TPN THROUGH PERIPHERAL AND CENTRAL LINE

1. What is the limit of osmolarity for
parenteral nutrition formulas used
in peripheral line administration?

2. 
Concerns about the osmolarity of
peripheral parenteral nutrition (PPN)
formulas

3. thrombophlebitis

4. incidence of thrombophlebitis is
estimated ato range from a low of
2.3% to as high as 70%.

5. The range is this wide as there are many
variables to consider

6. 



osmolarity
PPN additives such as heparin and lipids
duration of PPN administration
the types of catheters and needles used

7. So, although the etiology of
thrombophlebitis in PPN is often
multifactorial, the osmolarity of the
infused PPN solution may be an
important variable.

8. 
To decrease the likelihood of phlebitis, the
osmolarity of PPN should be between
600 and 900 mOsm.

9. For solutions with an osmolarity of
1100 mOsm or greater, lipid
emulsion may be added to increase the
patient's tolerance for the infusion. However,
this approach is not recommended for patients
with contraindications,
such as

10. high triglycerides.

11. Alternatively

12. 
hydrocortisone and heparin can be added to
hyperosmolar solutions of up to
mOsm to prevent phlebitis.
1200

13. 


Addition of heparin to PN solutions “reduces the
formation of a fibrin sheath around the catheter,
may
reduce phlebitis… and increases the duration of
catheter patency” (Groh-Wargo, et al., 2000).
Heparin also
stimulates the release of lipoprotein lipase,
which may improve lipid clearance.

14. 
This approach may not be appropriate for
all types of patients. For example, heparin
should be avoided in patients with a
history of heparin-induced
thrombocytopenia. In addition,
hydrocortisone and heparin may not be
stable additives for all PPN solutions,
especially those containing fat emulsion.

15. calculating the osmolarity of PPN
solutions

16. Osmolarity (mOsm/L) =
(grams dextrose / liter) x 5] + [grams amino
acid / liter) x 10] + [(mEq cations / liter) x 2]

17. Another way

18. Osmolarity (mOsm/L) =
(Amino acid 8)+(glucose
7)+(Na 2)+(phosphorus 0.2)- 50

19. Because of the limitations in osmolarity of
PPN solutions, the typical PPN composition
provides a final concentration of amino acids
that is generally between 2.5%
and 5% (50 g/L). Dextrose
concentrations
(25 g/L)

21. NaCL LR
0.9%
NaCL
3%
ALBU
M
5%
NaHCO3
D10
%
D5
1/2
NS
D5N
S
KCL
Na(mEq/
L)
154
130
513
130-160
4.2?%(.5mEq
/ml)
8.4%(1mEq/
ml)
154
CL(mEq/
L)
154
109
513
130-160
0
154
K(mEq/L 0
)
4
0
0
0
0
1ml=
2mEq
Osmolarit 308
y
(mOsm/L
)
275
1025
310
8.4%(2000)
Lactate
(mEq/L)
0
28
0
0
Dextrose
gm/L
0
0
0
0
406
560
4000
0
0
505
0
0
0
100
50
50

22. TPN SOLUTIONS
AMINOSIN 15% amino acid
1300
TRAVASOL 10% amino acid
998
LIPID 10%
276
LIPID 20%
258
NOVAMINE15% amino acid
1388
HEPTAMINE 8 % amino acid
785