Hi,
I was wondering if someone from INS is working through ASPEN to see that someday they change their reference point regarding acceptable PPN osmolality being 900. I am battling that in my organization again. I find that the ASPEN guidelines refer toa study from 1977 regarding this matter. I have pulled more recent data and presented but .... don't you think we should be pushing ASPEN on this issue a little more?
The Infusion Nursing Standards of Practice are in the revisions process now. One organization can not pressure another organization to change their position on anything. We are making a careful examination of all types of evidence for this revision and will be assessing all information from ASPEN. Can you tell me what document from ASPEN that you are looking at to find this 900 mOsm? 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
If I am not mistaken ASPEN is not a believer of PPN. PPN was only invented due to lack of central lines. It was invented by pharmacists to be able to give nutrition periperally. I guess your patients half eat since they are half fed. That is the bigger issue not the osmolarity. It is going to TPN for better patient outcome
Kathy Kokotis RN BS MBA
BArd Access Systems
Kathy,
I think you need to check ASPEN's guidelines. Nowhere does it say they do not believe in it. Our patients are not half fed either. The indication for PPN is pretty rare these day but some patients can still benefit.
Lynn, Let me go back and look it up so I can site the page etc for you....
Jose Delp RN BSN
CliClinical Nurse Manager IV Team
Upper Chesapeake Health
Below is from Seton Hospital Newsletter from August 2009 - This is the MD's policy on giving outdated PPN. Your pharmacist may find their policy of value. It seems a patient must half eat as there are very strict guidelines on PPN from ASPEN such as mild malnutrition.
A message from Seton’s Clinical Nutrition
Department and the Nutrition Advisory Committee
The Nutrition Advisory Committee has reviewed the usage of Adult Peripheral Parenteral Nutrition in the Seton
network and found that PPN is often started without appropriate ACOG/ ASPEN criteria. Often a patient receives
inadequate nutrition because he or she cannot tolerate adequate rates of PPN. In an effort to improve patient safety,
there will be a nutrition consult when PPN is ordered. The physician will then be called by the dietitian before the PPN is filled by pharmacy.
PPN is only recommended by ASPEN if a patient has:
PPN may NOT be the safest practice for the patient. Insertion of a PICC and TPN may be more appropriate.• Good PIV access.
• Needs at least five days and no more
than two weeks of partial or total PN.• Can tolerate 2.5-3 liters fluid/day.
• Does not need large amounts of
nutrients or electrolytes.• Has only mild malnutrition.
In the info posted, there is something missing from this post. This is from my network of hospitals. See the BOLD part.
Gwen Irwin
Seton Family of Hospitals (this is our new name)
Austin, Texas
PPN may NOT be the safest practice for the patient. Insertion of a PICC and TPN may be more appropriate.
PPN is only recommended by ASPEN if a patient has:
• Good PIV access.
• Needs at least five days and no more
than two weeks of partial or total PN.
• Can tolerate 2.5-3 liters fluid/day.
• Does not need large amounts of
nutrients or electrolytes.
• Has only mild malnutrition.
I am not saying that we use PPN inappropriately. I understand the indications. I am questioning why the
2009 ASPEN Parneteral Nutrition Hanbook page 72: discusses 900 mOm/l as the approximate maximum osmolality tolerated by a peripheral vein, with the 2004 referemce #9
That reference see page S65 3rd paragraph on the right, with reference #8 on page S70 ---- This references American Journal of Clinical Nutrition article, 1977.
The ASPEN Nutrition Support Core Curriculum 2007, pg 283, discusses mOsm/l stating "Omolality should generally be kept below 900 mOm/l...." again referencing the 1977 article in AJCN.
I am wondering if we could get that reference updated to reflect lower osmo as acceptable, so that it is in line with the INS standards. Their references could use an update?
The use and abuse of PPN is going to be there in some small way and we can continue as clinicians to fight that and win. Right!?!
Jose Delp RN BSN
CliClinical Nurse Manager IV Team
Upper Chesapeake Health
Here is what I have. At least it is more recent than 1977, although these are animal studies.
1. Kuwahara T, Asanami S, Kawauchi Y, Kubo S. Experimental infusion phlebitis: Tolerance pH of peripheral veins. Journal of Toxicology Science. 1999;24(2):113-121.
2. Kuwahara T, Asanami S, Kubo S. Experimental infusion phlebitis: Tolerance osmolality of peripheral venous endothelial cells. Nutrition. 1998;14(6):496-501.
3. Kuwahara T, Asanami S, Tamura T, Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: An experimental study in rabbits. Nutrition. 1998;14(2):186-190.
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
Thanks Lynn!
Jose Delp RN BSN
CliClinical Nurse Manager IV Team
Upper Chesapeake Health