. Compatibility chart 4. Medication Record (Medex) Form 5. Prescribed TPN and Lipid solutions with copy of orders. 6. TPN solution and/or 20% fat emulsion (lipids) 7. 2 Primary pump tubings 8. 2 Calibrated IV Pumps 9. 0.22 micron in-line filter (Adult or Pediatric) 10. Y-extension set with clamps 11. 70%, isopropyl alcohol swabs 12. Neonatal Parenteral Nutrition Order Form (completed and signed/ dated) 13. Sterile Surgical Gloves, face mask. REFERENCES

APPROVAL: Name Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Signature Date

JCI Standards

CBAHI Page 7 of 7