4 PARENTERAL THERAPY

Transcription

1 WOMEN AND NEWBORN HEALTH SERVICE CLINICAL GUIDELINES SECTION A: GUIDELINES RELEVANT TO OBSTETRICS AND GYNAECOLOGY 4 PARENTERAL THERAPY 4.11 TOTAL PARENTERAL NUTRITION Authorised by: OGCCU Review Team: OGCCU /Pharmacy / Dietetics 4.11 TOTAL PARENTERAL NUTRITION AIMS To provide nutritional support via the intravenous route, when oral or enteral routes are inadequate, inaccessible or non functional 1. To minimise the potential catheter related, metabolic and infectious complications associated with total parenteral nutrition (TPN). BACKGROUND Total Parenteral Nutrition (TPN) is the formulation of nutritional components for intravenous delivery. Included are carbohydrates, amino acids, fats including essential fatty acids, electrolytes, vitamins, minerals, trace elements, water and other additives. TPN is indicated when there is an inability to provide adequate nutrition via the oral / enteral route and is administered continuously until enteral feeding can be re-established. TPN is continuously infused via a controlled infusion pump into a high flow vein, usually the superior vena cava adjacent to the right atrium. KEY POINTS 1. Observe: Hand hygiene before and after any manipulation of vascular access devices or catheter sites 1, 2 (Level I) See Infection Control Manual, Policy 2.4, Hand Hygiene. An aseptic technique. Adhere strictly to the principles of asepsis at all times to prevent contamination of the solution, line and central venous access device.tpn solutions are an ideal growth medium for bacteria and fungi. Standard precautions. See Infection Control Manual, Policy 2.1, Standard Precautions 2 The standard TPN base solution available is SmofKabiven. Alternatively a TPN solution can be made specifically for a patient to meet each unique clinical requirement. This is coordinated daily by the multi disciplinary team comprising dietetic, pharmacy, medical and nursing staff to improve overall quality of care 1, Electrolyte, phosphate and magnesium imbalances must be corrected prior to commencement of TPN to provide optimal care and to prevent refeeding syndrome. 4. Blood glucose levels must be assessed prior to therapy and monitored according to this guideline throughout therapy. DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 6

2 5. Administration of hypertonic TPN solutions (concentrations of Dextrose greater than 10% / Protein 5%) require central venous catheter access with confirmed catheter tip placement in the superior vena cava 2, 4, 5 This allows rapid dilution of the solution. Peripherally inserted central catheter, non tunnelled central venous catheter (CVC), tunnelled CVC s (e.g. Hickman/ Brovac/ Groshong catheters) or implanted ports are all suitable. 6. Administration of TPN should be via a dedicated CVC or, if a multiple lumen catheter is in situ, a designated lumen identified for this use 5. This catheter/lumen should not be used for blood sampling as per MR741. Although undesirable, where no other access is available, bolus medications may be given. Consult pharmacy for compatibility and administration advice. Use the proximal port and flush pre and post bolus 6. TPN solution and the line shall be discarded at or before the expiry date and time (< 24 hours). 7. TPN solution is incompatible with blood transfusions. Alternative intravenous access or a proximal port of a multi lumen catheter 7 should be used. 8. Monitor: Blood glucose levels (BGL) every 6 hours during rate changes. Once stable, monitor once daily. Base line weight 8 then twice weekly. Vital signs Fluid balance Catheter insertion site for sepsis, migration, and to ensure an intact dressing. For signs of infection, fluid and electrolyte imbalance and nutritional status while receiving TPN. Commencement and cessation of TPN infusions should be planned and at a controlled rate in liaison with the RMO. Administration of TPN shall be via a volumetric device. PARENTERAL NUTRITION FLUID Prescribed daily (Parenteral Nutrition Order MR 741) after review of biochemistry results. Pharmacy requires this prescription prior to 1100 hours to enable the solution to be manufactured under laminar flow conditions 5. Infusion rates are titrated on commencing and discontinuation of therapy to prevent fluctuation in blood glucose levels 8 - as per MR741. A volumetric pump is required 5, 9. TPN solution: o May include some drugs, for example insulin. o Protect by a light sensitive cover. o Non standard bags must be stored in the refrigerator and removed 60 minutes prior to infusing to bring to ambient temperature 5. 5, 10 o Should be completed within 24 hours of commencement DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 5

3 Ceasing TPN abruptly may result in rebound hypoglycaemia 7. Dextrose 10% is suggested for use if TPN is interrupted or unavailable 8. COMPLICATIONS Catheter related: Includes site infection and sepsis. Observe site and report pyrexia and altered BSL. Insertion related pneumothorax, air embolism, thrombosis Metabolic alterations: Biochemical monitoring is required to prevent or treat the following: o Hypo/hyperglycaemia o Hyponatraemia o Hypo/hypercalcaemia o Hypomagnesaemia o Hypophosphataemia PROCEDURE Ensure daily morning blood samples are collected for the monitoring of biochemistry while the patient is receiving TPN. Ensure the biochemistry forms are marked priority TPN. The RMO shall review the daily biochemistry results and adjust the TPN prescription accordingly in collaboration with the ward Pharmacist. Ensure the central venous access is present and patent for TPN administration. ADMINISTRATION The usual commencement rate is 20mL per hour, although this may vary according to the patient s clinical condition. The rate increases by 20mL per hour every 1-2 hours up to a maximum rate of 80mL per hour. The total volume of TPN mixture is infused at an hourly rate over a 24 hour period. Two midwives / nurses check that the prescription form is signed by the prescriber. TPN must be checked at the bedside by two nurses/ midwives and the patient must be identified by three indicators (e.g. name, DOB. Address or URMN) Check the patient s identification band against the patient label on the Parenteral Nutrition request form (MR 741) and TPN bag. Check the TPN solution including o Total volume o Administration rate. o Expiry date and time. Inspect the TPN bag, line and filter to ensure all is intact and free of particulate matter. If the TPN bag is not intact or particulate matter is present do not connect the TPN to the patient. DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 5

4 For lipid containing TPN ensure there are no visible fat globules Document the time the infusion was commenced and completed on the Parenteral Nutrition request form (MR 741). Both midwives / nurses must sign the MR 741. Retain the blue plastic bag to cover the fluid bag for the duration of the infusion. TPN CONNECTION PROCEDURE Equipment Non sterile gloves Sodium chloride 0.9% 10mL flush 10mL syringe 1% chlorhexidine and 70% isopropyl alcohol swabs x 3 Volumetric infusion pump TPN solution with attached, primed infusion line and 1.2 micron filter Blue plastic bag. PROCEDURE TPN should be removed from the refrigerator approximately 30 minutes prior to connection to allow the solution to come to room temperature. Perform hand hygiene. Visually inspect the infusion for signs of precipitation, discolouration, leakage, separation or contamination. ( Contact the pharmacist if there are any concerns regarding the above). Observe the CVC site, prior to the connection, for signs of infection and extravasation. Perform hand hygiene. Don non sterile gloves. Observe a strict aseptic technique. Prepare and cleanse the selected port with the 2% chlorhexidine and 70% isopropyl alcohol swab 11,12 and allow to air dry. Flush the selected vascular access port with sodium chloride 0.9% 10mL. Using a non touch technique connect the TPN line to the dedicated central venous port and secure the Luer-Lok connection. With the SmofKabiven bag this is the blue infusion port with the arrow flag. On the non standard bag it is the middle port. Remove gloves and discard appropriately. Perform hand hygiene. Check the prescribed rate on the Parenteral Nutrition request form (MR 741). Programme the volumetric infusion pump to the prescribed rate and commence the infusion. The initial TPN rate is usually 20mL per hour, increasing by approximately 20mL / hour every 1-2 hours up to a maximum rate of 80mL per hour. Monitor the blood glucose every 6 hours during rate changes. Once stable, monitor once daily. DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 5

5 Be aware of the daily target fluid input of each patient. Consider the patient s total daily fluid intake (including IV, enteral and oral) in the 24 hours prior to starting the TPN. Measure and monitor the total daily fluid output. Maintain an accurate fluid balance chart. Liaise with the RMO for the monitoring of electrolytes and management of results. Document the TPN volumes infused on the fluid balance chart or ASCU chart (MR731). Record the commencement of the TPN in the patient s Integrated Progress Notes. MONITORING THE PATIENT WHEN ESTABLISHING TPN. Monitor the patient s heart rate, blood pressure and temperature every 4 hours or more frequently as determined by the patient s clinical status for the duration of the infusion. Do not perform a BP every 4 hours on patients with low platelets or bleeding disorders unless clinically indicated. Weigh the patient prior to commencing the TPN, then weekly at a regular time. Regular weights assist in the assessment of adequate nutrition and daily fluid balance. Perform BGLs 6 hourly on initiation of TPN. Inform the RMO if the BGL is outside normal range. Monitor the biochemistry daily and PRN. CEASING TPN. Follow the rate reduction protocol as prescribed by the RMO. Each change must be checked, dated and the time recorded and signed by two midwives / nurses. Document the rate change on the fluid balance chart and integrated progress notes. Once the TPN is ceased and the line disconnected, flush the port with 10mL 0.9% sodium chloride. Ports may then be used for other infusions. When disconnecting the line, always use a posiflow or clamp the lumen to prevent the risk of air embolus. REFERENCES 1. National Institute for Health and Clinical Excellence. Nutrition support in adults. Clinical Guideline 32. London: National Health Service; 2006 February. 2. Intravenous Nurses Society Parenteral Nutrition. Journal of Infusion Nursing 2006; 29((1)): S Centre for Disease Control. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Morbidity and Mortality Weekly Report 2002; 51(RR10). 4. Scottish Intercollegiate Guidelines Network. Postoperative management in adults. Postoperative nutrition, Edinburgh: National Health Service Scotland August. 5. Royal College of Nursing. Infusion therapies In: Standards for Infusion Therapy, 2005; 2nd edition: p47. DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 5

6 6. Louey Melissa. Clinical Information Service. Intervention: Total parenteral Nutrition, Joanna Briggs Institute; th September. 7. Morrisey Nancy A. Gastrointestinal Intubation and Special Nutritional Modalities, In: Smeltzer Suzanne C. BBG. Editor. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Philadelphia: Lippincott Williams & Wilkins; p. Chapter 36 p Hagle Mary GD, Kassulke., Laak K., Yale B,. Patient-Specific Therapies. Parenteral Nutrition, In: Weinstein Sharon M, editor. Plumer's Principles & Practice of Intravenous Therapy, Eighth ed. Philadelphia: Lippincott Williams & Wilkins; p. Ch 16. P Gianino Stephanie, Seltzer Rene, Eisenberg Patti. The ABCs of TPN. RN 1996; 59(2): The Joanna Briggs Institute, Intervention: Central Venous Implantable Ports - Needling, 10th August, 11. Ghosh D, Neild P. Parenteral nutrition. Clinical Medicine December 1, 2010;10(6): Pittiruti M, Hamilton H, Biffi R, et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care,diagnosis and therapy of complications). Clinical nutrition (Edinburgh, Scotland). 2009;28(4): ACKNOWLEDGEMENT Sir Charles Gairdner Hospital. Clinical Practice Guideline No 7: Total Parenteral Nutrition.2013 DPMS Ref: 7491 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 6 of 5