Skills

Administering Parenteral Nutrition Through a Central

Line (CPN)
Extended Text
ALERT
• Do not add medications to central parenteral nutrition (CPN) in the acute care setting.1 Do not piggyback other IV medications with
CPN or lipids.
• Remember to route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the
head; enteric lines toward the feet).2

OVERVIEW
Central parenteral nutrition (CPN) is a specialized form of nutritional support used when adequate nutrition cannot be delivered to or
absorbed by the gastrointestinal (GI) tract. It is a complex nutrition support therapy. CPN is considered a high-alert medication because an
error in CPN administration can harm the patient significantly.1

Enteral nutrition (EN) is always the preferred method for providing nutrition; however, when the GI tract is not functioning properly and the
patient cannot be fed enterally, CPN may be the only nutrition support option.1

Compounded CPN formulas include dextrose, amino acids, electrolytes in the form of salts (e.g., NaCl, KCl, KPO4, CaCl), vitamins, and trace
elements (e.g., zinc, chromium, manganese).3 Medications such as insulin may be added to the CPN solution during the compounding
process. IV lipid emulsions (ILEs) may be compounded with CPN admixtures or provided as infusions separate from CPN therapy. A CPN
admixture containing all three nutritional substrates of dextrose, amino acids, and ILE is sometimes referred to as a 3-in-1 admixture, and
CPN that does not contain an ILE is referred to as a 2-in-1 admixture.

CPN requires the expertise of an interprofessional team to assess the patient, prescribe CPN, compound the CPN formula, administer the
CPN, and monitor the patient. Assessment includes critically thinking about indications for CPN and discussing how to prevent or address
possible complications of CPN therapy with the team.

In adult patients, CPN is the preferred method of nutrition support for those who are malnourished or at risk for malnutrition when a
contraindication to EN exists or the patient does not tolerate adequate EN or lacks sufficient bowel function to maintain or restore nutrition
status.1

For acutely ill patients with electrolyte and fluid deficits, repletion of electrolytes and fluids is best accomplished in a separate infusion
outside the CPN. Daily or more frequent monitoring of the patient's glucose, electrolyte, and fluid levels is recommended for the first few
days of CPN administration, and the frequency of laboratory monitoring can be decreased to once or twice a week as the patient's laboratory
results stabilize.1 ILEs provide calories and prevent EFAD, which occurs when patients receive CPN without ILEs for an extended period.
Symptoms of EFAD include dry or scaling skin, alopecia, and thrombocytopenia.4

CPN solutions with osmolalities greater than 900 mOsm/L should be infused through a central venous access device (CVAD) with the tip
positioned in the lower third of the superior vena cava near the junction of the right atrium.5 Both CPN and lipid infusions require filters.
Because lipid particles are large and cannot pass through the 0.2-micron filter used for 2-in-1 CPN admixtures, use a 1.2-micron filter for 3-
in-1 admixtures or with lipids infused separately.5 Lipid emulsions may be administered through a separate peripheral IV catheter or by
means of Y-connector tubing. When coinfused by means of Y-connector tubing, the ILE requires a 1.2-micron filter and the 2-in-1 admixture
requires a 0.2-micron filter; if piggybacked, the ILE with the 1.2-micron filter is coinfused below the 0.2-micron filter used with the 2-in-1
admixture.5
Labeling the tubing reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use.2
Connections should not be forced, and equipment should only be used for its intended purpose.6 Forced connections or workarounds could
indicate that the connection should not be made.

If the patient expresses concern regarding accuracy of a medication, do not give the medication. Investigate the patient’s concern, notify the
practitioner and verify the order.

SUPPLIES
See Supplies tab at the top of the page.

PATIENT AND FAMILY EDUCATION

• Provide education that is developmentally and culturally appropriate and consider patient’s desire for knowledge, readiness to learn,
and overall neurologic and psychosocial state.
• Instruct patient and family in the purpose and goals of CPN. Keep them informed about daily care of central line.
• Educate the patient and family about central line-associated bloodstream infection prevention.
• Teach the patient about the potential side effects and adverse reactions of CPN.
• Encourage questions and answer them as they are asked.

ASSESSMENT AND PREPARATION

• Review the patient's medical history, and assess for indications of and risks for protein/calorie malnutrition. Confer with the nutritional
support team regarding the following:
• Weight loss from baseline or ideal body weight
• Muscle atrophy/weakness
• Edema
• Lethargy
• Failure to wean from ventilatory support
• Chronic illness
• Nothing by mouth for more than 6 days
• Triglycerides
• Glucose and electrolyte levels
• Renal, and hepatic function
• Allergies
• Inspect the condition of the central venous access site for the presence of inflammation, edema, and tenderness. Confirm the patency
of the tubing.
• Assess vital signs, auscultate lung sounds, measure weight, and check the patient’s blood glucose level by fingerstick.
• Assess the patient for clinical indications for CPN.1
• Review the patient's most recent chest x-ray to confirm that the catheter tip is centrally located, i.e., in the distal vena cava or right
atrium. Do not infuse the CPN if the catheter tip is not centrally located.1
• Assess the serum triglyceride level before an infusion of IV lipid emulsion (IVLE) and at regular intervals during administration to
monitor lipid clearance. Patients with serum triglyceride levels of 400 mg/dl or higher are at risk of developing pancreatitis and therefore
should not receive IVLE.1
• Store CPN in a refrigerator at 2° to 8°C (35.6° to 46.4°F) if it will not be used immediately and warm it to room temperature before
infusion.7
• Assess the patient for specific contraindications to receiving CPN or ILE and advise the practitioner accordingly. Available lipids in the
United States contain egg phospholipids as an emulsifier as well as soybean or safflower oil as a source of polyunsaturated fatty acids, as
well as others that have blends of soy, MCT, olive and fish oils, or fish oil–based lipids.8
• Verify the patient's actual admission weight in kilograms. Reweigh the patient if appropriate.7 Stated, estimated, or historical weight
should not be used.7
• Verify the practitioner’s CPN order for dextrose, amino acids, ILE, electrolytes, vitamins, trace elements, added nonnutrient
medications, and flow rate.
 • If the ILE is not compounded with the CPN, check the practitioner's order for the ILE and the flow rate.
• Check the administration time for the CPN solution and lipid emulsion. Do not exceed 24-hour IV bag hang times for 2-in-1 or 3-
in-1 CPN admixtures.5 Do not exceed 12-hour IV bag hang times for ILE administered outside of CPN therapy.5
• Compare the labels on the CPN bag and on the lipid emulsion bottle with the practitioner's original order.
• Verify that there are two patient identifiers on the CPN bag and on the lipid emulsion bottle per the agency’s practice.9
• Check that the beyond-use dates for the CPN and the lipid emulsion have not passed.
• Inspect the medication for particulates, discoloration, or other loss of integrity.
• Understand drug reference information pertinent to the medication's action, purpose, onset of action and peak action, normal dose,
common side effects, and nursing implications, if needed.
• Review the manufacturer’s instructions for the CVAD, administration sets, filters, needleless connectors and other add on devices,
including syringe sizes for aspiration, flushing, and locking the catheter.

DELEGATION
The skill of administering central parenteral nutrition (CPN) may not be delegated to nursing assistive personnel (NAP). Delegation of related
skills varies according to each state's Nurse Practice Act. Before delegating related skills, be sure to inform NAP of the following:

• Instruct NAP to report the following to you:

• Pump alarm sounds
• Catheter dressing is wet
• Patient's temperature becomes elevated or other vital signs fall out of range
• Patient has any complaints
• Instruct NAP to perform fingerstick blood glucose monitoring as directed and report any abnormal results to you.

PROCEDURE
1. Gather the necessary equipment and supplies.
2. Provide for patient privacy and perform hand hygiene.
3. To administer central parenteral nutrition (CPN) first introduce yourself to the patient and family, if present.
4. Identify the patient using two identifiers. Compare the identifiers in the medication administration record (MAR)/medical record with
the information on the patient's identification bracelet, and/or ask the patient to state his or her name.
5. Explain the procedure to the patient and ensure the patient agrees to treatment.
6. Follow strict aseptic technique during infusion tubing and filter changes.
7. These components must be replaced every 24 hours. Change them immediately if you suspect that either has become contaminated.
8. Compare the health care provider's orders with the MAR to ensure that you have the right solution and that it is labeled properly.
9. Compare the label of the central parenteral nutrition (CPN) bag with the MAR or computer printout to make sure they match. Make
certain that the solution contains the correct additives and has not expired.
a. A parenteral nutrition supplement typically contains amino acids, glucose, lipids, electrolytes, vitamins and trace elements.
10. Check for compatibility. Also check the patient's name against the label on the CPN bag.
11. Perform hand hygiene.
12. Apply clean gloves. Don additional PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
13. Attach the IV administration set to the CPN solution using aseptic technique just before use.
14. Attach the appropriate filter to the IV tubing using aseptic technique. Prime the tubing with the CPN solution, making sure that no
air bubbles remain. Turn off the flow with the roller clamp. Disinfect the connection surface and sides of the needleless connector
vigorous mechanical scrubbing for a minimum of 5 to 15 seconds,10 per the organization’s practice, using a flat swab pad containing
70% isopropyl alcohol or alcohol-based chlorhexidine suitable for use with medical devices. Allow the solution to dry.10 If a dedicated
port is not available, flush the port with a syringe filled with normal saline to clear it of residue.
15. If using a disinfecting port protector or cap, remove the protector or cap from the needleless connector. Discard the protector or cap
in the appropriate receptacle.
16. Label the CPN bag, indicating the date and time the solution was hung, and initial it. Label the tubing with the date of initiation or
date of change per the organization’s practice.11
17. Trace the tubing or catheter from the patient to point of origin (1) before connecting or reconnecting any device or infusion, (2) at
any transition (e.g., new setting), and (3) as part of the hand-off process.11
 18. Connect the end of the tubing to the appropriate port of the central catheter, and label the port. Open the roller clamp to a rate that
maintains the patency of the line.
19. Place the IV tubing into the IV infusion pump, open the roller clamp completely, and regulate the flow rate on the pump as ordered.
In some institutions, the infusion rate is immediately set at the ordered rate. In others, an initial rate of 40 to 60 mL/hr is established
first, and the rate is gradually increased until the patient's nutritional needs are being met. Refer to your agency's policy to determine
the initial rate.
20. CPN access is to be used only for that purpose. If the patient is to receive IV medications or blood, infuse them through a separate
line or an alternative lumen.
21. Use a different lumen or port to obtain blood samples and central venous pressure readings as well.
22. In addition, the CPN infusion should not be interrupted for routine patient care or procedures such as to give the patient a shower,
transport her to therapy or administer blood transfusions.
23. Once you have completed all required care and discarded your used supplies, remove and discard your PPE.
24. Document the patient’s tolerance of the procedure.
25. Help the patient into a comfortable position, and place toiletries and personal items within reach.
26. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance.
27. To ensure the patient's safety, raise the appropriate number of side rails and lower the bed to the lowest position.
28. Perform hand hygiene as you leave the patient's room.

MONITORING AND CARE

• Monitor the flow rate routinely (at least hourly).
• Monitor the patient's fluid intake and urine and gastrointestinal fluid output every 8 hours.
• Obtain the patient's weight in kilograms at regular intervals.
• Assess the patient for signs of fluid retention or fluid overload. Palpate the extremities for edema and auscultate the lungs. Notify the
practitioner if signs of fluid retention or fluid overload are present.
• Monitor serum glucose and electrolytes frequently during the first few days of CPN administration and then routinely per the
organization's practice or the practitioner's order.1 The recommended serum glucose goal range for hospitalized patients receiving CPN is
140-180 mg/dl (7.8-10 mmol/L).12 Notify the practitioner of alterations in serum glucose and other electrolyte disturbances.
• Inspect the central venous access site for signs of infection, infiltration, extravasation, or phlebitis. Notify the practitioner if evidence of
these complications is present.
• Monitor the patient for signs of sepsis (e.g., fever, elevated white blood count, malaise, and hypotension). Notify the practitioner if
evidence of sepsis is present.
• Monitor the patient for adverse and allergic reactions to the CPN or ILE. Recognize and immediately treat respiratory distress,
wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization's practice for emergency
response.
• Assess the patient’s ongoing need for CPN.

EXPECTED OUTCOMES
• Serum electrolyte levels are stable.
• Serum glucose levels are within range ordered by the practitioner.
• Triglyceride level remains stable.
• Central venous access device is patent, and insertion site is free of pain, swelling, redness, or inflammation.
• Patient is afebrile.
• Patient is euvolemic.
• Patient's weight is maintained or increases to established goal.

UNEXPECTED OUTCOMES
• Patient develops redness, swelling, and tenderness around the venous access site, indicating possible exit-site infection.
• Patient develops lipid intolerance if receiving supplemental lipids.
• Patient develops signs of systemic infection.
 • Unplanned interruption of CPN infusion.
• Patient's weight is not maintained within prescribed range, skin turgor is taut, and crackles are auscultated over lung fields.
• Serum glucose level is greater than target set by practitioner, indicating intolerance to glucose load in the CPN solution.
• Serum electrolyte levels are not within normal ranges.

DOCUMENTATION
Documentation Guidelines:
• Record the condition of the central venous access device, the rate and type of infusion, the catheter lumen used for the infusion, intake
and output (I&O) every 8 hours, blood glucose levels, vital signs, and weight in kilograms per organization's practice.

Sample Documentation:
0700 Weight stable at 58 kg for 1 week. No redness, swelling, pain, or drainage at triple-lumen central line at right subclavian site. Vital signs
stable. Blood glucose 110 mg/dL. Patient denies discomfort from catheter. Bottle #2 of 3-in-1 TPN infusion continues at 250 mL/hr as
ordered. Taking sips of water without problems. Urine output adequate at 700 mL this shift. –A. Stark, RN, 10/29/21

PEDIATRIC CONSIDERATIONS
• Consider children's developmental needs when they are on long-term CPN. Perform regular assessments of development to determine
child's progress. Implement interventions to encourage expected milestones.

OLDER ADULT CONSIDERATIONS

• Some older adults have impaired ability to tolerate higher fluid volumes because of cardiac or renal impairment.

HOME CARE CONSIDERATIONS

• Assess the home environment and determine the appropriateness of home CPN. The environment must be clean and accessible with
reliable utilities (electricity, refrigeration, sanitary water, electrical outlets, and telephone service).
• Patients requiring long-term CPN benefit from a referral to a home nutrition therapy team.
• Patients receiving home CPN usually have a tunneled or implanted catheter inserted into the subclavian vein to reduce the possibility of
infection.
• Teach the patient and family the home infusion procedures, equipment operation, dressing changes, the procedure for adding
multivitamins and medications to the CPN, and techniques for initiating and discontinuing the CPN solution daily using aseptic
technique. Some patients may perform catheter site care; other patients have site care performed weekly by their home health nurse.
• Some patients receive home CPN at night during sleep (cyclic CPN) to allow the freedom to leave home or work during the day. Most
patients also take oral diet as tolerated, although their impaired gastrointestinal function limits nutrient absorption.
• Teach patient and family to monitor patient's weight, oral intake, I&O, and serum glucose level if required.
• Teach patient and family about actions to take in case of emergency or unexpected outcomes such as telephoning the health care
provider or going to the hospital, depending on the circumstances.
• If home CPN patients require insulin in their CPN, they will need a home glucose monitoring device and instruction in its use.
• Patient teaching for home CPN administration will be given by home infusion nurses after discharge or may be initiated in the hospital
and continued at home.

REFERENCES
1. Worthington, P. and others. (2017). When is parenteral nutrition appropriate? JPEN: Journal of Parenteral and Enteral Nutrition,
41(3), 324–377. doi:10.1177/0148607117695251 (Level VII)
2. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 59: Infusion medication and solution
administration. Journal of Infusion Nursing, 44(Suppl. 1), S180-S183. (Level VII)
 3. Boullata, J.I. and others. (2014). A.S.P.E.N. clinical guidelines: Parenteral nutrition ordering, order review, compounding, labeling,
and dispensing. JPEN: Journal of Enteral and Parenteral Nutrition, 38(3), 334-377. doi:10.1177/0148607114521833 (Level VII)
4. Mogensen, K.M. (2017). Nutrition issues in gastroenterology, series #164. Essential fatty acid deficiency. Practical Gastroenterology,
41(6), 37-44. Retrieved February 2, 2021, from https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-
June-17.pdf (https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-June-17.pdf )
5. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 63: Parenteral nutrition. Journal of Infusion
Nursing, 44(Suppl. 1), S190-S191. (Level VII)
6. U.S. Food and Drug Administration (FDA). (2017). Tips for health care providers to reduce medical device misconnections. Retrieved
February 2, 2021, from https://www.fda.gov/medical-devices/medical-device-connectors/tips-health-care-providers-reduce-medical-
device-misconnections (https://www.fda.gov/medical-devices/medical-device-connectors/tips-health-care-providers-reduce-medical-
device-misconnections) (Level VII)
7. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved
February 2, 2021, from https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf
(https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf ) (Level VII)
8. Hise, M., Brown, J.C. (2017). Chapter 5: Lipids. In C.M. Mueller (Ed.), The ASPEN adult nutrition support core curriculum (3rd ed.,
pp. 71-95). Silver Spring, MD: American Society for Parenteral and Enteral Nutrition. (Level VII)
9. Ukleja, A. and others. (2018). Standards for nutrition support: Adult hospitalized patients. NCP: Nutrition in Clinical Practice, 33(6),
906-920. doi:10.1002/ncp.10204 (Level VII)
10. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 36: Needleless connectors. Journal of Infusion
Nursing, 44(Suppl. 1), S104-S107. (Level VII)
11. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 43: Administration set management. Journal
of Infusion Nursing, 44(Suppl. 1), S123-S125. (Level VII)
12. McClave, S.A. and others. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill
patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN:
Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. doi:10.1177/0148607115621863 (Level VII)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports