TPN/Central Line Care

Objective One

Demonstrate safe administration and discontinuation of

TPN

Parenteral Nutrition*Parenteral nutrition = intravenous delivery of

nutrition via central venous catheter (CVC)Indicated for clients who can not ingest food or

fluids through the GI tractTypes of parenteral nutrition include partial or

totalPartial parenteral nutrition (PPN) is indicated for

clients who can meet some of their nutritional requirements orally (i.e. shortened small bowel due to injury/disease)

Total parenteral nutrition (TPN) is required for severely malnourished clients, clients with severe and extensive burns or other trauma, and for GI recovery

Administered via central line into high-flow vein to prevent vessel damage due to hypertonicity

Total Parenteral NutritionContains amino acids, vitamins, minerals,

and trace elementsCan be modified to meet nutritional needs of

clientHigh in glucose

10-50% dextrose in waterStart infusion slowly to prevent hyperglycemia

Less than 30-60 mL/h Most TPN solutions contain insulin to aid in absorption

Do not increase rate without an order as this can cause osmotic diuresis and dehydration

Clients on TPN must receive concurrent weekly infusions of lipids w/fatty acids and triglycerides

TPN (cont’d)Prepared under strict asepsis procedures

Use surgical aseptic technique when changing TPN solution and tubing

Do not use TPN infusion line for administering other medications/solutions to prevent contamination

Formula bottles should hang for no longer than 12 hours to prevent complications

TPN formula adjusted based on client’s statusWeightLab values (electrolytes, blood sugar, albumin,

BUN, creatinine)TPN therapy must be discontinued gradually

(up to 48 hours) to prevent sudden drop in blood sugar

Objective Two

Demonstrate a sterile central dressing

change and changing central line caps

Central Line Dressing ChangeSupine position with client’s head turned

away from CVC siteDon gloves and mask; place mask on

clientRemove and dispose of old central line

dressing and glovesInspect siteRemove and dispose of maskAccess sterile CVC dressing change kitApply sterile gloves and maskCleanse site with 2% chlorhexidine

moving in a spiral direction; allow to dryMaintain sterility

CVC Dressing Change (cont’d)Apply dressing

Sterile gauzeSterile, transparent, semipermeable dressingChange CVC dressing every 7 daysReplace dressing if damp, loosened, or visibly soiled

For PICC line, check position with each dressing change to ensure proper placementIf PICC line position has changed more than 1-2 cm

since insertion, may need to x-ray chest for placement

*Changing central line caps --Prime new sterile caps with saline via sterile

syringeAssure all lumen are clampedClean existing caps with alcohol prior to

removal

Changing Central Line Caps (cont’d)

Clamp or kink central line prior to removing caps to prevent air from entering the line

Remove first central line cap and replace with primed cap, maintaining sterility; repeat for all caps, ensuring each is secure

Flush central line per institutional protocol to maintain patency and prevent occlusionNever use syringe with a barrel capacity of less

than 10mL Smaller syringes generate more pressure than larger

ones, potentially damaging the lineFlush with at least 10mL normal saline (NS)

whenever the central line is irrigatedUse push-pause flushing method to remove

particles that adhere to the catheter lumen

Objective Three

Discuss safe administration of

intralipids

*Intralipids are a source of essential fatty acids and energy

Fat emulsion must be included in longer-term TPN therapy in order to deliver adequate calories and high levels of essential fatty acidsTypically initiated within 1 week of TPN therapy

Change tubing every 12 hoursInfuse or discard emulsion within 12 hours

of hanging the containerBegin infusion slowly, increasing daily

based on client’s tolerancePotential for adverse reaction, fat embolus

w/rapid infusion

Objective Four

Demonstrate safety and sterility in discontinuing a

central line

*Removal of nontunneled, noncuffed central lines is an aseptic technique that can be performed by the RN

Place client in recumbent positionRemove dressing and any securing devices from

the central line insertion siteInstruct client to perform the Valsalva maneuver

Air is prevented from entering the catheter wound and pathway while client is bearing down

Remove the catheter and apply pressure to the site

Immediately apply antiseptic ointment and sterile occlusive dressing

Client remains recumbent and inactive for 30 minutes

Measure catheter length, document integrity

Objective Five

Identify types of central lines, safety

issues, and cares

*Indications for placement of a central venous access device (CVAD) include --Inadequate peripheral vascular accessNeed for frequent vascular accessHypertonic/hyperosmolar infusionsInfusion of irritating or vesicant drugsRapid absorption and blood/tissue perfusionLong-term IV therapy

*Contraindications for CVAD placement --Altered skin integrity,Anomalies of the central vasculature, superior

vena cava syndromeCancer at the base of the neck or the apex of

the lungImmunosuppression, septicemia

*Main types of CVADs --Nontunneled cathetersTunneled cathetersPeripherally inserted central catheters (PICC)Implanted ports

Nontunneled catheters are inserted into the superior vena cava via percutaneous stick through the subclavian or jugular veinSingle or multilumenMay be referred to as a percutaneous central

venous catheterExample is a Hohn catheterCatheter size ranges from 24 gauge and 3 ½

inches to 14 gauge and 12 inches

Tunneled catheters are inserted via percutaneous cutdown under anesthesiaInsertion and removal performed by a

physicianCatheter tip is placed in the superior vena

cava while the other end is tunneled subcutaneously to an incisional exit site on the trunk of the body

Single or multilumenDacron cuff near exit site anchors catheter in

place, acts a securing device, and serves as a microbial barrier

Left in place for indefinite period of timeExamples are the Broviac, Hickman, and

Groshong

PICCs are typically placed in the basilic vein due to diameter and straighter path to the superior vena cava Single or multilumenMay be placed by RNUsual dwelling time is 1-12 weeks (can stay much

longer)Decreases risk of CVC complications

*A midline catheter (MLC) is a percutaneously inserted IV line that is placed between the antecubital fossa and the head of the clavicle, then advanced into the larger vessels below the axillaDwelling time is 1 to 6 weeksCan deliver most infusates except caustic drugs and

TPN that need the dilution capabilities of the superior vena cava

May be placed by RN

An implanted port, or vascular access port (VAP), is surgically inserted into a subcutaneous pocket under the skin without any portion of the system exiting the bodySingle or double injection portConnected to a catheter positioned in the superior

vena cavaPort access must be with a noncoring needle to

avoid damaging the system Huber needle Port-a-Cath Gripper needle

Useful for long-term infusion therapy; should not be accessed more than every 1-3 weeks

Eliminates need for exit site care/dressing changes or regular flushing if not in use; reduces risk for infection

Contraindicated in patients with septicemia or bacteremia

*Risks/complications of CVADs --Pneumothorax (due to close proximity to lung

apex)Laceration of the subclavian artery

Difficult to control bleeding because this is a noncompressible vessel

HemothoraxMigration of the catheter tip across the sinoatrial

(SA) node Dysrhythmia

May become trapped in the tricuspid valve Permanent damage of the valve Requires valve replacement

Air or catheter embolismCatheter pinch-off = the anatomic compression of

a CVAD between the clavicle and first rib Intermittent occlusion of central line Catheter fracture

http://www.youtube.com/watch?v=ud8EWOQYqP0