PARENTERAL NUTRITION THERAPY

DOCUMENT TYPE: PROCEDURE

Site Applicability Applicable in all BC Children’s Hospital areas where patients with parenteral nutrition (PN) therapy are cared for.

Practice Level/Competencies Physicians: Parenteral nutrition (PN) ordering is an advanced competency. Prescribers ordering PN must have established knowledge and experience in prescribing or be directly supervised by another physician with established knowledge and experience. Registered : PN design is an advanced competency for dietitians. PN may be designed by a Registered (RD) with College of Dietitians Restricted Activity B. Pharmacists: PN dispensing is a foundational competency for pharmacist. Pharmacist must complete the required C&W parenteral nutrition dispensing training. Registered Nurses: Administration of PN is considered a foundational competency for Registered Nurses (RN) and may only be completed once the RN has received the required education in each clinical area, which may include completion of Administration Clinical Skills Validation tool with the appropriate clinical support person (ie. Clinical Nurse Educator or Clinical Resource Nurse) and annual LearningHub Alaris Pump training. Policy Statement(s) 1. Prescriptions for PN must be ordered daily by authorized prescribers using our PN Order Form. MSI, Clinical Clerks, and Registered Dietitians are unable to prescribe PN under prescriber regulations. 2. PN is a high alert medication. Adherence to “High Alert Medication” policy and “Independent Double Check for Medication Administration” policy is mandatory 3. PN will be administered via central venous whenever possible, and may require placement of a central line specifically for this purpose. PN can be delivered through peripheral (regular or extended peripheral IV). It is important to recognize that there are significant disadvantages to this approach: • Increased risk of extravasation due to the vesicant nature of PN solutions • Increased risk of significant tissue damage should extravasation occur. (See “Prevention and Management of Infiltration and Extravasation – Guidelines for Antidote Administration”) • Limited ability to deliver adequate nutrition due to restrictions in osmolarity ( 900 mOsm/L), and dextrose ( 12.5%) and ( 5%) concentrations in PN solutions for peripheral administration. For these reasons, peripheral PN is only appropriate for short term use until central line placement occurs. The decision to use peripheral PN must be made by the clinical team, weighing the benefits and risks for each individual patient.

Equipment & Supplies  with channels  Straight administration set x 2 OR Straight administration set x 1 and administration set containing 0.22 micron inline filter (as supply warrants)  0.22 micron filter extension x 1 (if not using tubing with inline filter)  Y-site connector (as needed)  PN solutions  Hospital grade surface disinfectant wipe  IV tubing labels: date change & tubing solution label  Refer to Changing the Needless Connector (CAP) on Vascular Access Lines for additional

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DOCUMENT TYPE: PROCEDURE

equipment Assessment Initial Assessment: The decision to begin PN must be based on a complete nutritional and medical evaluation considering:  Pre-morbid nutritional status  Impact of the current illness/condition on nutritional needs and ability to receive and utilize nutrition via the GI tract  Expected course of current disease/condition

Ongoing Assessment: Patients on PN must be reassessed on an ongoing basis to evaluate:  The ability to transition to enteral nutrition  Complications associated with delivery of PN – e.g. extravasation, line occlusions or breakage, malposition of lines, line associated infection, etc.  Metabolic complications of PN – hypo/, hypertriglyceridemia, , excessive or insufficient energy/ delivery, , etc.

Refer to Ongoing Care and Management for further details.

Procedure

PN Administration

STEPS RATIONALE 1. Approved prescriber to COMPLETE a new New daily PN order forms are to be completed after PN order form daily. All PN orders to be patient is assessed. This reduces error in ordering of SENT to Pharmacy by 1200. PN will be PN and ensures appropriate patient therapy. delivered to the appropriate care area. Ensures same day preparation of PN.

2. RN to PERFORM visual inspection for Infusion of a precipitate may lead to serious adverse integrity of the PN bag and formulation, effects including phlebitis, thrombophlebitis, including cloudiness or precipitation. thrombosis and major organ dysfunction. CONTACT pharmacy if PN appears compromised. PN administration should be withheld until safety can be verified.

3. Two RNs to PERFORM an independent double Performing an IDC reduces risk of medication check (IDC) as per the “Independent Double administration error to ensure the right PN, including Check for Medication Administration” policy. its components and diluent, is administered to the VERIFY: right patient through the correct route.  Patient identifiers  Product name  (central vs peripheral)  All components listed on the label to the PN order  Amino Acid/Dextrose and Infusion rates Note that some variations in names may be and volumes presented on labels.  Expiry date and time

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DOCUMENT TYPE: PROCEDURE

4. GATHER equipment. CLEAN working surface Routine Infection Control Practices; reduces with hospital grade disinfectant wipe and allow transmission of microorganisms. Work surface is appropriate dry time. PERFORM hand hygiene clean, not sterile, and it is important to keep sterile as per infection control standards. equipment sterile to reduce transmission of microorganisms. Aseptically PREPARE equipment on a clean Strict attention to aseptic technique while work surface. PRIME lines as per priming the tubing and hanging and “Administration Set Priming and Loading and connecting the PN is critical, due to the high Initiating or Changing the Infusion” procedure. risk of contamination and infection. PLACE tubing identification labels proximal to Alerts staff of when tubing is due to be patient. changed and assists with site to source check NOTE: Amino acid solution must run through a of infusion system. 0.22 micron filter. Please use filter extension or inline filtered tubing for the amino acid solution. NOTE: If using tubing with inline filter (pictured) the air eliminating filter on the amino acids/dextrose administration tubing must remain vertical to prevent malfunctioning. CLAMP tubing by using both roller clamp and the pinch clamp beneath filter.

5. PERFORM hand hygiene and DON appropriate Routine Infection Control Practices; reduces PPE. transmission of microorganisms.

6. IDENTIFY patient using two patient identifiers Ensures identification mechanism is present to and EXPLAIN procedure. prevent treatments, , and procedures to wrong patient.

7. If PN remains attached to patient, CLAMP Clamping before turning infusions off creates vascular access device and TURN OFF PN positive pressure within vascular access device. infusions. CLOSE clamps on old administration Clamping old administration set ensures no free flow set. DISCONNECT previous PN from patient. of fluid when disconnected.

8. REMOVE previous administration tubing from IV pump and DISCARD. LOAD new PN administration sets.

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DOCUMENT TYPE: PROCEDURE

9. PERFORM hand hygiene. PERFORM Daily Needleless Cap changes prevent catheter- needleless cap change as per “Changing the related bloodstream infections. Needleless Connector (Cap) on Vascular Access Lines (Peripheral or Central)” procedure and ATTACH primed PN administration lines.

10. 1st RN to SCAN (if applicable) and PROGRAM If QRS code is available, scan to minimize error amino acid and/or as per the rate when programming PN. This ensures the correct ordered and volume to be infused. solution is set to infuse at the prescribed rate via correct route. For cycled PN, PROGRAM pump to reflect initial rate ordered and initial volume to be infused. High infusion rates increase the risk of Pump will need to be re-programmed as complications and rate changes must be reviewed ordered at the time of tapering, see for safety before delivery to the patient. Discontinuing PN. NOTE: Amino Acid / Dextrose should always be 3-5 times higher than the Lipid infusion rate. COMPLETE a site to source check of the infusion set up and verify as per the IDC process. 2nd RN to PERFORM site to source IDC.

NOTE: PN (Amino Acid/Dextrose OR Lipid) infusion rates should NOT be increased above the prescribed rate unless specifically indicated by a physician order.

11. Upon completion of IDC, OPEN all clamps and Opening clamps before starting infusion prevents START infusion. pressure build-up and “bolus” infusion to patient on pump start-up. DOCUMENT on appropriate records. Assists with meeting Professional Standards for documentation and legal requirements.

Ongoing Care and Management

STEPS RATIONALE 1. On initial patient assessment and with any order Ensures therapy is administered as intended to the changes, VERIFY system set up against the correct patient. This helps facilitate the plan for the patient. day and promotes patient and family centered care. CHECK prescriber’s order, MAR and/or other appropriate documents for: a) solution to be infused and dose b) rate or range of administration c) date/time tubing change due (ensure date change label attached to tubing)

2. PERFORM hourly site to source checks of Provides thorough assessment of infusion system so infusion system as per Guidelines for complications can be detected early and immediate Maintaining IV Infusion Therapy Procedure interventions can be provided in a timely manner. If extravasation noted, follow “Prevention and Management of Infiltration and Extravasation – Guidelines for Antidote Administration” procedure. C-05-12-60768 Published Date: 18-Jun-2021 Page 4 of 9 Review Date: 18-JUN-2024 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current. PARENTERAL NUTRITION THERAPY

DOCUMENT TYPE: PROCEDURE

3. ASSESS for signs of PN complications. Refer Complications may include: fluid imbalance, to unit specific guidelines, care plans, and hypo/hyperglycemia, cholestasis, and . prescriber orders to ensure the frequency of following assessment parameters are clear: See “Guidelines for Pediatric Sepsis/Severe Sepsis  Strict intake and output Screening and Treatment” for further detail  Height and weight measurement (as per “Growth Measurements: Height and Weight Measurement” ) which includes: Accurate weight and height are essential o Daily weight (unless ordered measurements for assessment and clinical care otherwise) o Monthly height/length o Monthly head circumference (infants and neonates)  work as ordered Unmetabolized lipids can affect platelet function, increasing risk of bleeding.

4. Prescribers to ORDER routine blood work. Refer to departmental guidelines and pre-printed RN to COMPLETE blood sampling procedures order sets for guidance. for central venous line.  PICU refer to “TPN Blood Guidelines in PICU” Order Set. Further considerations are to be followed for PN:  Non-critical care areas refer to “TPN  When blood sampling from a double lumen Bloodwork (Pediatric Non Critical Care catheter, USE the opposite lumen if the catheter Inpatients)” Order Set. gauge permits. PAUSE or DELAY PN and CLAMP the PN lumen prior to performing your Refer to “Blood Sampling From Central Venous Lines blood sampling. Vacutainer Method” or “Blood Sampling From Central  When drawing triglyceride levels, lipid infusion is Venous Lines: Syringe Method” procedures as stopped for 4 hours. DELAY lipid infusion on IV appropriate. pump and RESTORE after blood sampling completed. DOCUMENT on MAR. The 4 hour pause in infusion is to allow the body time to clear glycerol found within the lipid infusion. If a 4 hour pause in the infusion was not completed, the triglyceride levels may be falsely elevated/inaccurate. Please contact the laboratory when this occurs to ensure accurate readings are obtained. 5. Whenever possible, co-infusion of PN solutions are diverse in their composition and medications shall be avoided. For patient’s compatibilities with drugs can vary from one PN receiving IV medication while on PN, UTILIZE formulation to another. a separate lumen or IV access when possible. If not possible, CONSULT with Pharmacy and consider if PN can be paused for medication administration. CONSULT with prescriber if PN is frequently paused. CONSIDER if the medication can be There will be an increased risk of hypoglycemia administered in a dextrose-containing solution during medication administration if PN is paused. or via another route. If this is not possible, blood monitoring should be performed every 15 minutes x 1 hour. If the blood glucose remains stable with the first medication administration, blood glucose monitoring may be discontinued.

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DOCUMENT TYPE: PROCEDURE

6. RD to COMPLETE nutritional assessment daily Clinical status of patients requiring PN change (excluding weekends/stat holidays). RD to frequently and may necessitate adjustments in the LIAISE with prescriber if changes in PN are PN prescription. recommended.

Discontinuing PN

STEPS RATIONALE 1. If on cycled PN, PERFORM an IDC to PN solutions can be discontinued without tapering IF DECREASE the infusion rate of the Amino the dextrose concentration less than or equal to Acid/Dextrose solution and wean the infusion as 12.5%. per prescriber’s order.

If infusion is being discontinued for the first time, CHECK bedside glucose 30 and 60 minutes after PN is discontinued.

If blood glucose is normal, further testing only PN solutions (greater than 12.5% dextrose) that are required if PN solution is changed to higher being delivered through a concentration of glucose OR if the solution is should not be discontinued abruptly due to the risk of infused at a higher rate. the patient developing rebound hypoglycemia.

DOCUMENT on appropriate record.

NOTE: If a PN solution that is being given Abrupt discontinuation of a high glucose infusion is through a central line must be discontinued expected to result in a short term decrease in abruptly, a prescriber should be contacted for blood glucose that should be self-limited as orders on IV fluid and blood glucose insulin levels decrease after the infusion stops. monitoring. Suggested monitoring is every 15 Treatment may only be required if glucose levels are minutes x 1 hour. If glucose levels are within unacceptably low (clinical assessment) or fail to rise normal limits monitoring can be discontinued. after an hour.

2. TURN OFF infusion pump and DISCONNECT PN tubing. DISPOSE of supplies.

If the patient will no longer be receiving an Maintains patency of the line without an active intravenous infusion, LOCK the line as per the infusion. appropriate protocol:  Converting a continuous peripheral intravenous infusion to or heparin lock  Heparin Locking Central Venous Lines

If the patient is beginning another infusion, PREPARE the new infusion as per the appropriate protocol.

Nursing Documentation DOCUMENT on PN order form:  verification of PN components indicated by an IDC and co-signature in the RN box on the PN order form

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DOCUMENT TYPE: PROCEDURE

DOCUMENT on PN bag label:  verification of PN components indicated by an IDC and two RN initials  time the bag was hung DOCUMENT on the Medication Administration Record (MAR)  time the PN is initiated (2 RN initials required as per IDC)  the ordered rates of the PN infusion  PN rate changes (including weaning process)  time the PN is stopped DOCUMENT on Patient Care Flowsheet:  intake and output  patient weight daily  bedside glucose readings DOCUMENT on the Central Line Flowsheet:  all central line specific care

Patient & Family Engagement/Education Provide individualized, developmentally appropriate education to patient and family regarding PN indication, administration, and care and management. Discuss expected outcomes of PN. Engage patient and family in plan for care and management of PN, including blood sampling, line/cap changes, time of initiating PN etc. Engage Child Life as appropriate. If patient will require home PN, ensure central venous catheter education completed and caregivers are validated with skills.

Related Documents  High Alert Medications  Independent Double Check for Medication Administration  Changing the Needless Connector (CAP) on Vascular Access Lines (Peripheral or Central)  Prevention and Management of Infiltration and Extravasation – Guidelines for Antidote Administration  Drug Extravasation Flowsheet  Appendix A: Assessment of Extravasation versus Other Reactions  Administration Set Priming and Loading and Initiating or Changing the Infusion  Guidelines for Maintaining Intravenous (IV) Infusion Therapy  IV Therapy: Use of Infusion Pump with Dose-Error Reduction Software  TPN Blood Monitoring Guidelines In PICU  Order Set: TPN Bloodwork (Pediatric Non Critical Care Inpatients)  Blood Sampling From Central Venous Lines Vacutainer Method  Blood Sampling From Central Venous Lines: Syringe Method  Heparin Locking Central Venous Lines (CVL)  Intravenous Administration Set Table

References Ayers P, Adams S, Boullata J et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr; 38:296-333. BD. (2019, August). Filtering out the Facts: Recommendations to Optimize Performance of In-Line Filters for Parenteral Nutrition and Intravenous Emulsion Infusions. Retrieved from: https://www.bd.com/documents/white-paper/MMS_IF_Filtering-out-the-facts-MGill-Aug-12-2019_WP_EN.pdf

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Bethune K, Allwood M, Grainger C et al. Use of filters during the preparation and administration of parenteral nutrition: position paper and guidelines prepared by a British Pharmaceutical Nutrition Group Working Party. Nutrition. 2001; 17:403–8. Baker, R.D., Baker, S.S., Briggs, J. and Bojczuk, G. (2020, April 8) Parenteral Nutrition in Infants and Children. UpToDate. Retrieved from: https://www.uptodate.com/contents/parenteral-nutrition-in-infants-and- children?search=parenteral%20nutrition&source=search_result&selectedTitle=3~149&usage_type=default &display_rank=2 Carefusion. (2010). IV in-line filters FAQs. In Alaris Pump Module FAQs. Retrieved from: https://www.bd.com/documents/faq/IF_IV-In-Line-Filters_FQ_EN.pdf Elsevier. (2019, December). Parenteral Nutrition Administration (Pediatric). Retrieved from https://point-of- care.elsevierperformancemanager.com/skills/918/quick-sheet?skillId=CCP_183 INTRALIPID®. Fresenius Kabi Canada. Product Monograph, Date of Revision: January 06, 2020 Pittiruti M et al. ESPEN Guidelines on Parenteral Nutrition 2009: Central Venous . Clin Nutr 2009;28(4):365-77 SickKids. (2017). Parenteral Nutrition Orders. Toronto, ON: SickKids. SickKids. (2017). Intravenous (IV) Therapy Administration and Guidelines. Toronto, ON: SickKids. SMOFlipid®, Fresenius Kabi Canada. Product Monograph, Date of Preparation: March 22, 2018 Definitions Cycled PN: The term “cycling” is used when the PN solution is infused for less than 24 hours, followed by several hours without a PN infusion. Cycling can be initiated when a patient has been on standard PN for at least one week. Generally the time off PN is increased and the infusion rate is increased to compensate, so that the total daily volume of PN is unchanged. For patients requiring longer-term PN, cycling offers the advantage of giving the patient some time without being connected to the PN infusion. However, this is not suitable or desirable for every patient. The decision to cycle PN must be made by the medical team, considering all aspects of the patient’s condition and PN requirements. Potential side effects associated with cycling PN are rebound hypoglycemia due to the rapid discontinuation of dextrose infusion. The rate of infusion is decreased (tapered) during the final 2 hours of infusion to help prevent rebound hypoglycemia. If PN cycling is ordered the infusion rates and number of hours of infusion will be indicated on the order form.

Parenteral Nutrition (PN) – an intravenous solution consisting of amino acids, dextrose, lipids, sodium, , , calcium, phosphate, acetate, chloride, and trace elements Baseline Blood Work: Refers to the level of blood work monitoring that is required for a patient when PN is initiated and the dose is being adjusted to meet the patient’s individual nutritional needs; typically this means daily blood work. Standard PN Blood Work: Refers to the frequency of blood work required once the PN prescription is no longer changing daily (or changes are minimal); typically this is twice a week. Independent Double Check: Refers to a process in which a second practitioner independently conducts a verification of work or a decision of an initial practitioner. Such verifications can be in the presence or absence of the first practitioner but, in either case, the most critical aspect is to maximize the independence (unbiased assessment) of the second check, by ensuring that the first practitioner does not communicate what he/she expects the second practitioner to conclude is correct.

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DOCUMENT TYPE: PROCEDURE

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN 14-JUL-2020 C-05-12-60768 Parenteral Nutrition Therapy Approved at: Pharmacy, Therapeutics & Nutrition Committee 08-JUN-2021 “ “

Disclaimer This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

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