I am finding conflicting info in a quest for information; I had a Dr ask about keeping a peripheral line and giving some peripheral nutrition for less than 5 days. I was talking to pharmacy about the subject and found that there standards on osmolarity are differnt that what I was educated on.
I am continually referencing the INS and see in several areas where they say ; Therapies not appropriate for short peripheral catheters include continuous vesicant therapy, parenteral nutrition, infusate with pH less than 5 or greater than 9, and infusates with an osmolality greater than 600mOsm/L. The nurse should collaborate with the pharmacist and licensed independent practitioner to assist in selction of the most appropriate vascular access device based on a projected treatment plan.
Then in another area it states; parenteral nutrition solutions with a final concentration of 10% dextrose or lower administered via a short peripheral or midline catheter should be reserved for situation in which a CVAD is not currently feasible and delay of ffeeding would be detrimental to the patient. The solution's osmolarity should not exceed 600 mOsm. ...
I bring this up to the pharmacist to be sure we are making the proper decisions for our patients. He says he is pretty sure the osmolarity standard is 900 for peripheral nutrition. I did a search and found ASPEN and there standards.
They state; Since 10% and 20% IVFE products are isotonic, they may be infused separately via a peripheral vein or as a part of TNA when osmolarity does not exceed 900mOsm/L.
Then in a different section in their standards they state; Central venous access should be used for the delivery of a parenteral nutrition formulations with and osmolarity >900mOsmL
Peripheral PN may be given, if indicated, through a peripheral access device, provided the osmolarity of the formulation is < or = 900mOsm/L. Intravenous fat emulsion shoul be concurrently infused.
How does a person/facility handle these conflicting standards? Thanks in advance, Gina Ward R.N.
What is the date on the ASPEN source you found? When we wrote the INS SOP, we colloborated with ASPEN and said they were in the same process of revising documents. They were waiting to see what we decided. Based on the research, we stayed with 600 because there is only one study from about 40 years ago that supports the 900. I don't know if ASPEN has released anything new, but based on the evidence, I would go with 600 and that measns that there is NO parenteral nutrition formula that should be infused through peripheral veins. The lowest osmolarity of any formula is around 750. More than 600 has been shown to produce 100% phlebitis in the veins of rabbit ears. Yes, this is an animal study but the similarities between veins of the rabbit and heman hand is very similar in size and construction. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
The resources ; Nutrition in Clinical Practice ( http://ncp.sagepub.com/) Standards for Nutrition Support; Adult Hospitalized Patient . August 11,2010; version of Record;
the other was; ASPEN Safe Practices for PN: Parenteral Nutrition Administaration , JPEN J Parenteral Enteral Nutr. 2004; 28S:s65-S70
Neither of these are as new as our INS standards. I got this directly off of ASPEN website search.
Thank you for your information. I will meet this week with our pharmacist.
Gina Ward R.N., VA-BC