List of meds that must go centrally

[pharmacy7424]

1) Concentrated KCl
2) 3% NaCl
3) TPN

Please help add to this list

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[PharmDstudent]

concentrated KPhos

 

[sakigt]

Hardly anything "must" be given centrally in an emergency....

Up on the floor, yeah, those. Plus calcium chloride, pressors, most chemo? and like the above mentioned, not all TPNs have to go centrally....

 

[fauxden]

i thought you meant mail order....

 

[njac]

Vasopressors should, but not must, go centrally.

 

[pharmacy7424]

bump

 

[PharmDstudent]

Some tpn can go peripherally.

TPN vs PPN

 

[Promethean]

Partial parenteral nutrition rather than total parenteral nutrition.

Most anything CAN go peripherally... it just carries much higher risks/side effects when administered that way. But "in ideal circumstances, really should be given" takes more words than "must go." I think OP's point is pretty clear.

 

[Sparda29]

For TPNs, we based the central vs peripheral on the dextrose concentration. I believe anything higher than D10 was given centrally.

 

[KidPharmD]

Partial parenteral nutrition rather than total parenteral nutrition.

Most anything CAN go peripherally... it just carries much higher risks/side effects when administered that way. But "in ideal circumstances, really should be given" takes more words than "must go." I think OP's point is pretty clear.

I can easily give "TPN" in a peripheral line. We do it every day. The things that limit you are K/Ca concentration and total osmolarity. You can pretty easily give D12.5 and 3g/kg or protein to a neonate in a peripheral line provided you have a reasonably low sodium load. Lipids have actually been shown to prolong the life or a PIV, so no problem there either.

 

[Promethean]

I can easily give "TPN" in a peripheral line. We do it every day. The things that limit you are K/Ca concentration and total osmolarity. You can pretty easily give D12.5 and 3g/kg or protein to a neonate in a peripheral line provided you have a reasonably low sodium load. Lipids have actually been shown to prolong the life or a PIV, so no problem there either.

Again, you point out what CAN be done. It is possible to modify the infusion, as you do, to accommodate the parameters imposed by the route. That is good pharmacy.

What more commonly IS done is that the people who are to administer the drugs (nurses, usually) are given hard and fast rules about what must not be given peripherally because they don't have the pharmaceutical knowledge to know when modifications of this type have been made. When there is a disconnect between medication preparation and medication administration, such that the person pushing the drug has only a label and a policy to guide their actions, adhering to those policies makes good sense.

The situation that is avoided by always using a central line for TPN is one where nursing staff become accustomed to the idea that they can use peripheral lines because they have been working closely with a pharmacist who has been preparing limited K/Ca/total osmolarity solutions for their patients. Then they rotate out of the NICU and give a solution that hasn't been made to those specifications through a 24 gauge in the hand somewhere.

I'm not arguing with you. It sounds as if you must have a great working relationship with the folks who administer your drugs. I wish that I could tell you that was the situation in every facility. If it were, we would be able to talk about how to modify therapy to fit the route available, instead of talking about what routes a given therapy is restricted to.

 

[PharmDstudent]

For TPNs, we based the central vs peripheral on the dextrose concentration. I believe anything higher than D10 was given centrally.

basically

 

[KidPharmD]

Again, you point out what CAN be done. It is possible to modify the infusion, as you do, to accommodate the parameters imposed by the route. That is good pharmacy.

What more commonly IS done is that the people who are to administer the drugs (nurses, usually) are given hard and fast rules about what must not be given peripherally because they don't have the pharmaceutical knowledge to know when modifications of this type have been made. When there is a disconnect between medication preparation and medication administration, such that the person pushing the drug has only a label and a policy to guide their actions, adhering to those policies makes good sense.

The situation that is avoided by always using a central line for TPN is one where nursing staff become accustomed to the idea that they can use peripheral lines because they have been working closely with a pharmacist who has been preparing limited K/Ca/total osmolarity solutions for their patients. Then they rotate out of the NICU and give a solution that hasn't been made to those specifications through a 24 gauge in the hand somewhere.

I'm not arguing with you. It sounds as if you must have a great working relationship with the folks who administer your drugs. I wish that I could tell you that was the situation in every facility. If it were, we would be able to talk about how to modify therapy to fit the route available, instead of talking about what routes a given therapy is restricted to.

Just for clarity... What it is in a TPN that is not in a PPN?

We don't actually designate them differently. Our labels either say "For central administration ONLY" or "For Central or Peripheral administration" but that line is based on Osmolarity/K/Ca content.

 

[Promethean]

Just for clarity... What it is in a TPN that is not in a PPN?

We don't actually designate them differently. Our labels either say "For central administration ONLY" or "For Central or Peripheral administration" but that line is based on Osmolarity/K/Ca content.

TPN is total parenteral nutrition, so lipids, amino acids, dextrose, and all the other necessary nutrients that a patient may require. This is given to patients who require long term nutritional support and is generally more complex. Used if the patient can't take any nutrition by mouth or can't possibly absorb everything they need that way (short gut, malabsorption etc.) for an extended period of time.

PPN, or partial parenteral nutrition may just be moderate concentration dextrose, maybe some intralipid. This is mostly just caloric support for a patient who may only require short term supplementation, or who can eat but has high short term needs that aren't being met by diet. I've heard intralipid alone or dextrose alone referred to as PPN.

At a certain point, hairs are split. I was just responding to the inquiry about what PPN stood for and describing the distinctions as I have heard them defined by others. I am not advocating any position on how a pharmacist ought to indicate that any solution be given. That quickly exceeds my depth.

 

[Dred Pirate]

For TPNs, we based the central vs peripheral on the dextrose concentration. I believe anything higher than D10 was given centrally.

is has to do with the overall osmolarity - something around 950 depending on institutional specifics

 

[KidPharmD]

TPN is total parenteral nutrition, so lipids, amino acids, dextrose, and all the other necessary nutrients that a patient may require. This is given to patients who require long term nutritional support and is generally more complex. Used if the patient can't take any nutrition by mouth or can't possibly absorb everything they need that way (short gut, malabsorption etc.) for an extended period of time.

PPN, or partial parenteral nutrition may just be moderate concentration dextrose, maybe some intralipid. This is mostly just caloric support for a patient who may only require short term supplementation, or who can eat but has high short term needs that aren't being met by diet. I've heard intralipid alone or dextrose alone referred to as PPN.

At a certain point, hairs are split. I was just responding to the inquiry about what PPN stood for and describing the distinctions as I have heard them defined by others. I am not advocating any position on how a pharmacist ought to indicate that any solution be given. That quickly exceeds my depth.

Thanks for your perspective. In that case our institution simply does not do PPN unless you include dextrose containing clear fluids. Protein is the most important thing for many of our patients, and we would never leave it out. Our doctors like to use the term PPN, but they don't really know what it means (though I am not sure there is an agreement on what it means).