Peripheral Intravenous Nutrition Therapy: Outpatient, Office-Based Administration

Alternative Medicine Review,  August, 2000  by Ian D. Bier

• E-mail
• Print
• Link

Primary Considerations in PIN

Osmolality

Normal serum osmolality is 275-300 milliosmoles per liter (mOsm/L) depending on the source.[43,44] Excessive infusion of hypertonic fluids can lead to a variety of complications, including tissue irritation, pain, electrolyte shifts in the serum, red blood cell crenation, and general cellular dehydration. If the injection of a hypertonic solution is too rapid, blood pressure can fall, cardiac irregularities or arrest may occur, respiration can become shallow and irregular, and heart failure and pulmonary edema may result. This may be due to a large bolus of concentrated solute reaching the myocardium. Rapid infusion of hypertonic saline has also been shown to cause a sudden rise in cerebrospinal fluid.[45]

In PIN, the main effect of hyperosmolal solutions cited is phlebitis. Many studies have examined the effects of osmolality on the induction of phlebitis. Gazitua et al[22] found phlebitis was universal when osmolality exceeded 600 mOsm/L. They also found phlebitis occurred more commonly with the use of solutions that contained amino acids. The important factors in the production of phlebitis by amino acid solutions were osmolality and the amount of potassium infused per day.

Bodoky et al[23] showed that an infusion solution including amino acids and carbohydrates with an osmolality of 1,100 m0sm/L exhibited no difference in peripheral venous thrombosis (PVT) after 48 hours compared to nutrition solution commonly used in hospitals such as Lactated Ringer's, five-percent glucose, and an electrolyte solution with osmolalities of 280-407 m0sm/L. Comberg et al[46] concluded that under normal clinical circumstances a hyperosmolar basic nutrition solution (806 mOsm/L) does not cause a higher rate of peripheral venous irritation compared with an iso-osmolar electrolyte solution, and should be administered to patients with an expected infusion time of not longer than four days.

Daly et al[47] studied 80 patients in four groups receiving infusions with osmolalities ranging from 630 to 983 mOsm/l. There was no difference in rates of phlebitis between patients who received peripheral infusion with high osmolar solutions compared to lower osmolar solutions.

Wilson et al[48] randomly allocated to two groups 20 patients who had undergone uncomplicated surgery of moderate severity who were fed using a peripheral vein for up to six days. Group I received a daily nutrient solution with an osmolality of 490 mOsm/kg, while group II received a daily solution with an osmolality of 376 mOsm/kg. Venous thrombophlebitis at the infusion site was assessed daily using Maddox's criteria,[49] with a minimal degree of inflammation which reached a maximum of 30 percent after five days.

Mattioli et al[50] used three standard lipid emulsion diets with final osmolalities not higher than 900 milliosmoles in 118 patients. Frequency and type of phlebitis were evaluated in patients submitted to PIN and in two groups of 10 patients who received five-percent dextrose in water (S-D5W) infusions and Protein Sparing Nutrition (493 mOsm/L) in the postoperative period. Frequency of phlebitis was significantly lower in PIN patients than in control patients. A treatment period of 15 days did not increase the frequency of phlebitis.