Parental Nutrition (TPN)

Some medical conditions prevent the body from being able to absorb nutrition through the GI tract. When that happens, the body cannot function properly without Parental Nutrition (PN) due to the effects of starvation.  With starvation, tissues begin to break down, wounds won’t heal, and the internal organs stop working properly. To prevent starvation’s effects, patients receive Parenteral Nutrition (intravenously feeding).

Peripheral Parenteral Nutrition (PPN)

Peripheral Parenteral Nutrition (PPN) is the IV route used with needle insertion occurring in an extremity for short-term therapy. Unfortunately, while PPN IV administration provides all the calories someone needs, it’s very harmful to the veins. Larger veins in the center of the body are the way to go when administering medicines with large particles. The larger diameter inside the vein allows them to carry a greater number of larger-sized particles with less trauma making long-term treatment safer.

Total Parental Nutrition

The number of particles in total nutrition makes it thick and harder to give through the smaller veins of the hands and arms. Therefore, Total Parental Nutrition (TPN) administration works best if given through veins leading to the aorta (i.e., the subclavian vein or the superior vena cava). Usually, access to these veins comes through a central venous catheter inserted through a neck vein or a device like a porta cath implanted under the skin that connects to one of the larger internal blood vessels.

What’s in TPN?

Why is TPN so thick? TPN contains amino acids (very large protein molecules), plus lots of carbohydrates, electrolytes, vitamins, and other trace minerals, mixed with Dextrose 15%-25% in water. The combined mixture is six times thicker than blood! Though fat is needed, adding it directly to TPN would make the mixture too dense. Therefore, the pharmacy makes a separate lipid emulsion to run in conjunction with TPN  but not as part of it to add fat. In addition, insulin may be necessary to add to help the body with absorption. 

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     The following YOUTUBE video by PruittHealth provides an overview of Total Parental Nutrition (TPN)

TPN at Home – Instructions and Overview 

Home TPN

Total Parental Nutrition (TPN) allows a person who cannot digest food to receive all their nutritional needs intravenously. In the past, the use of medications that required an IV required hospitalization; not anymore. With proper training, family caregivers can now learn to administer TPN as safely in the home as when their family member received TPN in the hospital.

If your family member receives an order for TPN, a pharmacy receives the order, pre-mixes it for you, and has it delivered directly to your doorstep. Supplies for the medication administration typically come with the solution; however, you should clarify that with the pharmacist or Home Health Nurse if one is helping to coordinate the process.

High Risk for Infection

Due to the high sugar and protein content, infection is a significant risk with TPN administration. Therefore, when preparing to administer TPM, follow procedures carefully. I’ve linked to several videos to help you see how to perform various TOP procedures. Please take the time to review them. In addition, you may send me questions if there is something you don’t understand.

     Key Points to Remember

1. Handwashing is the MOST important part of the process for preventing infection. Don’t skip that step. Scrub with soap and water while you hum Happy Birthday
2. Use paper towels to cover work surfaces after washing them with soap and water to create a second barrier of protection against germs.
3. Keep your IVs in the refrigerator until ready for use. However, please don’t give them while they are still cold.
4. IVs should be at room temperature when you infuse them. Take them out at least 30 minutes in advance to warm up. Please DO NOT put them in the microwave or run them under hot water to warm them up.

TPN at Home – Pump Instructions

Using the Pump to Give TPN     

Each company that provides your TPN supplies will have its pump equipment. Most work the same way the one in the video works, but there may be some differences. When you get a pump, it will have a tutorial associated with the pump to assist you in learning what to do. Be sure to review it. However, by reviewing this video, you can become familiar with what to expect, the terminology used, and what it means. Therefore, it still serves a vital learning purpose. Just remember, where there are differences between what is on this video and what you see on your pump, the details in your manual take priority.

TPN at Home – Monitoring your PICC Lines

Watch Those PICC Lines!

Since TPN has sugar and other ingredients that could feed bacteria, you should know how to recognize signs of infection in an IV line. If you develop the symptoms below, contact your doctor or pharmacist and stop the TPN promptly. It may be contaminated.

• Check your IV insertion site daily to confirm it looks fine.
• Look for redness, swelling, puffiness, tenderness, pain, drainage, or increased skin temperature at the site.
• Chills, achiness, increased heart rate, fever of 100-100.5^oF, the overall feeling of fatigue, and illness.

TPN at Home – Priming the Tubing

How to Get Fluid into IV Tubing Prior To Starting IV (Priming)

• Assemble all supplies.
• Lay down clean paper towels
• Put on gloves
• Open packages
• Remove caps from extension tubing and IV port 
• With twist motion, insert extension tubing into the IV port and open the clamp on the tubing.
• Allow fluid to run through the tubing until it fills tubing.
• Re-clamp extension tubing.
• Connect new tubing.

TPN At home – adding multi-vitamins

How to Add Multi-vitamins to TPN

• Wash your hands and put on gloves. 
• Identify the medications you plan to add.
• Pop off the medicine tops and clean the rubber stoppers with an alcohol wipe.
• Using a 10cc syringe, pull up five ccs of air to insert into the vial. 
• Inject the air into the vial. The added pressure causes the medicine to rush into the Syringe. Remove the Syringe.
• Using the same syringe, pull back on the plunger to add five more ccs of air for the next medicine vial.
• Insert the five ccs into the second vial. The same thing happens. Take the Syringe out and carefully recap the needle.
• One-Hand Recap Technique: A one-hand cap is done by lying on the tabletop and carefully inserting the needle into the cap using one hand.
• When ready to inject the vitamins, remove the needle cap. 
• Using an alcohol wipe, scrub the round rubber stopper of the IV port for about 10 seconds and insert the needle through the center of the port, being careful not to puncture the sides of the bag.
• Discard the needle into a sharp’s container 
• Mix the IV by rolling it gently between your hands. 

 TPN at Home – Stopping & Disconnecting

Stopping TPN Therapy

If you need to stop your TPN for just a brief period, keep temporary caps with you. 

• Turn your pump off (or pause it).
• Remember to clamp both lines before disconnecting.
• Use a red cap to attach to the tubing going to the pump.
• Use a green cap to put on the IV line attached to your body.
• If your short time turns longer than expected, you will need to flush with saline and Heparin.
• If you have to be off the pump for a long time, you only have 24-hours to use a solution once it’s opened before you must throw it out.

TPN at Home – Flushing IV Line and Attaching TPN

Steps to Flushing the IV Line before Starting TPN

1. Gather supplies, clean the area, and wash hands.
2. Set aside Heparin Flush and one Saline Flush to use after TPN is infused.
3. Put on Gloves.
4. Take the remaining Saline Flush and push the plunger just enough to remove the air bubble. (If you removed the cap, don’t let the inside of the cap touch anything, or it will become contaminated). Recap the Syringe if you removed the cap during this process.
5. Remove the green cap from the end of the IV line and discard it.
6. Scrub line 10 seconds with an alcohol wipe.
7. Remove the cap of the saline syringe and set it aside. Attach the Syringe to the IV line.
8. Inject saline using the push/pause technique until push is complete.
9. Leaving Syringe attached to the IV line to protect its end while getting the TPN ready.
10. Remove the Syringe when you’re ready.
11. Clean opening with alcohol again.
12. Remove the cap from the end of the tubing, insert it into the extension tubing with a push and a twist.
13. Although the tubing is already in the pump, it needs to be programmed when to start, how fast to run, and when to stop.

 

TPN at Home – Pump Beeping for Occlusion

Typical Reasons for Alarms

1. Downward Occlusion:  left the clamp closed – need to release it.
2. Other alarms sound and they show up on the monitor’s screen. Plus, the monitor tells you what to do.

TPN at Home – Backpack Instructions

Carry TPN with You in a Backpack

The backpack is a travel kit that the pharmacy provides to make it easier for you to move around with TPN. It looks like many straps and pouches, but each has the purpose of keeping the contents safe and secure. Please use them as directed so the pump doesn’t fall out or the tubing doesn’t get kinked or pinched off as easily. 

 

TPN at Home – Pharmacy and labs

Weekly lab work results determine the nutritional content added to your TPN. Do not draw lab work during the TPN transfusion. Stop the TPN, wait ten minutes, and then draw the lab.