Do not abruptly discontinue TPN especially in patients who are on insulin because this may lead to hypoglycemia. Do not obtain blood samples or central venous pressure readings from the same port as TPN infusions. There are many complications related to the administration of TPN Perry et al. Table 8.
Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature.
IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing frequently as per agency policy usually every 24 hours. Localized infection at exit or entry site Due to poor aseptic technique during insertion, care, or maintenance of central line or peripheral line.
Interventions: Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess CVC site for redness, tenderness, or drainage. Notify health care provider of any signs and symptoms of infection. Pneumothorax A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse.
Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia. Interventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion. Air embolism An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open or removed without being clamped.
Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
Interventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed. Hyperglycemia Related to sudden increase in glucose after recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis.
Excess glucose also leads to lipogenesis again caused by insulin stimulation. This may cause fatty liver, increased CO 2 production, hypercapnea, and respiratory failure. Interventions: Monitor blood sugar frequently QID four times per day , then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Refeeding syndrome Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts decreased phosphate, magnesium, and potassium in serum levels that may lead to widespread cellular dysfunction.
Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly and titrated up for four to seven days. Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment. Fluid excess or pulmonary edema Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia decreased O 2 sats. Interventions: Notify primary health care provider regarding change in condition.
Patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.
Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work. Common blood work includes CBC complete blood count , electrolytes with special attention to magnesium, potassium, and phosphate , liver enzymes total and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin , and renal function tests creatinine and urea.
Most TPN patients administer the TPN infusion on a pump during the night for hours so that they are free of the Intravenous pump during the day to do work, do errands or take care of day to day life.
Overall, TPN must be administered in clean, sterile environment. All of these healthcare members are trained to help the TPN patient navigate the nuances of their care. Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment.
As always, you should consult with your healthcare provider about your specific health needs. How is total parenteral nutrition TPN given? Kathleen Handal, MD. Throughout the course of therapy, patients may or may not be able to ingest anything orally; whatever the case, they will not get any substantive nutrition via the oral route. Because patients are not getting any other true form of nutrition, the TPN formula needs to contain all of the essential nutrients a body needs to be healthy. This includes proteins, carbohydrates, fats, electrolytes, vitamins, and minerals.
There are standard formulations that are available, and these are often what are used by large hospital systems. Infusion Solutions, however, batches each TPN formula to meet the individual dietary needs of the patient. This leads to optimal nutrition and a better chance of restoring health. The TPN formula is monitored by the Infusion Solutions team, including pharmacists, nurses, and dieticians.
The formula can be adjusted as necessary based on lab markers and the progress of the disease state. The rate of TPN administration can also be changed under some circumstances. Generally, patients are initially started on a continuous cycle and are given their TPN over a 24 hour period.
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