It has been my practice to keep my TPN infusion as a CLOSED system. However, working in the home infusion setting, some things are different than an acute care setting. Recently, I had a patient going home on cycled TPN in the home setting and also had a single IV abx. Q8 hrs using a Single Lumen Hickman. A "Y" connector was used. The TPN was directly connected to one of the "Y legs" and then a needleless cap was placed to the 2nd "leg" on the "Y" connector for intermittent access for the Q8hr IV abx...thus maintaining it as a closed system. The TPN tubing, "Y" connector, including the one needleless cap are all changed out Q24hrs or at the completion of the TPN cycle. Another method that was discussed by my colleague was to not place a needleless cap at the end of the one "Y" leg, but place a sterile red cap that would cover the end. Each time the line needed to be accessed by the cgr., the cgr. would have to remove the red sterile cap, openly exposing the port and attaching the IV abx. tubing. Point was made that the "Y" connector has a backcheck valve that does not allow reflux; however, my concern was the open exposed port leading to the TPN lumen...since ultimately, the central line catheter is a single lumen and should be a CLOSED SYSTEM. Any thoughts or evidenced based info for or against? Thank you again in advance!!!!
The evidence as outlined in CDC and INS point to maintaining a closed system with the least amount of manipulation as possible. I do not know of any studies assessing this particular set-up and have serious doubts about whether there is any direct evidence for or against this. Your first goal is to avoid using any PN line for anything other than the PN. If that is not possible, I would look at how long the PN actually infuses. Is there a way to schedule the ABX before and after the PN infusions so that both do not have to be given at the same time. This would depend upon the length of infusion time for the PN. If that can't be done, I would opt for using a Y-type extension set, also called bi-fuse sets with a needleless connector on the side being used for the ABX. Many companies will also put a needleless connector on the lumen being used for the PN so that the non-professional caregiver does not need to open the line, risking the entry of air, organisms, etc. A dead end cap would not be desirable on either side of this Y-set, in my opinion. But with all needleless connectors you must teach the caregiver how to scrub the connector, provide enough alcohol pads to scrub before and after each entry, and ensure they totally understand this procedure. They will also need to wear gloves. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861