Hi Lynn:
I work with the Nutritional Support Team at Loma Linda University Medical Center and Children's hospital as a TPN/CVAD nurse specialist. Our department is in the process of updating our TPN administration policy. I would like to ask for your expertise in regards of the use of midline catheter and the administration of Peripheral Parenteral Nutrition.
Our team had recommended in the past that not parenteral nutrition be administered through a midline due to risk factors associated with its use (thrombosis, occlussions, phlebitis). Current INS standards of practice for midline use and PN administration states:
Our team is interpreting this statement as "Midline catheter should not be used for continuous veicant therapy (e.i chemotherapy) and parenteral nutrition. . ." or infusates with osomolarity greater than 900 mOsm/L. Is this interpretation correct?
This current article from ASPEN 2017 recomends not to use midline for peripheral PN administration again due to concerns about risk for phebilitis and inability to see symptoms of phlebitis due to catheter deep vein location. In exceptional cases where patients are in need of nutritional support PPN using a midline or peripheral IV, our TPN pharmacist will adjust PN formula to decrease osmolarity way below 900mOsm/L. We will really appreciate your feedback and guidance in this topic. Thank you again for all your support in the past.
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 When Is Parenteral Nutrition Appropriate - Consensus Recommendation ASPEN - JPEN March 2017.pdf | 983.34 KB |
You have 2 professional organizations stating plainly that NO parenteral nutrition solutions should be infused through a midline catheter. I have serious doubts that a peripheral PN formula can be made to benefit the patient AND have the total osmolarity "way below 900 mOsm/Liter". The lowest osmolarity I have ever seen with any PPN solution is a pre-mixed formula using glycerol that is 735 mOsm/L. When using dextrose, plus amino acids, plus all the electrolytes and other additives, 900 is about the lowest you can go. If you do choose to use a midline for any nutrition formula, you should plan to use 2 or 3 midlines, depending upon the length of time the patient will need this formula. I would never expect one single midline to get a patient through an entire course of nutrition therapy. This means you will have complications that require removing and replacing with a new midline. So you will have to make sure the patient has enough veins for this. This is not cost effective. The INS standard on VAD Planning also states "Peirpheral vein preservation is considered when planning for vascular access." The PPN solution will cause phlebitis and thrombophlebitis and this is not vessel preservation. Once you can no longer obtain a blood return from the midline due to inflammatory changes, it shoud be removed as greater vein damage will occur. In my professional opinion, (and I am a strong proponent of appropriate use of midlines) a midline is simply not appropriate for any parenteral nutrition formula. 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
Hi Lynn:
Thank you for your prompt response. Our team agrees with you on the concerns about administering parenteral nutrition and even peripheral parenteral nutrition through a midline. Do you mind sharing with us the citations from the 2 organizations you are mentioning above. Thank you again for your support and expertise.
Rebecca Estanque, MSN, RN, PNP
Pediatric TPN/VAD Nurse Clinician
Pharmacy, Nutritional Support Team
(909) 558-4000 ext 42380 . fax (909) 558-4847
Pager (909) 558-1717,8327 . [email protected]
I was referring to the INS Standards and ASPEN guidelines that you quoted. 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
Thank you, for your support and for clarifying the statment from INS. We will share this information with the rest of the NST and vascular team. Thank you again for your invaluable support.
Rebecca Estanque, MSN, RN, PNP
Pediatric TPN/VAD Nurse Clinician
Pharmacy, Nutritional Support Team
(909) 558-4000 ext 42380 . fax (909) 558-4847
Pager (909) 558-1717,8327 . [email protected]