Total Parenteral Nutrition

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Chapter 13
Total Parenteral
Nutrition
2012 Paradigm Publishing

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Learning Objectives
 Recognize the origins of total parenteral nutrition.
 Identify the special situations and actions that must be
considered when preparing total parenteral nutrition.
 Identify the risks associated with parenteral products.
 Identify the USP Chapter <797> procedures that must be
performed when compounding total parenteral nutrition.
 Demonstrate correct technique in the preparation of a total
parenteral nutrition solution.

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Topics
 Learning Objectives
 Introduction
 Types of Parenteral Nutrition
 Indications for Prescribing TPN
 Formulation of TPN Solutions
 Guidelines for Ordering TPN
 Compounding of TPN Solutions
 Cleaning and Calibration of the ACD
 Premixed TPN Solutions
 Preparation Risks of Parenteral
Fluids
 Standard Mixing Protocols for TPN
Preparation
 The Final Container
 Storage of the Final Container
 Administration of TPN Solutions
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 Administration Risks of Parenteral
Fluids
 Special Considerations for Preparing
TPNs
 USP Chapter <797> Guidelines for
TPN Preparation
 Understand the Resources and
Supplies
 Preview the Lab Procedure
 Chapter Summary

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Introduction
 Nutritional therapy is administered
to patients who have a condition
that prevents proper absorption of
nutrients from food and/or medical
conditions that render them unable
to swallow or move food along the
gastrointestinal (GI) tract
the feeding tube may be a nasogastric
(NG) tube, a gastric (G) tube, or a
jejunum (J) tube

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Types of Parenteral Nutrition
Peripheral Parenteral Nutrition
 Also known as partial parenteral nutrition or PPN,
this type of parenteral solution provides a portion of
the daily calories, electrolytes, and hydration to a
patient in need of nutritional supplementation
the long-term administration of PPN is rarely done due to
the risk of extravasation

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Types of Parenteral Nutrition…/2
Total Parenteral Nutrition
 TPNs are administered into a
large vein in the neck, the chest,
the groin, or the abdomen
a CVC is placed into the vein
there are a number of different
methods of inserting a CVC,
including tunneled catheter and
nontunneled catheter insertion
and peripherally inserted central
catheters (PICCs)

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Indications for Prescribing TPN
 Some medical conditions that may lead to the
prescription of TPN include:
diseases of the stomach, bowel, or GI tract, such as Crohn’s
disease, short-bowel syndrome, ischemic bowel disease, or
ulcerative colitis
any GI trauma or disease that results in gastrectomy or
colectomy
congenital disorders of the GI tract

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Indications for Prescribing TPN…/2
 Some medical conditions that may lead to the
prescription of TPN include…continued:
diseases such as cancer, stroke, or acquired immune
deficiency syndrome (AIDS)
severe cachexia, a type of malnutrition created by conditions
such as marasmus or anorexia
any type of trauma, treatment, or disease that impairs the
patient’s ability to intake nutrition

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Formulation of TPN Solutions
 A 2-in-1 TPN solution provides a 24-hour supply of
all nutrients except fatty acids
 The most common TPN formula is the 3-in-1 TPN
solution which provides all of the nutrients needed
for a 24-hour period, including fatty acids in the form
of Liposyn

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Formulation of TPN Solutions…/2
 Regardless of the formula, most TPNs are comprised
of the same basic ingredients:
sterile water, which provides hydration
dextrose, which supplies the primary source of
carbohydrates for calories and energy
Aminosyn (amino acids or AA), which provides the
molecular building blocks for protein synthesis
Liposyn, which supplies essential fatty acids
electrolytes, vitamins, and minerals, which provide the
body with the nutrients needed for a myriad of chemical
processes (considered additives)

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Guidelines for Ordering TPN
 When ordering sterile TPN components, prescribers
consider several factors, including the patient’s age,
diagnosis, kidney function, liver function, and
electrolyte levels
 Medications other than the typical TPN components
are usually not added to a TPN solution due to the
potential for incompatibility
exceptions to this guideline are insulin, an H2 antagonist
such as ranitidine, and heparin

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Guidelines for Ordering TPN…/2
TPN Medication Order
 The prescriber orders
the components of the
TPN solution by filling in
a TPN order form
the TPN label should
match the information on
the order form exactly

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Compounding of TPN Solutions
Manual Compounding
 Compounding continues to be a common practice
among IV technicians
requires an IV technician to run the various base solution
components through IV tubing and into an EEC or IV bag
(often referred to as the final container)
another popular term for this procedure is the gravity
draining method
the underfill method is another frequently used procedure

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Compounding of TPN Solutions.../2
 In partially automated TPN
compounding, the TPN base
solution is prepared using an
automated compounding
device (ACD)
comprised of up to eight different
pump stations
provides a separate source-tubing line
and color-coded IV tubing spike for
each of the TPN base components
(often called source solutions and are
held within source containers)

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 Fully automated TPN compounding
is a common procedure in facilities
that prepare large numbers of TPN
solutions each day
the TPN base solution is formulated
using a TPN compounding device, such
as an automix compounder, and the
TPN electrolytes and most other
additives are prepared by a special
automated device called a micromix
compounder

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Benefits and Drawbacks of Manual and Automated
Compounding Methods
 Manual TPN preparation is generally the most cost-
effective method
is also very time-consuming and labor-intensive
the tasks carry a greater risk for human error
 Partially automated TPN preparation is considerably
faster and more accurate
 Fully automated TPN preparation is by far the fastest
and most accurate method

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Cleaning and Calibration of the ACD
 USP Chapter <797>
requires that an ACD be
cleaned and calibrated
daily prior to TPN
preparation
record these tasks on an
ACD Cleaning and
Verification Log Sheet

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Premixed TPN Solutions
 Premixed TPN solutions are
primarily used in home
healthcare situations in which
the patient requires long-term
TPN therapy and has
consistently stable lab values
called multiple-channel TPN
solutions

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Your Turn
1) This is the most common TPN formula.
a. 1-in-2 TPN solution
b. 2-in-1 TPN solution
c. 1-in-3 TPN solution
d. 3-in-1 TPN solution
2) These TPN solutions are primarily used in home healthcare situations
in which the patient requires long-term TPN therapy.
a. automatic mixed
b. manual mixed
c. premixed
d. postmixed
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Preparation Risks of Parenteral
Fluids
 Every time a needle pierces a vial’s rubber top or the
injection port of an IV bag, there is a risk of
contamination of the CSP
because TPN solutions are comprised of multiple solution
components mixed with multiple additive components,
the risk of contamination is greater with TPNs than it is
with other CSPs

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Preparation Risks of Parenteral
Fluids…/2
 In addition to the risks associated with the procedure
itself, the chemical makeup of TPN solutions makes
them especially susceptible to incompatibility
complications, including:
therapeutic incompatibility
chemical incompatibility
physical incompatibility
 In general, therapeutic and chemical incompatibilities
are not visible to healthcare personnel and may only
be identified by end-product testing

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Standard Mixing Protocols for TPN
Preparation
 Protocols should specify appropriate ingredients and
doses to ensure that all TPN components are both
therapeutically and chemically compatible
in general, the ingredient mixing order for TPNs is as
follows: the base solution—dextrose, amino acids, sterile
water, and then fatty acids—followed by the additives

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The Final Container
 The glass EEC used in TPN preparation may have a
special type of aluminum cap that must be removed
it is important to remove the cap very carefully
 An empty bag constructed of plastic or polyvinyl
chloride (PVC) is more commonly used among sterile
compounding personnel
although more costly than an EEC, a TPN bag is easier to
handle during the sterile compounding process
 The final container must be inspected for evidence of
particulate matter or incompatibility

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Storage of the Final Container
 Prepared TPN solutions should be refrigerated
removed approximately 30 minutes before administration
 It is very common to set the maximum storage
period for medium-risk CSPs as follows:
not more than 24 hours at controlled room temperature
not more than 7 days at controlled cold temperature
not more than 30 days in a solid frozen state
 All TPN solutions prepared using strict aseptic
technique have a beyond-use CSP date (BUD) clearly
marked on the CSP label

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Administration of TPN Solutions
 TPN solutions are typically infused through a CVC
and are administered continuously at a rate ordered
by the prescriber
because the catheter is placed directly into a major blood
vessel and may remain in place for a week or longer,
nursing personnel must exercise proper care of the
catheter
patients must also be closely monitored to ensure that
they receive adequate nutrition, maintain balanced
electrolyte levels, and remain free of infection

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Administration Risks of Parenteral
Fluids
 All patients receiving parenteral fluids should be
monitored for the following complications:
nosocomial infection
allergic reaction (including anaphylaxis)
phlebitis
tissuing
embolism
extravasation
cellulitis
Stevens-Johnson syndrome
nephrotoxicity

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Administration Risks of Parenteral
Fluids…/2
 The primary risk associated
with TPN administration is
nosocomial infection
 It is advisable for nursing
personnel to filter the TPN
solution for possible
particulate matter
most facilities employ an in-
line filter

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Special Considerations for
Preparing TPNs
Training for Sterile Compounding
Personnel
 Must pass both a written exam and
hands-on process validation test
as well as successfully complete a
negative-growth ATTACK kit (or similar
type of basic media-fill test
procedure) upon completion of
training, prior to preparing IVs for
patient use, and upon observance of a
break in aseptic technique

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Special Considerations for
Preparing TPNs…/2
Training for Sterile Compounding Personnel…continued
 Advanced training includes the completion of a
negative-growth, media-fill test procedure that is
more difficult than the basic media-fill test procedure
the advanced media-fill test procedure requires the
technician to aseptically perform manipulations from
multiple containers
 Those who prepare TPN solutions must also receive
special training

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USP Chapter <797> Guidelines for
TPN Preparation
 In addition to the sterile compounding preparatory
procedures, the related procedures and overarching
principles are presented in USP Chapter <797> and in
each facility’s P&P manual
 Sterile compounding personnel must pay strict
attention to aseptic technique protocols both in the
anteroom and clean room

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Understand the Resources and
Supplies
Essential Supplies
 Supplies used in the anteroom include a medication order and a
CSP label; a standard calculator; a pen; a permanent, felt-tip
marker; large and small plastic bags; aseptic garb; a sterile gown;
presaturated, aseptic cleaning wipes; sterile, foamed 70%
isopropyl alcohol (IPA); a waste container; and a transport
vehicle
 In the clean room, essential supply items include sterile, foamed
70% IPA; sterile, powder-free gloves; sterile 70% IPA swabs; a
sharps container; a waste container; and a laminar airflow hood

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Supplies…/2
Procedure-Specific Supplies
 TPN Supplies
a 1000-mL EEC is used as
the final container into
which the base
components and additives
are injected

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Supplies…/3
Procedure-Specific
Supplies…continued
 TPN Supplies…continued
during the TPN compounding
process, IV tubing transfers
fluid from each of the source
containers into the EEC
a hemostat is used to clamp
the tail of the base
component bag

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Supplies…/4
Procedure-Specific
Supplies…continued
 TPN Supplies…continued
several TPNs may use the
same additive vials, so to
reduce the likelihood of
coring, use a vented
dispensing pin

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Supplies…/5
Critical Sites of TPN Supplies
 Before beginning preparatory procedures in the
anteroom or clean room, the IV technician must
recall the critical sites of the supplies
identifying the critical site of each supply item helps you to
determine the proper procedure for handling the item
once you have entered the clean room and begin to work
in the hood

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Preview the Lab Procedure
 Anteroom Preparatory Procedures
verifying the CSP label (TPN label) against the medication
order (TPN order)
performing correct pharmacy calculations to determine
type, size, and number of supply items needed
gathering and cleaning of supplies
performing aseptic garbing and hand washing
donning a sterile gown

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Preview the Lab Procedure…/2
 Clean Room Preparatory Procedures
when preparing TPNs for patient administration, sterile
compounding personnel must diligently follow established
pharmacy clean room protocols which include:
• cleansing hands with sterile, foamed 70% IPA
• donning sterile gloves
• cleaning the hood

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Preview the Lab Procedure…/3
 TPN Compounding Procedure
when compounding a TPN solution, you must follow a
specific order for mixing the ingredients
you begin with the base solution components: dextrose
first, followed by the amino acids (in this case, Aminosyn),
and then the sterile water
you will add the additives last

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Your Turn
3) The chemical makeup of TPN solutions makes them especially
susceptible to these complications.
a. calibration
b. shadowing
c. incompatibility
d. process validation
4) All TPN solutions prepared using strict aseptic technique have this type
of date on the CSP label.
a. beyond-use
b. best-before
c. shelf-life
d. discontinue
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Total Parenteral Nutrition

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