Central versus Peripheral Administration | Clinical Nutrition LAM Initiative

Central versus Peripheral Administration

Determining the Appropriate Route of Access

When the clinical nutrition care plan calls for parenteral nutrition (PN), it is important to determine the appropriate route of access.1,2

Delivery of PN may be classified according to:3

  • Insertion site (peripheral or central venous)
  • Insertion method (puncture through a small skin incision or surgical)
  • Duration of treatment (short-term, long-term, or permanent)
  • Distance between intravenous entry site and skin exit (tunneled or non-tunneled)
  • Number and diameter of catheter lumen(s)
  • Nature of the extra venous end (external port or totally implanted device)

Choosing the Appropriate Route of Access

PN solutions are administered either via a central venous catheter or peripheral venous cannulas.4 When choosing the appropriate route of access for PN delivery, there are several criteria that should be taken into consideration. Examples for these criteria are condition of the patient, accessibility of the venous system, or the osmolarity of PN products.1,4,5

Different PN infusion techniques

Central Venous PN Administration

A non-surgical central venous access can be indicated in patients with the need for long-term nutritional support of greater than one month, patients with poor peripheral veins, or patients with the need for hyperosmolar solutions (osmolarity greater than 850 mosmol/l.3,5

In the case of central venous PN, different catheter types are used:1,3,5

  • Broviac-Hickman® catheter
  • Groshong catheter
  • Port system (surgical)
  • Peripherally inserted central catheters (PICC)

Proper placement of central catheters is recommended to be monitored by:4,5,6

  • Ultrasound support
  • Chest x-ray support

Peripheral Venous PN Administration

Peripheral parenteral nutrition (PPN) offers a non-surgical, easy-to-use and, if handled adequately, safe method of feeding patients in need of PN for a limited duration up to approximately 10 days.3 PPN is also indicated in patients with a moderate disease-related malnutrition status, with lack of central venous access, and when a central venous PN is not justified due to a negative risk-benefit ratio (catheter sepsis or bacteraemia) or not possible due to burns or skin infection etc.1,3,7

PPN also offers several benefits compared to PN delivered via central vein catheters, which include:7

  • Simpler and quicker
  • No need for central venous insertion
  • No chest X-ray required
  • No risk of catheter-related sepsis
  • Lower risk of complications
  • 1. a. b. c. d. National Collaborating Centre for Acute Care (UK). Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. NICE Clinical Guidelines, No. 32 London 2006.
  • 2. Singer P, Berger MM, Van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009;28(4):387-400.
  • 3. a. b. c. d. e. Pertkiewicz M, Dudrick SJ. Parenteral nutrition. In: Sobotka L, editor. Basics in Clinical Nutrition. Prague: Galen 2011:348-417.
  • 4. a. b. c. Jauch KW, Schregel W, Stanga Z et al. Access technique and its problems in parenteral nutrition. - Guidelines on Parenteral Nutrition, Chapter 9. Ger Med Sci 2009;7(19):1-18.
  • 5. a. b. c. d. Pittiruti M, Hamilton H, Biffi R et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28:365-377.
  • 6. A.S.P.E.N. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002;26(1):144.
  • 7. a. b. Gura KM. Is there still a role for peripheral parenteral nutrition? Nutr Clin Pract 2009;24(6):709-717.

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