Clinical Experience With Three‐in‐One Admixtures Administered Peripherally

Abstract

The purpose of this report was to describe the tolerance of hyperosmolar nutritionally complete solutions infused peripherally, as a bridge to enteral therapy in the surgical patient. Solutions providing approximately 40% of calories as carbohydrates were administered to 23 surgical patients with the fats, amino acids, and dextrose mixed in one container. Final osmolarity, when measured directly with additives, ranged from 1200-1350 mOsm/L. Approximately 85% of the patients had acceptable tolerance to this new technique. The patient tolerance of the high osmolar admixture in peripheral veins might be attributed to the buffering and dilution effect of the IV fats in combination with the higher pH of the amino acid solutions and the addition of heparin to the admixture. Strong support for this technique was voiced by experienced nutritional support physicians and hospital personnel for use in surgical patients who have immediate short-term needs.

A.S.P.E.N. Clinical Guidelines

“…Dextrose and amino acids are significant contributors of solution osmolarity. Other factors that may influence the incidence of thrombophlebitis include addition of heparin, 31,32 addition of corticosteroid, 31 or the presence of fat emulsion when PPN is prepared as a TNA. [32][33][34][35] The coinfusion of intravenous fat emulsion (IVFE) has not been shown to reduce phlebitis.…”

“…Other factors that may influence the incidence of thrombophlebitis include addition of heparin, 31,32 addition of corticosteroid, 31 or the presence of fat emulsion when PPN is prepared as a TNA. [32][33][34][35] The coinfusion of intravenous fat emulsion (IVFE) has not been shown to reduce phlebitis. 36,37 All available studies that have evaluated peripheral vein thrombophlebitis with infusion of PPN are limited by small sample size.…”

Incidence of Adverse Events During Peripheral Administration of Sodium Chloride 3%

“…4,5 There are several studies describing adverse events in peripherally administered hyperosmolar parental nutrition; however, there are limited data regarding the safety of sodium chloride 3% via this route in an acute setting. [6][7][8][9][10][11][12][13][14] When specifically evaluating sodium chloride 3%, there is currently no published literature in the adult population. Retrospective studies in the pediatrics population have found that patients who received these infusions peripherally had no evidence of adverse events.…”

Prediction of Parenteral Nutrition Osmolarity by Digital Refractometry

“…[1][2][3] A PN formulation contains a mixture of hypertonic dextrose, amino acids, electrolytes, and vitamins, thereby resulting in hyperosmolar solutions. 4,5 The intravenous access site used for a given PN formulation is dictated by the osmolarity. High-osmolarity PN formulations infused into a peripheral vein will damage the vessel and require frequent changes of injection site.…”

“…[5][6][7] The risk of vascular damage increases when PN formulation osmolarity rises above 600 mOsm/L, and the peripheral vein cannot tolerate an osmolarity >900 mOsm/L. [5][6][7][8][9] Isaacs et al 6 reported that PN with an osmolarity of 900 mOsm/L infused infused via peripheral veins was rapidly stopped about 4 ± 3 hours at a particular site because of local phlebitis reactions consisting of pain, erythema, swelling, or heating. Timmer et al 7 demonstrated that a PN osmolarity of 1,044 mOsm/L may induce a 91% phlebitis rate after 2.8 days of peripheral venous feeding.…”