title: Peripheral venous nutrition: the equal relevance of volume load and osmolarity in relation to phlebitis.
abstract: This study aimed to investigate the peripheral vein tolerance for total parenteral nutrition (TPN) and to point out the factors which induce phlebitis. TPN was administered from 'all-in-one' bags. Five different types of TPN were investigated, wherein the amounts of amino-acids, dextrose, lipids, osmolarity and volume were varied. Type I (829 mOsm/l) was a low energy (1570 NPE kcal) nutritive mixture of 2425 ml with 9.5 g N. Type II (842 mOsm/l) was an intermediate energy (1800 NPE kcal) mixture of 2525 ml with 9.5 g N. Type III (860 mOsm/l) contained 1800 NPE kcal and 13.5 g N in 2775 ml. Type IV (790 mOsm/l) was only a dilution of Type III with 250 ml water. Type V (1044 mOsm/l) covered normal energy needs (2000 NPE kcal) and 13.5 g N in 2580 ml. All bags contained standard amounts of electrolytes, vitamines, trace elements and heparin (1.000 IE/l). The infusion site was not changed until phlebitis developed or oral feeding could be started. Type I, II, III and IV were given to at least 30 patients, and Type V to only 11 patients because of an unacceptable high phlebitis rate (91% after 2.8 days). The phlebitis rate for Type I, II, III and IV was 4%, 12%, 24% and 27% respectively after 48h increasing to 14%, 37%, 55% and 73% respectively after 14 days. The mean infusion time and phlebitis rate were related to each component of the nutritive mixture. A poor relation was found between the phlebitis rate and the amount of amino-acids, dextrose or lipid respectively. Both osmolarity (with variabl volume) and volume (with variable osmolarity) correlated poorly with the phlebitis rate (r = 0.37 and 0.29 respectively). However, the osmolarity rate, defined as the number of milliOsmols infused per hour, correlated well with the phlebitis rate (r = 0.95). Our results demonstrate that the peripheral route can be used as a practical alternative for central venous administration, if the osmolarity rate is limited.
authors.affiliation: Department of Pharmacy, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
authors.forename: J G
authors.initials: JG
authors.lastname: Timmer
authors.forename: H G
authors.initials: HG
authors.lastname: Schipper