TPN

Question 1

What is TPN

Answer 1

Total Parenteral Nutrition

Intravenous feeding – a nutrient mixture is administered directly into the venous circulation. Includes totally digested vitamins, minerals, amino acids, dextrose, fat

Question 2

Is TPN Sterile?

Answer 2

Yes, it’s made in a sterile environment

Question 3

What is the danger of TPN creaming, cracking or oiling?

Answer 3

Seperation of TPN could lead to fat embolism. Cracked or oiling bag must be discard. Creaming bags can be gently mixed

Question 4

How long is TPN good for at room temperature?

And lipids alone

Answer 4

24 hours

lipids every 12

(Out of fridge one hour prior)

Question 5

Possible Indications for TPN Admin

Answer 5

Non- functioning gastro-intestinal tract.
Gastric or intestinal obstruction
Abdominal distension, bowel ischemia, severe hypotension with ischemia, bowel perforation, peritonitis
Enteric fistula
Refractory (unmanageable) diarrhea or vomiting
Paralytic ileus
Severe radiation enteritis –
small bowel removed
Pancreatitis -severe
Anticipated need of more than 7 days

Question 6

What solutions or situations require CVAD for administration?

Answer 6

The higher viscosity/ higher osmolality solutions need this CVS access.

Normally central (more then 10% Dex, 0ver 2000)
Can be peripheral if 10% or less (up to 1800 cal)

ALSO
Consideration by team about the length of the therapy, home vs hospital, osmolality, veins , patients/family ability to support ,

Question 7

MRN role in TPN admin?

Answer 7

Nutritional assessment w/ dietician
Check TPN order, check expiry date
Assessing the response to the TPN – blood sugars
Monitoring and maintaining the access route
Monitoring* lab results and notifying RD or s
Check weight bi weekly (nutrition/fluid balance concerns)

Question 8

What is required in Pre TPN bloodwork? (As reflected in TPN protocol)

Blood draw timeline after initiation?

Answer 8

CBC, Na+, K+, CI, CO2, creatinine, urea, glucose, ionized calcium, magnesium, phosphorus, pre-albumin, albumin, total bilirubin, PT-INR, PTT, ALT, alkaline phosphatase, GGT, ferritin, serum folate, vitamin B12, triglycerides

POST TImeline

Initial: Daily in a.m. x 2 days,
then: Twice weekly Na+, K+, CI, CO2, creatinine, urea, glucose, magnesium, phosphorus

Question 9

What labs value might initiate a pause to TPN?

Answer 9

 Serum Na <132 or >145 mmol/L 
 Serum K <3.2 or >5mmol/L 
 Serum CO2 <22 or >30 mmol/L 
 Serum glucose <3.9 or >9mmol/L 
 Serum phosphorus < 0.8 or > 1.5 mmol/L 
 Serum magnesium < 0.7 or > 1mmol/L

Question 10

What is the timeline for changing or renewing TPN orders on the South Island

Answer 10

In South Island, Pharmacy must be notified daily of continuation of “same” TPN orders by 1100 h, and “new” or “adjusted” TPN orders by 1200 h.

Question 11

How often is TPN Tubing Changed?

Intermittent? Continuous?

Answer 11

Tubing and label (marked w/ expiry day) always changed every 24hrs

Question 12

Which port is used for TPN Admin

Answer 12

Designated port on CVAD for TPN ONLY (normally middle lumen)

Question 13

What are the rule for pausing TPN nutrition

Answer 13

Do not interrupt TPN for showers procedures or blood transfusions

If absolutely necessary (MRI or radiation) then cap with new luer lock cap

Check interruptions for surgery, tests (etc) and think of the change to BG

May change to a D10 solution at 50ml/hour

Check with physician

TPN may be paused for blood draw

Question 14

How would one monitor BG?

Answer 14

Blood glucose every 6hrs. (first is with pre-TPN blood work)

(or 2 hrs pre and 2 hrs post Admin with intermittent)

Glucose urine Dip may be ordered

Question 15

Is TPN ever administered intermittently

Answer 15

TPN admin is generally continuous (unless otherwise ordered)

So… yes, in theory.

Question 16

How often should you check TPN infusions?

Answer 16

Q1h

Question 17

Key action before starting TPN Admin

Answer 17

Confirmation of placement of vascular access devices. i.e. CXR

Question 18

Complications of TPN

Answer 18

• Fluid overload
o Crackles (moist rales), DJV, puffy eyes
• Allergic response
• Fat embolism (checki f solution is separating out)
• Infection (high risk) (Site assessment)
o Murky, water, sugar, lots of touching (hand wash/gloves key)
• Poor Nutrition (weight x2 weekly)
• Dry Mouth
• Psychosocial dynamics of not eating
• Hyperglycemia (high sugar solution, may need to change rate or mix)
• Refeeding syndrome

Question 19

What is creaming of TPN

Answer 19

refers to the aggregation of lipid droplets which rise to the surface. It looks like a distinct layer at the top of the emulsion (e.g. cream separating from milk)

Question 20

What is cracking?

Answer 20

refers to the separation of the oil (lipid) and water (amino/dextrose) phases of the TPN solution. When this happens, yellow droplets, or an oil layer, will be visible in
the solution. This TPN must not be infused and infusion must be discontinued immediately. “Cracked” emulsions are toxic and will block pulmonary capillaries. There is also an increased risk of the patient developing a fat embolism.

Question 21

How does dehydration occur?

Answer 21

High osmolarity can lead to dehydration.

Hyperglycaemia and glycosuria

Question 22

What level of malnutrition indicates TPN

Answer 22

Severe

Question 23

Can there be an allergic response to TPN

Answer 23

Yes indeed

Question 24

What is the range of dextrose% in TPN

Answer 24

10-70%

Question 25

When is 3 in 1 used vs two separate bags for TPN admin?

Answer 25

Using a separate bag for fat/amino acid mix is rarely done on adult floors – the TPN is usually administered in a single bag.

The exception is on pediatrics where it is more common to have the fats separated from the rest of the TPN.

Question 26

Why don’t lipids in TPN form fat emboli

Answer 26

TPN solution includes digestive enzymes – the same as if they were swallowed!

Question 27

When might TPN be administered centrally vs peripherally?

Answer 27

Usually TPN is administered CENTRALLY (through a CVAD) if solution is greater than 10% Dextrose, but it can be administered peripherally if it is 10% or less.

The rule of thumb is:
Peripheral = 1800 calories or less and may be supplemented with po nutrition
Central = 2000 calories or more

Question 28

What might bring about hypoglycemia with TPN Admin?

Answer 28

Because the body adjusts insulin to the increased glucose load, then when TPN stopped too quickly, the increased insulin that the body produces can lead to hypoglycaemia.

Question 29

How might we approach a patient with CHF requiring TPN

Answer 29

We want to Limit fluid excess. Use Central line – more concentrated/calorie dense version in a smaller fluid amount.

Question 30

What concerns might we have with TPN administration to Children

Answer 30

children have smaller vessels, so peripheral nutrition increases the danger of extravasation/vessel sclerosis. Also, children have less fluid in cells to begin with which increases the risk of dehydration from the high sugar content.

Question 31

Discuss ways to create a healing environment for Children dependent on TPN

Food is more then sustenance!

Answer 31

Using a soother for infants

Holding the infant as the infusion goes in

Having a special activity for the child while others in family eat

Some children may be permitted hard candies or be able to chew and spit food!

Question 32

Key assessments prior to TPN administration

Answer 32

 Assess the bag of TPN (it should look creamy/mixed)
Assess site and tubing
Assess baseline/recent lab data
Assess patient history (e.g. diabetes, heart disease, allergies etc.)
Others?

Question 33

What elements of teaching are necessary for those going home with TPN long term?

Answer 33

Teaching pump function and troubleshooting as TPN is only administered through a pump

Emergency measures

Emergency contacts

Home nutrition therapy team contacts

Catheter site care

I and O / glucose monitoring


Question 34

What size filter do you use with TPN (lipid or without)

Answer 34

Lipids - 1.2

None 0.22