Preparing to Administer Parenteral Nutrition (PN)

These instructions are for Children's Hospital of Philadelphia (CHOP) patients going home on intravenous (IV) nutrition, also known as parenteral nutrition (PN).

Important information before you go home:

• Parenteral nutrition is given to your child using infusion pumps. There are several types of infusion pumps.

• Your home infusion company and infusion nurses will teach you about the pump that you will be using at home. This training occurs on your first day home from the hospital. Your child may need 1 or 2 infusion pumps to give the PN.

• You will receive a PN backpack. You may get an IV pole to hang the backpack and PN.

• There are some general rules to follow no matter which type or number of pumps you will be using.

Instructions for storing and checking supplies:

• PN and supplies will be shipped to your home weekly. You should always have at least 1-2 days of PN bags at home on PN delivery day. This means you will not run out of PN if a delivery is delayed due to weather or other issues.

• Store PN bags and medicines in the refrigerator.

• Do not stack more than 3 PN bags. The weight could cause the bags to break.

• Rotate your PN stock and choose the PN bag with the oldest expiration date.

• Remove the solution at least 4-6 hours before your child is due to start their PN or follow your pharmacy's instructions.

• Do not use any PN bag that has particles, looks separated, or has fatty oil droplets.

• Confirm bag(s) have your child's name and date of birth. Review the label for accuracy.

• Check expiration dates for all supplies. Use the oldest supplies first.

• Your infusion pharmacist will call you each week to review needed supplies. Let your infusion pharmacist know if you have thrown out a PN bag for any reason (for example, expired, leaking, questionable appearance, concern that bag is contaminated).

Instructions for cleaning:

1. Clean your hands before gathering the supplies. Liquid soap is preferred. Dry hands with a paper towel. Bar soaps and cloth towels can hold germs.

2. Close the door to the room if able. Turn off overhead fans or window units. Secure any pets away from your preparation area.

3. Wipe your surface well with an antibacterial cleanser before laying supplies down.

4. Try to lay supplies down in order of use. Do not assume outside packaging is clean. Remove saline and heparin flushes from their wrappers.

5. Have a "time out" before you start PN preparation and line accessing. Double check that you have all supplies. This includes a timer to use when cleaning, extra alcohol wipes, and hand sanitizer.

6. Always clean hands again with hand sanitizer right before starting care on your child's central line.

Instructions for adding tubing to PN bags:

1. Clean your hands with soap and water or hand sanitizer.

2. Follow instructions for medicine preparation and injection, if needed.

3. Remove the clear plastic twist tab from the spike port of the PN bag.

4. Select appropriate IV tubing and remove the protective cover over the spike on the IV set. Do not let anything touch the end of the spike.

   • Use tubing with a 1.2 micron filter for white bags (lipids) and TNA bags (3 in 1).

   • Use tubing with 0.22 micron filter for clear bags (Amino Acid/Dextrose).

5. Y-connector, also called a bi-fuse, will be provided if two pumps are needed to give the PN.

   Insert the spike into the PN bag and push the spike in as far as it will go.

6. You are now ready to prime the tubing using your pump.

7. You will be provided Y-connectors if you need 2 pumps to give the PN. A Y-connector is also called a bi-fuse. Call the CHOP team managing your home PN if you get a bi-fuse that does not have the needleless caps permanently attached like the photo below.

8. Change disposable IV sets, tubing, bi-fuse, and filters daily.

Instructions for connecting PN to your child's central line:

1. Make sure hands have been cleaned.

2. Gather your supplies:

   • Hand sanitizer

   • Timer

   • Alcohol pads or Site-Scrubs®

   • Saline flush

   • Prepared PN bag and tubing

   • Protective barrier if this applies to your child

   • Dressing reinforcement or central line securement devices may also be needed

     * Follow instructions for ethanol, antibiotic, or other lock therapy if this applies to your child's regimen.

3. Make sure your infusion pump is working properly. Complete the pump system check as taught by your home infusion nurse. Do this before you connect the primed IV tubing to your child's central line.

4. Clean your hands with hand sanitizer. This is in addition to hand washing done before gathering supplies.

5. Perform a visual check of the line:

   • Check that the dressing is intact.

   • Check that the central line exit site and length of line looks unchanged.

   • Look for any soiling of the dressing or needleless cap (for example, MicroClave®) on the end of the central line.

   • Reinforce dressing if appropriate.

   • Do not flush into a needleless cap that is wet or soiled with body fluids.

   • Call your infusion company to discuss concerns about the needleless cap, the central line, or if a dressing change is needed.

6. Scrub the needleless cap of your child's central line with an alcohol pad or Site-Scrub® for 15 seconds and let it dry for 15 seconds. Do not blow or fan the needleless cap. If anything touches the cap, you must clean again.

7. Twist the end of the IV tubing (white) to the right to connect tubing to the needleless cap (blue).

   Flush the line with a saline syringe, using push-pause method as you were previously taught. Remove the syringe.

   • Your PN team will review with you when and if checking for blood return is appropriate.

8. Scrub the needleless cap with an alcohol pad or Site-Scrub® for 15 seconds and let it dry for 15 seconds. Do not blow or fan the needless cap. If anything touches the cap, you must clean again.

9. Remove the sterile cover on the end of the IV tubing. Twist the end of the IV tubing to the right to connect tubing to the needleless cap. Do not twist the central line.

10. Starting nearest to your child, unclamp any line or tubing clamps. Check that all connections are snug. Start PN pump(s).

11. Valguard®

    You will need to apply a protective barrier (like ValGuard®, Parafilm® or other product provided by your infusion company) to cover all tubing connections if your child:

    • Wears a diaper or has accidents overnight.

    • Occasionally vomits or spits up.

    • Has a feeding tube or ostomy. Call the team managing your home PN if you have not been shown how to apply this, do not have this item, or have questions.

12. Use a velcro device to secure IV tubing to your child's clothing. Secure so that tubing does not pull on your child's central line or drag on the floor. Check that your child will not be sitting on any metal clips.

    Example of velcro device securing IV tubing to clothing.
13. Example of Grip-lok® used to secure connections away from G-tube.

    Secure any connections away from areas at risk for soiling like diaper area, ostomy, or feeding tube. The device that you will use will depend on the type of central line your child has. Some families purchase vests or cloth covers for additional protection and security.

14. Before you leave your child, double check that each pump is running.

15. Check that each bag is infusing on the correct pump if you have 2 bags and 2 pumps.

16. Contact your home infusion company immediately if your pump is not running or is alarming.

Instructions for disconnecting PN once the infusion is complete:

1. Clean your hands and follow cleaning instructions above.

2. Gather your supplies:

   • Hand sanitizer

   • Timer

   • Alcohol pads or Site-Scrubs®

   • Saline and heparin flushes (or appropriate lock medicine)

   • Protective alcohol caps

   • Protective barrier if this applies to your child

   • Dressing reinforcement or central line securement devices may also be needed

3. Turn off the infusion pump(s) and close all clamps.

4. Clean your hands with soap and water or hand sanitizer again.

5. Perform a visual check of the line. Reinforce dressing if needed. Call your infusion company if a dressing change is needed and to discuss any concerns about the line or needleless cap.

6. Remove any protective barriers.

7. Disconnect the IV tubing from the needleless cap by twisting it to the left:

   • Use one hand to secure the line and hold the needleless cap where it meets the central line. This helps to prevent accidentally unscrewing the needleless cap while removing the IV tubing.

8. Be sure to unhook the tubing from your child's clothing and set it aside to be disposed.

9. Scrub the needleless cap with an alcohol pad or Site-Scrub® for 15 seconds and allow to dry for 15 seconds. Do not blow or fan the needleless cap. If anything touches the cap, you must clean again.

10. Examples of different brands of alcohol-containing protective caps that you may see at home.

    Flush your child's central line with a normal saline syringe using push-pause method.

11. Scrub the needleless cap with an alcohol pad or Site-Scrub® for 15 seconds and allow to dry for 15 seconds. Do not blow or fan the needleless cap. If anything touches the cap, you must clean again.

12. Place prescribed lock therapy, or flush your child's central line with heparin, as ordered by your team.

13. Place protective alcohol cap. Example: in the hospital we use DualCaps®

14. Clean line and apply protective barrier (like ValGuard) as you were shown if this applies to your child.

15. Secure any connections away from areas at risk for soiling like diaper area, ostomy, or feeding tube. The device that you will use will depend on the type of central line your child has. Some families purchase vests or cloth covers for additional protection and security.

    Example of Grip-lok® used to secure connections away from G-tube.

Home Parenteral Nutrition Program Contact Information

Reviewed on April 1, 2022, by Jean Abraitis, BSN, RN