Standard operating procedure - parenteral nutrition (PN)

Administering PN

PN can be administered in two ways:

Continuous PN: This is a 24-hour continuous treatment of PN. This may also be supplied as a 48-hour bag with the lipid needing changed 24-hourly.

Cyclical PN: This is when parenteral nutrition is infused for less than 24 hours. Cyclical PN can be used when the child is on a stable regime and tolerates a reduced infusion time.

Constituents of PN

Aqueous Solution

Amino acids
Glucose and electrolytes
Trace elements - zinc, copper, selenium, manganese, fluorine and iodine (and iron, chromium and molybdenum in patients over 40kg)

Lipid Solution

Lipid emulsion e.g. SMOF lipid or Intralipid
Water and fat-soluble vitamins

The PN can be supplied as separate aqueous and lipid solutions, usually in those patients less than 2 years of age, or as an all-in-one (3-in-1) bag for patients over 2 years of age with all the ingredients combined together in one bag.

NB. Where the concentration of glucose is above 10% the PN must be administered via a central line (C) and not peripherally (P). The pharmacy prescription will clearly state ‘C’ or ‘P’ dependant on the glucose concentration.

A higher glucose percentage is hypertonic and acidic; this can cause phlebitis and lead to extravasation.

Nursing procedure for administration of PN on a ward

Nursing procedure for administration of PN on a ward
ACTION	RATIONALE
Remove PN from fridge at least one hour prior to use.	PN should be brought to room temperature to minimise the formation of “champagne” bubbles which are difficult to remove when running the PN through the giving set.
PN should be set up in the ward treatment room with restricted access and no fans on and no open windows. Checking Staff nurse should wear drug tabard.	To minimise the risk of infection while providing ease of access to required resources and promoting effective time management. To reduce the risk of mistakes through interruptions and distractions.
It is best practice to set up PN on an individual basis, i.e. immediately prior to connection, not in advance.	To reduce the risk of errors.
One nurse should set up the infusion while both nurses should independently check the prescription, pharmacy paperwork, bag/syringe labels and rate chart where appropriate.	To reduce the risk of errors.
PN must always be administered via an appropriate administration set and a 0.2 micron filter used for aqueous solutions.	To prevent microorganisms plus any particles generated during the pharmacy preparation process from entering the bloodstream.
Check the PN solution for leakage and precipitate prior to running through administration set.	To minimise the risk of infection and maintain the microbiological and physical stability of the product while ensuring the PN is fit for use.
Check the following match when comparing the child’s PN pharmacy sheet and intravenous prescription chart against the PN solution, according to NHS Lothian Medicine Administration Policy: Given name and surname Date of birth CHI number/hospital number Ward name/number Date of infusion and expiry date Route of administration Constituent parts on the PN label match the pharmacy sheet Volume to be infused Duration of infusion Rate of infusion	To ensure the prescription is correct and the correct product is prepared and given to the correct child.
If there are any discrepancies between the child’s prescription and the pharmacy sheet then these must be resolved with the ward pharmacist/on-call pharmacist and/or medical staff responsible for the child.	To ensure patient safety.
A thorough hand wash must be performed before and after the procedure and standard (universal) precautions must be adopted. The PN must be prepared using an aseptic non-touch technique.	To minimise risk of infection.
PN must be covered and protected from light.	To prevent degradation of light sensitive vitamins.
Do not add any other drugs or solutions to the prepared PN solution. If fluids or IV medications need to be administered via the same access then a 3 way tap should be used and compatibility checked with pharmacy prior to administering.	To minimise the risk of infection and maintain the microbiological and physical stability of the product.

Connection of infusion

Connection of Infusion
ACTION	RATIONALE
The windows and doors should be shut and fans should be switched off	To minimise the risk of infection.
Immediately prior to commencing PN, the following observations of the child should be recorded: Temperature Heart rate Respiratory rate Blood pressure	To establish the baseline for subsequent observations.
The prescription, rates and child’s identity should be independently checked by two IV competent registered nurses in line with medicine administration policy before connection using an aseptic non-touch technique. Rates should also be checked and documented at each shift handovers (8am and 8pm).	To reduce the risk of a drug error and to minimise the risk of infection.
Prepare and access the child’s intravenous access according to Hospital Policy.	Infusion ports are associated with an increased risk of extravasation and infection. To assess patency and position of the CVC/PVC.
Attach the administration set to the patient.	To enable treatment to commence.
The infusion pumps should have the following correctly set: • Rates • Volume to be infused • Pressure alarms The infusion pumps should not be labelled.	To maintain patient safety and promote the effective use of the medical device.
The level of the pump should be positioned within 30cm of the heart and the pressure alarm set, according to Hospital Policy.	To maintain gravity thus avoiding siphonage and to ensure the pressure alarms function correctly.
The infusion pump must be secured onto the infusion stand and whenever possible run off mains electricity. Check: • All connections are tight • All the relevant clamps are open.	To prevent accidental disconnection and facilitate the flow of PN.
All equipment must be disposed of according to Waste Management Policy.	Safe practice as detailed in Hospital Policy.
The accessing of the intravenous therapy device and the beginning of PN infusion must be documented in the child’s healthcare records. The prescription and rate charts must be signed by both registered nurses. The infusion device numbers must be recorded on the prescription chart. Any difficulties encountered must also be documented.	To maintain an accurate record and ensure accountability and traceability.

Management of infusion

Management of Infusion
ACTION	RATIONALE
If there are any concerns about a child receiving PN then their medical team should be contacted.	To enable issues to be resolved.
Disconnection or manipulation of the PN system should not occur.	To ensure the safety of the child.
If there is an accidental disconnection: Clamp patient line Discard the PN, do not re-spike or reattach the PN bag Seek medical advice IV fluids should be commenced Check patient blood sugar 30 minutes post disconnection
Interruption of the PN should be avoided whenever possible. IV medications should not be administered via the PN administration set. If the child requires multiple infusions and/or antibiotics these should be filtered via a multiple lumen extension set or a 3-way tap should be connected to the child’s CVC before connecting the PN line.	To ensure the nutritional requirements of the child are met. To prevent potential drug interactions and potential absorption of the drug into the filter.
The intravenous access device should be cared for according to Hospital Policy.	To minimise the risk of infection.

Patient monitoring

Patient Monitoring
ACTION	RATIONALE
The frequency of patient observations will depend on the clinical condition of the child and any underlying disease processes.	To meet the needs of the child/young person.
The following should be monitored and recorded hourly: Infusion pump pressures Fluid volume infused Infusion rate	To ensure accuracy of infusion pump while contributing to the assessment of CVC patency.
All lines and connection should be checked hourly for leakage and kinking.	To enable the early detection of extravasation and phlebitis, to reduce the risk of haemorrhage and minimise the risk of embolism.
Accurate recordings of the child’s intake (enteral and parenteral) and output should be made in the fluid monitoring chart.	To monitor fluid intake and output to help prevent dehydration or fluid overload.
The following observations should be recorded at least every four hours: Heart rate Temperature Respiratory rate Blood pressure	To observe for fluid overload or deterioration in condition.
If the patient spikes a temperature 38.0-38.4°C, but is clinically well, recheck temperature in an hour if remains 38.0-38.4°C, pause PN contact medical staff to review patient. Follow guidance for temperature 38-38.4°C and clinically unwell. If temperature <38.0°C when rechecked continue PN and continue to monitor	Early detection and treatment of line sepsis
If the patient spikes a temperature 38-38.4°C and is clinically unwell, contact medical staff to review patient, Discontinue PN Blood culture of central line should be taken along with FBC, U&E’s, CRP Attempt to obtain peripheral cultures Obtain, urine for culture, viral and bacterial throat swab or secretions Commence IV Cefotaxime and Teicoplanin Commence IV fluids	Early detection and treatment of line sepsis
If the patient spikes a temperature 38.5 °C or above PN infusion should be stopped. Contact medical staff to review patient, Blood culture of central line should be taken along with FBC, U&E’s, CRP Attempt to obtain peripheral cultures Obtain, urine for culture, viral and bacterial throat swab or secretions Commence IV Cefotaxime and Teicoplanin Commence IV fluids	Early detection and treatment of line sepsis
Blood sugar should be monitored and recorded: Every six hours until established on PN. For neonates and infants it takes 4 days to establish on PN. For children and young people it takes 2-3 days to establish on PN. Pharmacy will advise when patient is established on PN When receiving cyclical PN, at 30 minutes after stopping PN and as clinically indicated, medical and pharmacy staff should be notified if Blood glucose is 3mmol/L or less	to ensure patient safety to monitor tolerance to glucose in PN to check for rebound hypoglycaemia
PN bloods should be monitored as per pharmacy and the medical team’s instructions.	To guide the maintenance of normal blood chemistry by altering constituents of the PN solution.
The child/young person must be weighed regularly as per the medical team/dietician instructions. This should be recorded and dated appropriately on the child’s weight chart.	To observe for fluid overload. To ensure the effectiveness of treatment. To enable accuracy of PN formulation. To ensure consistency of recording.

Completion of infusion: continuous PN

Completion of Infusion: Continuous PN
ACTION	RATIONALE
The total volume of PN infused must be recorded on the child’s fluid balance chart.	To maintain an accurate record.
When disconnecting the PN, the infusion rate and volume to be infused must be cleared on the infusion pump. These must be reset when reconnecting the new PN.	To minimise the risk of error on reconnecting.
All used equipment must be disposed of according to waste management policy.	To ensure safe practice

Completion of infusion: cyclical PN

Completion of Infusion: Cyclical PN
ACTION	RATIONALE
Cyclical PN helps reduce liver complications related to PN. During the last hour of the infusion, the infusion rate of the non-fat bag must be reduced to prevent rebound hypoglycaemia.
The rate reduction must be checked independently against the rate chart prescription by two IV competent registered nurses and signed for on the rate chart.	To reduce the risk of mistakes and ensure patient safety.
The total volume of PN infused must be recorded on the child’s fluid balance chart	To maintain an accurate record.
When disconnecting the PN, the infusion rate and volume to be infused must be cleared on the infusion pump. These must be reset when commencing new PN.	To minimise the risk of error on reconnecting
All used equipment must be disposed of according to waste management policy.	To ensure safe practice.

PN weaning

PN Weaning
ACTION	RATIONALE
The volume of PN to be infused will be decreased as the child’s enteral intake increases. This will be calculated and monitored by a registered dietician in conjunction with pharmacy	To prevent fluid overload while re-establishing enteral nutrition.
The intravenous access device should be removed when no longer required.	To minimise the risk of infection.
Refs: https://www.gosh.nhs.uk/health-professionals/clinical-guidelines/nutrition-parenteral ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition (2018). Clinical Nutrition 37(6).