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

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. Gather Supplies
2. Hand Hygiene & Surface Preparation
3. Inspect TPN bag
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. Flush Your IV Line with Saline, Followed by Heparin
10. If You Are Not Connecting Another TPN bag, Secure Your IV Line Injection Port With Alcohol Cap (or Curos)
11. Dispose of Used Supplies 

Step 1: Gather Supplies

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

• TPN Prep Mat
• TPN Bag
• One 10 ml syringe, and one needle. You may need additional syringes/needles if you are adding multiple additives to the TPN bag
• Prescribed additives or multivitamins 
• Curos cap(s) to secure your IV injection site when not in use
• IV administration tubing (Curlin tube set)
• Infusion pump (Curlin pump)
• 2 “C” batteries
• Alcohol pads 
• Two saline (sodium chloride 0.9%) and one heparin prefilled syringes to flush the central line
• Sharps container to discard supplies after using

Step 2: Hand Hygiene & Surface Preparation

It is important to ensure proper hand hygiene and a clean work surface before preparing your TPN infusion. This is done to avoid introducing germs or an infection.  

1. Clean the TPN placement area with alcohol pads or a disinfectant wipe.  Allow time for it to dry.  Ideally, you should use a TPN mat for your placement area, or use one of the sterile drapes that was sent to you.
2. Wash your hands thoroughly using antibacterial soap and warm water (see Figure 1) or alcohol-based hand sanitizer if no soap is available. Proper hand washing should last for at least 30 seconds and then dried with a paper towel or clean hand towel.
   
   

   Figure 1

Step 3: Inspect TPN Bag

Before mixing your prescribed medications or multivitamins into the TPN bag, inspect the TPN formula.

• Verify your TPN bag has your name on it.
• Verify that the expiration date is current and not expired.
• Ensure that your TPN solution is consistent in color. It should be free from cloudiness, visible fat particles, or crystals.
• Ensure the TPN bag is at room temperature. Remove TPN bag from the refrigerator 2 to 3 hours prior to your next TPN cycle. Infusing cold TPN solution directly from the refrigerator can make you uncomfortable and cause chills and headache.

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

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 for directions, dose and expiry date.

1. Lay the TPN bag on your work surface with the ports hanging off of the table.
2. Remove the protective cap of your multivitamins (MVI) vial.
3. Clean the top of the vial using an alcohol pad by wiping the exposed top one time for at least 15 seconds and allowing it to dry for 10 seconds (see Figure 2). Use a separate alcohol pad for the second vial.
   
   

   Figure 2

   Open the syringe package by holding the peel tabs, and peel them back to expose the barrel (Figure 3). Using the same concept, peel back the tabs of a needle package, only enough to expose the hub of the needle (Figure 4). Hold the Syringe from the barrel in one hand, and attach it to the partially-exposed needle hub as shown in Figure 5. This will reduce the likelihood of touch contamination. It will also reduce the potential for contamination of the fluid path.
   
   

4. Remove the cap from the needle.
5. Without touching the body of the plunger with your hands, pull back the syringe’s plunger to draw air into it.
   
   The air in the syringe should be the equivalent amount of multivitamins 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 6).
   
   

   Figure 6

6. Insert the syringe needle into the center of the vial’s rubber stopper and push the air into the vial (see Figure 7).
   
   

   Figure 7

7. Turn the vial upside down and withdraw the solution from the vial into a syringe (see Figure 8). After that, carefully remove the needle from the vial. 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 any of the multivitamins to come out of the end of the needle. Do this until all air bubbles are removed.
   
   

   Figure 8

8. Using the same syringe, repeat the process for the second multivitamin vial (MVI) and other prescribed medications, such as thiamin, folic acid, or famotidine.

Step 4.2: Add Medication to the TPN Bag

To inject the multivitamins or other medications into the TPN bag, first, clean the injection port of your TPN formula bag with alcohol pads. 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 9). However, if the medication is colorless, the TPN solution color will not change.
   
   

   Figure 9

2. Remove the needle from the TPN bag and discard the needle in the sharps container. 
3. Gently rock the bag several times to mix the vitamins and other medications with the TPN solution. 

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 10).
   
   

   Figure 10

4. Remove the cap from the other end of the IV tubing.
5. Hold the bag up, and let the TPN solution flow through the tube until you see a few drops come out of the other end, then place the end cap back on.
6. Put the batteries into the infusion pump and turn it on. 
7. Use your infusion rate sheet to check your TPN infusion settings, then load the IV tubing to the pump as instructed in the manual.
8. After that, select the “prime tubing” feature to begin priming your IV tubing. 
9. During priming, hold the filter on the tube upside down (with the flow downwards) to prevent air bubbles in your tubing (see Figure 11).
   
   

   Figure 11

10. The TPN fluid will travel downward from your TPN bag until your tubing is completely filled with fluid.
11. Once the priming process is complete, secure the other end of the IV tube by tightening the end 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 your IV catheter using an alcohol pad. Vigorously wipe it in a twisting motion for 30 seconds. Then, allow the cap to dry for 10 seconds. 
2. Hold the saline syringe straight with the cover cap pointing upward and push the plunger to remove air bubbles (see Figure 12). Then remove the cap and push out any remaining air.
   
   

   Figure 12

3. Without touching the tip of the injection cap, insert the saline syringe into the center of the IV catheter cap (see Figure 13).
   
   

   Figure 13

4. Once inserted, push and twist the saline syringe clockwise to secure the connection and unclamp the IV extension of the catheter. 
5. 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 14).
   
   

   Figure 14

6. 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. Again, scrub the injection cap of your IV catheter with an alcohol pad vigorously for 30 seconds and let it air dry for 10 seconds (see Figure 15).
   
   

   Figure 15

2. Now remove the protective cap at the end of the IV tubing and connect it to your catheter. Use a push and twisting motion to secure the connection (see Figure 16).
   Note: Be careful not to touch the top of the IV tubing.
   
   

   Figure 16

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 3 (Inspect TPN Bag) 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. 

• Your pump will show the alarm, “infusion complete,” and go into KVO (keep vein open) mode. 
• Press the “RUN/PAUSE” button. Pump will read “REPEAT RX” AND “NEW PROGRAM”. Press “ON/OFF” button to power down your pump. 
• Disconnect the TPN IV tubing from the catheter.
• Scrub the IV cap with alcohol for at least 15 seconds. 

Step 9: Post Flush the Central Line With Saline, Followed by 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 as described in Step 6. 
2. Now use a new alcohol pad 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: If You Are Not Connecting Another TPN bag, Secure Your IV Line Injection Port With Alcohol Cap (or Curos)

After the final flush, re-clamp your central line and clean with the alcohol pad, then put a green Curos cap to cover the injection cap. You can also put your catheter in a stockinette or small cloth sleeve so it does not freely hang around.

Step 11: Dispose of Used Supplies

Throw the needles into the sharps container.  Discard the TPN bag with IV tubing, and syringe in a garbage bag. Change the batteries in the curlin pump.

Seek medical attention immediately if:

• You experience a break in the catheter line
• If you experience leaking in the catheter
• If you have a temperature greater than 100.4 degrees
• If you experience chest pain
• If you experience sudden shortness of breath or increased shortness of breath

If your catheter is leaking, use your dravon clamp and go to the ER.

Consult your healthcare provider:

• If you have a temperature greater than 100.4 degrees 
• If your catheter is broken
• If you are struggling to flush the catheter (central line) 
• If you experience high blood pressure during TPN infusion
• If there is a new onset of headache or migraine
• If there are other complications

Consult your pharmacist

A TPN (Total Parenteral Nutrition) patient should consult their pharmacist if they have any queries or need any assistance regarding any aspect of their TPN therapy.

Specifically, TPN patients should consult their pharmacist if they experience any of the following:

1. Problems with the administration or infusion of their TPN medication (including pump issues)
2. Concerns regarding the compatibility or interactions of their TPN medication with other medications or supplements
3. Adverse effects or allergic reactions to the TPN medication or ingredients
4. Changes in the dosage or duration of their TPN therapy
5. Any adverse changes in lab values or monitoring parameters associated with their TPN therapy
6. Any upcoming healthcare changes like surgery or medication shifts that could affect their TPN therapy
7. Inquiries related to the storage, handling, or disposal of TPN medications and equipment
8. Need clarification of instruction regarding administration of medication
9. Consultation on medication management, refill, or any insurance-related queries

The pharmacist is the medication expert on the healthcare team. They can provide dosage recommendations, compatibility knowledge and monitoring assistance, and guidance on nutrition management. Therefore, TPN patients can receive invaluable assistance by consulting the pharmacist in various aspects of their therapy management.