What is the protocol for Peripheral Parenteral Nutrition (PPN) administration?

From the Guidelines

Peripheral parenteral nutrition (PPN) should be administered through peripheral veins when central venous access is unavailable or contraindicated, using solutions with osmolarity less than 900 mOsm/L to minimize vein irritation, as recommended by the most recent study 1.

Key Considerations for PPN Administration

• Typical PPN formulations contain 3-5% amino acids, 5-10% dextrose, and lipid emulsions (typically 20%) 1.
• The recommended infusion rate is 60-100 mL/hour, with a maximum daily volume of 2-3 liters 1.
• PPN should be delivered through a large peripheral vein using a 20-22 gauge catheter, with rotation of sites every 72-96 hours to prevent phlebitis 1.
• Add multivitamins, trace elements, and electrolytes as needed based on patient requirements 1.

Patient Selection and Timing

• PPN is appropriate for short-term use (5-7 days) in patients with functional gastrointestinal tracts who cannot meet nutritional needs orally but don't require full nutritional support 1.
• PPN may be administered to supplement limited oral and/or enteral intake at any time during the perioperative period, including postoperative day 1 and prior to surgery for patients at high risk of surgical stress response 1.

Monitoring and Complications

• Regular monitoring of infusion sites, electrolytes, and blood glucose is essential to prevent complications like phlebitis, infiltration, and metabolic disturbances 1.
• The lower nutrient concentration in PPN compared to central parenteral nutrition limits its caloric delivery, making it suitable only for partial nutritional supplementation or short-term use 1.

From the Research

Protocol for Peripheral Parenteral Nutrition (PPN) Administration

The protocol for PPN administration involves several key considerations, including:

• Patient selection: PPN is suitable for patients requiring short-term parenteral nutrition, particularly those with malnutrition or at risk of malnutrition 2.
• Nutrition formulation: A standardized PPN formula can be used, providing a balanced mix of nutrients, including amino acids, glucose, and lipids 3, 4.
• Venous access: Peripheral veins can be used for PPN administration, with options for rotation of venous access sites or use of ultrafine cannulas 3.
• Infusion protocol: PPN can be administered via continuous or cyclical infusions, with the latter showing reduced venous morbidity 3.
• Monitoring and management: Regular monitoring of patients receiving PPN is essential, including assessment of nutrition status, energy and protein provision, and complications such as phlebitis or extravasation 5, 2.

Key Considerations for PPN Administration

Some key considerations for PPN administration include:

• Osmolality of the nutrient solution: Lower osmolality solutions may be less phlebogenic 6.
• Lipid emulsion: The use of lipid emulsion with PPN can help reduce phlebitis rates and provide essential fatty acids 4, 6.
• Cannula management: Regular rotation of cannula sites and adherence to recommended cannula management guidelines can help minimize complications 2.
• Cost implications: PPN may offer cost savings compared to total parenteral nutrition (TPN), particularly for short-term use 2.

Complications and Safety

PPN is generally considered safe, with low rates of complications reported in several studies, including:

• Phlebitis: Rates of phlebitis vary, but are generally lower with PPN compared to TPN 5, 3, 6, 2.
• Extravasation: This complication can occur, but is relatively rare 2.
• Septicaemia: No cases of septicaemia were reported in one study, despite suboptimal compliance with cannula management guidelines 2.