Parenteral nutrition (PN) is the intravenous administration of nutrition, bypassing the gastrointestinal (GI) tract. Parenteral nutrition may be total (TPN), where the digestive system is not functioning at all, or supplementary (SPN), where some intake via the digestive system is possible but inadequate to meet requirements. Some conditions that may require parenteral nutrition include ileus after abdominal surgery, major gastrointestinal surgery, enterocutaneous fistula, bowel obstruction, short bowel syndrome and necrotising enterocolitis.

PN is associated with several avoidable risks, which include infectious complications, catheter insertion complications and metabolic complications (e.g., related to glycaemic control, lipid clearance and biochemical imbalances). One of the most serious and avoidable complications is catheter-related infection.

Factors contributing to the PN incidents recorded on NIMS, the National Incident Management System include:

• Prescribing issues, e.g. incorrect regimen prescribed
• Ordering or delivery issues, e.g. not ordered in time, not delivered to the pharmacy or ward
• Administration issues, e.g. incorrect infusion rates, extravasation of venous catheters
• Monitoring issues, e.g. of central venous catheters (CVCs) and peripherally inserted catheters (PICCs), electrolytes

Risk considerations

There are a number of recognised factors that may contribute to PN incidents, including:

• Non-compliance with infection prevention and control policies, procedures, and guidelines (PPGs), resulting in increased catheter-related infection risk
• Inadequate safety checks resulting in the incorrect bag being used, administration to the wrong service user or incorrect infusion rates
• Dislodged, damaged or leaking CVCs and PICCs
• PN not ordered, prescribed, or delivered to ward
• Incorrect dose of electrolytes and nutrients
• Lack of dietitian involvement in care planning and/or prescribing
• Failure to monitor electrolytes to evaluate response to treatment

Minimising the risks associated with parenteral nutrition

The State Claims Agency, in conjunction with the Irish Society for Clinical Nutrition and Metabolism (IrSPEN), has prepared the following advice to mitigate the risks associated with parental nutrition:

• Have in place, and adhere to, PPGs for the use of PN, including ordering and prescribing; preparation, delivery, and storage; and administration and monitoring
• Adhere strictly to infection prevention and control measures, which should include care bundles for venous catheters and monitoring for suspected catheter related infections
• Ensure all health and social care professionals have the correct level of education and training on the use and administration of PN, relevant to their setting, prior to undertaking practice in this area. An e-Learning programme is available on www.hseland.ie.
• Educate patients / service users and their carers on the risks associated with infusion lines, to include the risk of dislodging and disconnecting lines, such as when mobilising and dressing
• Monitor biochemistry and adjust PN accordingly to optimize treatment and prevent electrolyte imbalances
• Ensure multi-disciplinary team involvement to oversee the provision of PN (the multi-disciplinary team should include medical, nursing, dietetic, pharmacy and infection control staff as a minimum)
• Undertake regular audit of implementation and impact of PN guidelines through outcome and process measures to support continuous quality improvement

*This advice was prepared in conjunction with the Irish Society for Clinical Nutrition and Metabolism (IrSPEN).

References available on request.

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