Biffi - NP centrale vs. periferica

SCELTA TRA VIA CENTRALE

E PERIFERICA:

OSMOLARITA’, pH

E COS’ALTRO?

Prof. Roberto Biffi

Divisione Chirurgia Addomino-Pelvica

Istituto Europeo di Oncologia - Milano

SIMPOSIO SINPE-GAVeCeLT

NUOVE PROSPETTIVE DELLA NUTRIZIONE

PARENTERALE PERIFERICA E CENTRALE

European Institute

European Institute

of Oncology

Journal of Intravenous Nursing, Vol. 23, No. 6S, November / December 2000,

pages S69 - S70

References

BMA and RPS (2003)

British national formulary. London. (III)

GUIDELINES (III)

GUIDELINES (IV)

References

Halderman, F. (2000). Selecting a vascular access device.

GUIDELINES (IV)

References

Halderman, F. (2000). Selecting a vascular access device.

GUIDELINES (V)

Infusate criteria for therapeutic agents (drugs, fluid loss

replacement…) administered via a peripheral access:

Infusate criteria for parenteral nutrition

administered via a peripheral access:

Criteria

Author

Osmolarity < 800 mOsm/l

ASPEN

Criteria

Author

Ph between 5 and 9

AVA

EXPERIMENTAL INFUSION PHLEBITIS

Animal model designed to evaluate the impact of solution infusion on

endothelial cells and venous vessels

Solutions with known osmolality (mOsm/l), pH and titrable acidity

(mEq/l) are infused in ear veins of rabbits with the smallest

commercial peripheral venous catheters available. Infusion duration

and infusion rates can be adjusted depending on the experimental plan.

Table taken from: Kuwahara T., Asanami S., Kubo S. Experimental Infusion Phlebitis: Tolerance Osmolality of

Peripheral Venous Endothelial Cells. Nutrition Vol. 14, No. 6, 1998

EXPERIMENTAL INFUSION PHLEBITIS

Osmolality (I)

Adapted from:

Bachiller C., Tovar JA., Díez-Pardo JA., Lassaletta L., Nistal N., Monereo J.

Effects of parenteral nutrition solutions on the venous walls (an experimental study) [Article in Spanish].

An Esp Pediatr. (1978) 11(1):5-12.

Solution

A

B

B + Lipids

Lipid solution

Dextrose

12

12

15.83

15.83

15.83

0

Aminoacids

1.25

1.25

2.08

2.08

2.08

0

Na, Cl, K and PO

1.5

1.5

2.5

2.5

2.5

0

Ca, Mg

1.5

1.5

0.2

0.2

0.2

0

Lipids

0

0

0

0

4

0

Osmolality

930

930

1600

1600

1280

317

pH

6.9

6.9

6.7

6.7

6.7

6.7

Duration of infusion

6

12

6

12

6

6

Cumulated grade of histopathologic

findings after solution AG 814

(pH: 6.89, Titrable acidity: 5.6 mEq/l,

Osmolality: 814 mOsm/Kg) infusion for

24, 12, or 8 hours.

EXPERIMENTAL INFUSION PHLEBITIS

Osmolality (II)

Table and graph taken from:

Kuwahara T., Asanami S., Kubo S.

Experimental Infusion Phlebitis: Tolerance Osmolality of Peripheral Venous Endothelial Cells.

Nutrition Vol. 14, No. 6, 1998

These results suggest that the tolerance

osmolality of peripheral venous endothelial

cells with poor blood flow is about 820

EXPERIMENTAL INFUSION PHLEBITIS

Osmolality (III)

This study aimed to determine the osmolality that peripheral venous endothelial

cells can tolerate and to clarify the relationship between tolerance osmolality and

duration of infusion. [...]

In conclusion hypertonic solutions should be infused at as high a rate as is

clinically acceptable and compatible with nutrient bioavailability because

increasing the infusion rate reduces the duration of infusion and phlebitis.

Proximal region of vein after 8 h infusion at 15 mL • kg-1_{• h}-1

with 3% amino acid / 7.5% glucose solution AG814. No changes are observed.

Endothelial cells are lining over the whole venous wall; small dense humps (arrow) are nuclei of venous endothelial cells.

Proximal region of vein after 24 h infusion at 5 mL • kg-1_{• h}-1

AG 814. No nuclei of venous endothelial cells are observed (loss of venous endothelial cells) on the right venous wall, although some nuclei of endothelial cells are observed as small dense humps (thick arrow) on the upper venous wall. Some inflammatory cells (thin arrow) are observed in the right venous wall, and perivascular edema (*) is also observed.

EXPERIMENTAL INFUSION PHLEBITIS

Osmolality (IV)

Pictures taken from:

Kuwahara T., Asanami S., Kubo S.

Experimental Infusion

Phlebitis: Tolerance Osmolality of Peripheral Venous

Endothelial Cells.

Table taken from:

Kuwahara T., Asanami S., Kubo S.

Experimental Infusion

Phlebitis: Tolerance Osmolality of Peripheral Venous

Endothelial Cells.

Nutrition Vol. 14, No. 6, 1998

EXPERIMENTAL INFUSION PHLEBITIS

Osmolality and Dilution

Graphs taken from:

Kuwahara T., Asanami S., Tamura T., Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: an experimental study in rabbits.

Table and graph taken from:

Kuwahara T., Asanami S., Tamura T. Kubo S. Experimental infusion phlebitis: importance of titratable acidity on phlebitic potential of infusion solution.

Clinical Nutrition (1996) 15:129-132

CLINICAL DATA

Osmolality (I)

The study shows that, with most patients, it is possible to give TPN (Total

Parenteral Nutrition)

with an osmolality around 1100 mOsm/Kg for up to 10

days

via peripheral veins.

Hoffmann E. A randomised study of central venous versus peripheral intravenous nutrition in the perioperative period.

Clinical Nutrition (1989) 8(4):179 - 180 Device Peripheral Venous Cathether Central Venous Cathether N. pts 30 30 Complications 11 (37%) 0 General inconvenience 4 0 Transient pain in infusion arm

(NO phlebitis signs)

7 0

No complications 19 (63%) 30

Patients: 60 pts. undergoing surgery for colo-rectal

cancer (randomized groups)

CLINICAL DATA

Osmolality (II)

Timmer JG., Schipper HG. Peripheral venous nutrition: the equal relevance of volume load and osmolarity in relation to phlebitis. Clinical Nutrition (1991) 10(2):71 - 75

Patient assignment: at least 30 pts.

received solutions Type I - IV.

Type V solution administered to 11

pts.only (unacceptably high phlebitis rate).

Solution Type I Type II Type III Type IV Type V

Osmolarity (mOsm/l) 829 842 860 790 1044 Volume (ml) 2425 2525 2775 3025 2580 Energy content (Kcal) 1570 1800 1800 1800 2000 N content (g) 9.5 9.5 13.5 13.5 13.5

Solutions: Type I - V (see table)

All solutions prepared as “all-in-one bags”

with standard amounts of electrolytes,

vitamines, trace elements and heparin

(1.000 EI/l).

Solution

Type I

Type II

Type III

Type IV

Type V

Phlebitis

rate

4%

12%

24%

27%

> 90%

Phlebitis

rate

14%

37%

55%

73%

N/A

CLINICAL DATA

Osmolality (III)

Solution _osmolality“High” _osmolality“Low” Osmolality (mOsm/l) 1700 1200 Energy Content 2000 2000 Nitrogen (g) 12 12 Patients 19 20 Mean Age (Range) 56.1 (27 – 83) 55.6 (16 – 78) Lines positioned 20 20 Duration of treatment (Range) in days 6.3 (0 – 18) 6.8 (2 – 16) Line failures _{(25% )}5 _{(50% )}10 Thrombophlebitis 4 8 Occlusion 1 2 Failed insertions 1 0 Lines removed due

to patient’s request 1 0

N. lines positioned

40

100%

Electively removed

19

47.5%

Developed

thrombophlebitis

12

30%

Occluded

3

7.5%

Fell out

4

10%

Failed insertion

1

2.5%

Removed for

non-medical reasons

1

2.5%

Kane KF., Cologiovanni L., McKiernan J., Panos MZ., Ayres RC., Langman MJ, Lowes JR.

High osmolality feedings do not increase the incidence of thrombophlebitis during peripheral i.v. nutrition.

JPEN Journal of Parenteral and Enteral Nutrition (1996)

CLINICAL DATA

Osmolality (IV)

The aim of this study was to determine whether standard feeding formulas can be

given via the peripheral route and also to establish whether increasing osmolality

does increase the incidence of thrombophlebitis under these conditions. [...]

Increasing osmolality of total parenteral nutrition did not increase episodes

of thrombophlebitis in this trial and did not affect the success rate of lines

.

We conclude that standard total parenteral nutrition formulas of higher osmolality

than previously thought can be safely given via the peripheral route fro short-term

feeding and do not increase the risk of thrombophlebitis.

CLINICAL DATA

Fat emulsions (I)

We prospectively evaluated the effect of the continous infusion of peripheral

nutrition solutions with and without fat emulsions on the incidence of, probability

of, and time to infiltration of peripheral venous lines in infants. [...]

We conclude that

the incidence of infiltration

among the three solution groups

studied

is not different

. However,

the time to infiltration is prolonged and the

probability of infiltration is decreased

following the infusion of either dextrose

alone or dextrose/amino acid/fat emulsion solutions when compared to the

administration of dextrose amino acid solutions without concomitant fat emulsion

infusion.

CLINICAL DATA

Fat emulsions (II)

Patients: 53 infants

Median Age: 1.0 month

Range: 1 day - 11.9 months

97 peripheral venous lines

positioned

Three solutions

administered by positive

pressure infusion devices

through Teflon catheters

with similar gauge

Infants in study groups

similar with respect to age,

race, gender, weight,

administration of

intravenous medications

and catheter site (p > 0.05)

Phelps SJ., Cochran EB. Effect of continous administration of fat emulsion on the infiltration of intravenous lines in infants receiving peripheral parenteral nutrition solutions. JPEN Journal of Parenteral and Enteral Nutrition (1989) 13(6):628 - 632

Solution 10% dextrose _{2% amino acids}10% dextrose /

CLINICAL DATA

Fat emulsions (III)

A prospective, randomized study was conducted to determine whether simultaneous

infusion of lipid emulsion with an amino acid-dextrose-electrolyte solution would

reduce the incidence of thrombophlebitis (TP) during postoperative peripheral

parenteral nutrition (PPN). [...]

The incidence of edema in group A (lipid emulsion) was significantly lower than in

group B on postoperative days 2 and 4, although there was no difference in the

incidence of redness and pain between the two groups. These findings suggest that the

simultaneous infusion of lipid emulsion has a preventive effect against TP during

postoperative PPN

. [...]

Group A B

Patients 15 15

Amino-acid /

glucose solution Yes Yes

Additional infusion 10% lipid emulsion

5 % glucose solution Osmolarity

(mOsm/l) 853 853

Matsusue S., Nishimura S, Koizumi S., Nakamura T, Takeda H. Preventive effect of simultaneously infused lipid emulsion against thrombophlebitis during postoperative parenteral nutrition. Surgery Today (1995) 25(8):667 - 671

Patients: 30 patients undergoing gastric resection for

adenocarcinoma

End points: signs of thrombophlebitis

CONCLUSIONS

• Osmolarity around or less than 800 mOsm/L seems to be

effective in reducing endothelial damage during PPN

• Infusion rate is critical (it should be limited as much as possible,

depending on metabolic requirements and nutrient bioavailability)

• pH is critical, but titrable acidity should be considered as well.

Gold standard in experimental studies is 6.5

• Vesicant and irritant agents or drugs (Chemo!) must be avoided

•

There aren’t RCT’s comparing different

THANK YOU FOR YOUR ATTENTION

Roberto Biffi, MD