What steps do you need to take in setting up for commencement of parenteral nutrition?

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A Complete Step-by-Step Guide To Administering TPN

Total parenteral nutrition (TPN) can be safe and easy to administer when you follow the instructions given by your doctor or healthcare nurse. This step-by-step guide is designed to assist patients on parenteral nutrition. By following these guidelines, you or your caregiver will know how to set up the TPN infusion and administer the bags at home. 

• Key Steps To Administering TPN
• Step 1: Maintain Aseptic Condition
• Step 2: Inspect and Warm the TPN Formula by Taking It Out of the Fridge and Letting the Bag Get to Room Temperature
• Step 3: Gather and Arrange TPN Supplies
• Step 4: Add Medications or Multivitamins Into the TPN Formula Bag
  • Step 4.1: Withdraw Medication/Multivitamins From Vial
  • Step 4.2: Add Medication to the TPN Bag
• Step 5: Prime IV Tubing Through Infusion Pump
• Step 6: Flush the Central Line With Saline Solution Prior to Infusion
• Step 7: Start the TPN Infusion Process
• Step 8: Disconnect the TPN Administration Setup
• Step 9: Post Flush the Central Line With Saline and Heparin
• Step 10: Secure the Central Line (Catheter)
• Step 11: Dispose of Used Supplies
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Key Steps To Administering TPN

Below are the key steps to administering TPN safely. Each step is covered in greater detail below. Make sure you follow each step carefully. In case of any unusual events during the TPN infusion process, call your healthcare nurse immediately to avoid severe complications.

1. Maintain Aseptic Condition
2. Inspect and Warm the TPN Formula by Taking It Out of the Fridge and Letting the Bag Get to Room Temperature 
3. Gather and Arrange TPN Supplies
4. Add Medications or Multivitamins Into the TPN Formula Bag
5. Prime IV Tubing Through Infusion Pump 
6. Flush the Central Line With Saline Solution Prior to Infusion 
7. Start the TPN Infusion Process
8. Disconnect the TPN Administration Setup 
9. Post Flush the Central Line with Saline and Heparin 
10. Secure the Central Line (Catheter)
11. Dispose of Used Supplies 

Step 1: Maintain Aseptic Condition

It is important to ensure a proper hygienic environment before starting TPN infusion. This is done to avoid the risk of microbial infections. 

1. Clean the TPN placement area with soap and water and dry it with a paper towel thoroughly. You can also use disinfectant to clean the surface of your TPN placement area.
2. Wash your hands for at least 30 seconds with antibacterial soap and dry them with a towel (see Figure 1).
   

   Figure 1

Step 2: Inspect and Warm the TPN Formula by Taking It Out of the Fridge and Letting the Bag Get to Room Temperature

Before mixing your prescribed medications or multivitamins into the TPN bag, inspect the TPN formula. Make sure it contains the prescribed solution with the correct dosage and is not expired. Moreover, ensure that your TPN solution is consistent in color. It should be free from cloudiness, visible fat particles, or crystals. If it is not, DO NOT use that bag and discard it immediately.

After inspecting the TPN bag, warm it to room temperature by following the steps below: 

1. Remove the TPN bag from the refrigerator, where it is typically stored between 36°F and 46°F. 
2. Place the TPN bag on a clean, dry paper towel and leave it for 2 to 3 hours until it reaches room temperature. Infusing cold TPN solution directly from the refrigerator can make you uncomfortable and cause chills and headaches. 
3. After the TPN formula reaches the desired room temperature, it is time to add the recommended medication mixture to your bag for infusion. 

Note: Do not try to warm the TPN formula faster by placing it in the oven, hot water, or microwave. 

Step 3: Gather and Arrange TPN Supplies

Gather all your TPN supplies and assemble them on the sterile surface. Make sure you have all the supplies required for TPN infusion. The list of TPN supplies mainly includes the following:

• Syringes (10 ml) with needles to draw medications from the vials and inject them into the TPN bag 
• Prescribed additives or multivitamins 
• A pair of medical gloves
• Antiseptic caps for closing catheter end
• IV tubing for pump administration set
• TPN infusion pump for administering TPN into your central line 
• Alcohol or antiseptic wipes to clean catheter or TPN bag injection port 
• Two saline (NaCl) and one heparin prefilled syringes to flush the central line
• Sharps container to discard supplies after using

Step 4: Add Medications or Multivitamins Into the TPN Formula Bag

Step 4.1: Withdraw Medication/Multivitamins From Vial

If your doctor has prescribed multivitamins (MVI), you will receive two vials, 1 blue top and 1 white top vial (equal to one dose). Each will be added to your TPN formula bag. Before using the multivitamins or other medication, check the label. The dose(s) should be correct and not expired.

1. Remove the protective cap of your multivitamins (MVI) vial.
2. Clean the top of the vial using alcohol or antiseptic wipes by wiping the exposed top one time and allowing it to dry for 10 seconds (see Figure 2). Use a separate antiseptic wipe for the second vial.
   

   Figure 2

3. Remove the syringe with the needle from the package and pull back the syringe’s plunger to draw air into it. Do not touch the body of the plunger with your hands. The air in the syringe should be the equivalent amount of medication to be drawn from the vials. For instance, if your healthcare provider prescribed taking 5 ml of multivitamins from the vial, draw 5 ml of air into the syringe first (see Figure 3).
   
   

   Figure 3

4. Insert the syringe needle into the center of the vial’s rubber stopper and push the air into the vial (see Figure 4).
   

   Figure 4

5. Turn the vial upside down and withdraw the solution from the vial into a syringe (see Figure 5). After that, carefully remove the needle from the vial.
   

   Figure 5

6. To expel air or air bubbles from the syringe, gently tap the syringe and firmly hold the syringe with the needle pointed upright. Carefully push the plunger upward while not allowing the fluid of active medication to be expelled. Do this until all air bubbles are removed. 
7. Cover the needle with a protective cap. 

Repeat the process for the second multivitamin vial (MVI) and other prescribed medications. 

Step 4.2: Add Medication to the TPN Bag

To inject the medication and multivitamins into the TPN bag, first, clean the injection port of your TPN formula bag with antiseptic wipes. Then allow it to dry for 10 seconds. Make sure the injection port does not make contact with other items.

1. Now insert the needle into the center of the injection port. Push in the syringe plunger at a slow and steady pace to instill all the medications into the TPN bag. The color of the TPN solution formula will change from white to yellow (see Figure 6). However, if the medication is colorless, the TPN solution color will not change.
   

   Figure 6

2. Remove the needle from the TPN bag and discard it in the sharps container. 
3. Gently rock the bag several times to mix the medication. 

Note: If you see any leaks in the TPN bag, DO NOT use that bag and repeat the insertion process from step 1 with a new TPN bag. Make sure the new TPN bag is at room temperature. 

Step 5: Prime IV Tubing Through Infusion Pump

Priming is a process of withdrawing the solution from the TPN bag via the pump and into the IV tube line. This is done to remove air from the IV tube line before attaching it to the patient. This process is important and prevents the air from going into your bloodstream and reduces the risk of air embolism (a condition in which air bubbles block the passage of blood). 

Most of the infusion pumps have an automatic prime feature in them. After attaching the IV tube to the TPN bag, you will only need to turn on that feature. 

1. Remove the IV tubing from its packaging and untie it. In your IV tubing, you will see two ends of different shapes. One round tube end will attach to your catheter, and the other end with a spike tip will be inserted into the spiking port of your TPN bag. 
2. To spike the TPN bag, remove the protective cover from the spike tip of the IV tubing. Ensure you don’t touch the tip; otherwise, your TPN solution formula will become contaminated. 
3. Remove the cap from the spike port of the TPN bag and insert the spike tip of IV tubing into the bag using a pushing twisting motion (see Figure 7).
   

   Figure 7

4. Put the batteries into the infusion pump and turn it on. 
5. Use your infusion rate sheet to check your TPN infusion settings and attach your IV tubing to the pump as instructed in the manual.
6. After that, select the “prime tubing” feature to begin priming your IV tubing. 
7. During priming, hold the filter on the tube upside down (with the flow downwards) to prevent air bubbles in your tubing (see Figure 8).
   

   Figure 8

8. The TPN fluid will travel downward from your TPN bag until your tubing is completely filled with fluid.
9. Once the priming process is complete, secure the other end of your IV tube by tightening the cap.

Step 6: Flush the Central Line With Saline Solution Prior to Infusion

Before administering TPN, it is important to flush the lumen of your catheter (central line). This is done to remove medication residues that may have been left during the last infusion and prevent the risk of blockage during your TPN infusion process. The saline solution is compatible with your body fluids and only consists of salt and water to clear the central line. 

1. Clean the injection cap of the catheter in a twisting motion by using an antiseptic wipe. Allow the cap to dry for 10 seconds. 
2. Hold the saline syringe straight with the cap pointing upward and push the plunger to remove air bubbles (see Figure 9). Then remove the cap and push out any remaining air.
   

   Figure 9

3. Using an alcohol pad, clean the injection cap of the catheter for 15 seconds, and let it air dry for 5 seconds.
4. Without touching the tip of the injection cap, insert the saline syringe into the center of the IV catheter cap (see Figure 10).
   

   Figure 10

5. Once inserted, push and twist the saline syringe clockwise to secure the connection and unclamp the IV extension of the catheter. 
6. Flush your central line with saline in a push and pause method as instructed by your nurse. In this method, you will first push the plunger and then pause for a second and push the plunger again until your central line is completely flushed (see Figure 11).
   

   Figure 11

7. Now clamp your central line and remove the syringe by holding the bottom of the injection cap (not the central line). Discard the syringe in the sharps container. 

Note: Do not use a lot of pressure during flushing. If you feel pain, burning, or swelling, stop the procedure immediately and contact your healthcare nurse. 

Step 7: Start the TPN Infusion Process

1. Scrub the injection cap of your IV catheter with an antiseptic wipe vigorously for 30 seconds and let it air dry for 10 seconds (see Figure 12).
   

   Figure 12

2. Now remove the protective cap for the end of the IV tubing and connect it with your catheter. Use a push and twisting motion to secure the connection (see Figure 13).
   Note: Be careful not to touch the top of the IV tubing.

   Figure 13

3. Now start the pump as instructed by your nurse. The pump will have a pre-programmed setting according to your infusion rate sheet. Make sure you check the setting every time before activating the pump.

If you are doing continuous TPN feeding, then this is a good time to start preparing your next TPN formula bag. To prepare your next bag, follow Step 2 (Inspect and Warm the TPN Formula) and Step 4 (Add Medications or Multivitamins Into the TPN Formula Bag). When it is time to change your bag,  repeat Step 5 (Prime IV Tubing) and Step 6 (Flush the Central Line With Saline Solution). 

If you need to pause the infusion for any reason, please follow the instructions in the pump guide. 

Step 8: Disconnect the TPN Administration Setup

Your pump will alert you once your TPN infusion process is complete. After receiving the alert, turn off the infusion pump, disconnect the IV tubing from the catheter, and proceed to step 9.

Step 9: Post Flush the Central Line With Saline and Heparin

Get a prefilled saline syringe and heparin syringe for flushing the central line after TPN infusion if you are doing cyclic feeding. First, flush the central line with saline and then with heparin (if ordered) by repeating the following steps:

1. Hold the saline syringe with the tip upright and gently push the plunger forward to expel air bubbles from the syringe. 
2. Now use a new antiseptic wipe to scrub the catheter injection cap and repeat steps 3 to 6 from Step 6: Flush the Central Line With Saline Solution Prior to Infusion. 
3. For a heparin flush, repeat the same steps you’ve followed for a saline flush. 

Step 10: Secure the Central Line (Catheter)

After the final flush, re-clamp your central line and use the antiseptic cap to cover the catheter’s injection port. You can also put your catheter in a small cloth bag so it does not freely hang around.

Step 11: Dispose of Used Supplies

Throw the syringes and needles into the sharps container.  Discard the TPN bag with IV tubing in a garbage bag. 

Consult your healthcare provider if:

• You feel fever, chills, or a headache
• There is leaking of fluids or blood from the catheter
• You are struggling to flush the catheter (central line) 
• You experience high blood pressure during TPN infusion
• There are other complications

Dr. Dara Bai Abacan, PharmD was born in Long Beach, CA. She graduated from Western University of Health Sciences in 2009, and has 13 years of experience as a pharmacist. After graduation, she worked at Walgreens Infusion Services (now Option Care), followed by Premier Infusion, where she was selected to be in charge of the specialty department. While at Premier Infusion, she learned about chronic therapies like IVIG, SCIG, and monoclonal antibodies. Later, she worked at KabaFusion, where she gained further clinical knowledge of IVIG and SCIG. Since joining AmeriPharma, she has developed expertise in many other therapies, including oncology and hepatitis. The most rewarding part of her job is talking to patients and providing excellent customer service and clinical information pertaining to their therapy. In her free time, she loves to practice meditation.

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