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Wafaa O. Cafege
IV/PN Supervisor Children's Pharmacy
 Introduction
 Situation in which PN is commonly
 Initiation of PN
 Administration of PN
 Monitoring and management of PN
 Complications of PN
 PN refers to combination of nutrients
–crystalline amino acids
 Dextrose
 fat emulsions
 Electrolytes
 Vitamins and minerals
 PN admixture are two types:
 Mixture of dextrose, amino acids,
vitamins, minerals are referred to
as 2-in-1 I.V fat infused
 Total nutrition admixture (TNAs),
 3-in-1 contain IVFE in the same
 PN administered via a peripheral
line PPN or central line PN.
Situation in which PN is
commonly used

 GI tract is not functioning or can’t be

 Nutrition needs cannot be met with
oral diet or enteral tube feeding
 The anticipated duration of PN is at
least 7 days
Initiation of PN
Due to nutrition’s direct impact on
health and disease
nutritional goals should be set clearly:

1. Prevention of nutrient deficiency

2. Prevention of chronic disease

3. Nutrition support for therapeutic aim.

Initiation of PN

 Patient who are hemodynamically

stable, able to tolerate the fluid volume
necessary to provide macronutrients.
 Who have central vascular access
 PPN is commonly used in neonatal and
Nutrition Screening
 Hospitalized patients are at risk (up to
65%) of developing malnutrition

 Malnutrition and malabsorption of macro

and/or micronutrients contribute to
many disease outcomes
 malnutrition: cancer, acute and chronic

 Malabsorption: gastrointestinal disease

A.S.P.I.N ‘05
Pediatric nutritional goals

 Maintain the rate of growth and

reverse weight loss
 Maintain positive nitrogen balance
 Children can lose as much as one
third of there body mass in 3-5 days
after caloric stores are depleted
Pediatric PN
Age Kcal/Kg Protein g/Kg
< 6 mos 85 – 105 3–4
6 – 12 mos 80 – 100 2–3
> 1 – 7 yrs 75 – 90 1–2
> 12 – 18 30 – 50 0.8 – 1.5
Carbohydrates in PN
 Carbohydrate is provided as dextrose
 With 3.4 Kcal/Kg
 Dextrose is the major contributor to the
osmolarity of the PN formulation
 Glucose without fat increases water
retention, worsen existing respiratory
 Glucose alone may exacerbate fatty
infiltration of the liver
Lipids in PN
 Lipids are provided as IV fat emulsions
 10 Kcal/g
 Dose 1 -3 g/Kg/day
 Serum triglycerides should be monitored
(DC lipids only when triglyceride > 4.5 mmol/L)
 20 % IVF promote optimal metabolic
Monitoring and management
 Central
 Osmolarity
 The maximum osmolatrity for PPN is 900
mOsn/L (1100 in Neonatal)
 Infusion of PPN needs careful monitoring
of the venous access site phlebitis and/or
 A 0.22-micron filter should be used for 2–
in-1 formulations
 The indication of PPN is short term need of
 Proper CVC tip placement must be
confirmed prior to initial PN administration

 Because its hypertonic, central PN is

administrated via a CVC with distal tip
placed in the superior vena cava adjacent
to the right atrium
Administration PN
 PN is to administered via an infusion pump
having adequate protection from “free
flow” and reliable audible alarms

 PN infusion should be completed within 24

hrs of initiation
Monitoring and management
 monitoring fluid electrolyte and acid/base
balance (acetate as NA, K to correct metabolic
 All patients receiving PN should be
monitored for proper glucose control
 Adjustments of the PN formula may be
necessary as oral intake begins or
Complications of PPN
 The centers of disease control CDC recommended the following:
 Replace the venous catheter at least every 72 hrs in adult however
in pediatrics the risk of phlebitis is not increased. So it should be left
alone until the complete of the I.V therapy .

 The peripheral venous access catheter should be removed as soon

as thrombophlebitis develops or an infiltration is noted

 Use a transparent, semi-permeable polyurethane dressing or a

gauze dressing to cover the peripheral access site
 Hydrocortisone and heparin may be added to PN to decrease

JCAHO. 2005 National Patient Safety Goals FAQs. accredited+organizations/patient+safety/05_npsg.html Accessed
December 8, 2004
 Catheter occlusion: the inability to infuse a
solution and/or aspirate a blood sample
 Subclavian vein thrombosis: can occlude a catheter
and manifest clinical symptoms of vascular
 Treatment: catheter removal; elevation of the affected arm,
catheter-directed thrombolytic agent infusion
 Thrombotic occlusion : intraluminal clotting as a result
of inadequate flushing or blood reflux
 Treat by instilling a Thrombolytic agent directly into catheter

JCAHO. 2005 National Patient Safety Goals FAQs. accredited+organizations/patient+safety/05_npsg.html Accessed
December 8, 2004
Infectious complications
 75% catheter related infections occur in pediatric
 Proper hand hygiene must be observed
 Aseptic technique must be observed for the
insertion and care of the intravascular catheter
 All catheter injection ports should be cleansed
with 70% alcohol before the system is accessed
 Antibiotic lock solutions should not be routinely

JCAHO. 2005 National Patient Safety Goals FAQs. accredited+organizations/patient+safety/05_npsg.html Accessed
December 8, 2004
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