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Your body needs to be supplied with life essential nutrients and fluids on a daily basis
and normally you are supplied with these things in the food you take in.
Parenteral nutrition, so in other words the uptake of nutrition directly into a vein or via
infusion therapy, becomes necessary if food and fluids cannot be consumed normally or
if tube feeding (supplying the body with nutritional solution via a tube that goes directly
into the stomach or intestine) is not possible.
The cause often lies in the underlying illness itself, in the accompanying nutritional
status, and in therapy measures that have already been carried out (e.g. operations,
radiotherapy and chemotherapy).

All life-essential nutrients are contained in the nutritional solution in such a way that they are suitable for intravenous infusions and ready to benefit the body immediately.

  • Amino acids are important component parts of body proteins that serve to sustain important bodily functions.
  • Glucose is the smallest building block of the carbohydrate family and serves to provide energy and is especially important for the functioning of the brain.
  • Fat is, alongside glucose, an important supplier of energy to the body.
  • Electrolytes are to be found in the form of salts and play an important role when it comes to regulating water balance in the body.
  • Body water, on a quantity basis, is the most important component part of the body. Water serves as a means of transport and as a solvent and regulates body temperature.
  • Trace elements are inorganic elements that are found in the body in small quantities only. They are the building blocks of other important substances, for example iodine, which is a component part of the thyroid hormone.
  •  Vitamins are vital for certain body functions. Our body cannot create these itself – or can only do so in very little quantities.

Your doctor has allocated you with a vein access catheter so that nutritional solution may be entered directly into your blood stream. The choice of access depends on your individual situation, the composition of your nutritional solution and on the foreseen duration of your nutritional therapy (please go to page 18 for more information about the types of access catheters). The connection piece of your venous access catheter will get connected to the nutritional solution bag.

Modern products and competent advice ensure that parenteral nutrition/infusions can be carried out at home.

Once a course of instruction has been undertaken, you or a relative will be able to administer your parenteral nutrition. Naturally, you may also have the possibility to enlist the help of a nursing service.


Order and delivery of the necessary products and materials can go via your pharmacist or via a specialist trader in your area.


TransCare will be happy to plan and organize your parenteral nutrition/infusion therapy*. Our wide network of Care Managers will ensure that the process is carried out smoothly.

The Care Manager in your area will instruct and advise you, your relative(s) and/or your assigned nursing service. He or she will liaise with all those that are involved in your delivery, care and treatment process, and with the institutes involved.

 

*Depends on your local health care structures. Please check locally.

Parenteral nutrition must be carried out at a very moderate speed. If you are up and mobile you really do not want to be bound to your infusion stand and at home all day. You therefore have the possibility to take the bag of parenteral nutrition with you in a pouch or backpack. The dosage of your parenteral nutrition is taken care of by a mobile pump that can also be packed into the pouch or backpack.

Important patient notice
Please check whether the battery capacity is sufficient before leaving the house. In case of doubt, please make sure to take additional batteries with you.


If you are not out and about, you can connect the pump to the mains in order to spare battery life. Connection and disconnection of the parenteral solution should always be carried out in your usual surroundings.

 

Our body cells work around the clock, which is why the parenteral solution can also be administered during the night. Nightly applications have shown to have a positive affect on the uptake of nutrition and fluids during the daytime. Nightly application can however increase the need of having to go to the toilet.

If a full 24-hour cycle is not needed for the nutrition infusion, you can use and plan any infusion-free hours for optimal use (job, walks, shopping, recreation etc.).


The duration of the infusion depends largely on your energy and nutritional needs, and the parenteral infusion products needed as a result of your needs.


Each cell of your body can only cope with a certain amount of nutrients per hour, which is why your hourly-infused nutrition level needs to be attuned to your metabolism and your body weight.

Important patient notice
For your own wellbeing and in order that the nutrients be used optimally, the dosage (infusion amount and duration) should be adhered to.

The parenteral solution/infusion must get from the infusion bag to your venous access catheter. The rate at which the parenteral nutrition flows must be adjusted to suit you individually. There are different possibilities for both means. Administration and dosage can be taken care of by a pump (please see question "What needs special attention when it comes to pump-controlled parenteral nutrition?") or with the help of gravity.
Depending on which method is chosen, you will receive a transfer line that is variable in length, so either an Original Infusomat® line, a line for a mobile pump or an Exadrop® (precision flow regulator for gravity infusions).
The set up of the infusion system at home is somewhat different to a set up in hospital. Additional infusion filters (Intrapur® Lipid/ Intrapur® Plus) and valves offer more protection and more safety in parenteral nutrition/infusion therapy.
A safe connection between each of the component parts is established by using Luer-Locks.

Please consult your attending doctor about any such changes.

Our shared goal: to improve your wellbeing

Control examinations should take place that are based upon on your clinical picture, your course of therapy and your general condition. Your attending doctor will decide upon what intervals and what types of examinations are best.

Should you encounter changes in your overall wellbeing - tiredness or exhaustion - then it could be a sign that your nutritional regime needs to be adjusted or changed. The TransCare team at B. Braun Melsungen AG are happy to support and advise you and those parties involved in such matters.

Some symptoms can, in some cases, indicate the onset of an additional illness.

Despite regular checkups and examinations by your GP or clinic, and despite careful adherence to the correct and learned handling, situations can arise during a parenteral nutrition infusion that require immediate abortion of the nutritional therapy so that you may be protected from greater ensuing complications. Your GP, nursing service and in some cases an A&E doctor must be notified in such cases.

Please therefore clarify, together with your GP and your nursing service before beginning your course of therapy, how you would like to proceed in the event of such a situation.

Please let us demonstrate in which cases parenteral nutrition could be aborted.

Please discontinue your parenteral nutrition therapy and consult your doctor or nursing service if any of the following appears or occurs:

  • Fever and shivering (ague)
  • Any swelling, reddening and pain in the exit area of the catheter or in the area of the port chamber, that is to say, the puncture site
  • Nausea, vomiting, headache
  • Blood in the catheter or transfer line (infusion no longer flowing)
  • One-sided swelling of the neck and arm of the catheterized side of the body
  • The catheter ‘slips’ out
  • The catheter is ripped off (please clamp off the catheter as close to the body as possible)
  • The infusion system has leaks
  • The port cannot be flushed with a normal level of resistance

Please contact an A&E doctor immediately if you experience any abrupt chest pain or are short of breath. Please abort your parenteral nutrition therapy in this case.

Please inform your GP if you experience any other unpleasant symptoms.

You can make a considerable contribution to the longevity of your central venous catheter. Infection of your central venous catheter (e.g. Hickman, Broviac, Groshong or port catheters) is minimized if certain basic hygiene principles are adhered to. Such principles, amongst others, include:

  •  that you allocate yourself a clean workspace
  • that you observe and carry out aseptic procedures (spray disinfect the ampules, disinfect your hands, use gloves)
  • that you keep all connection points of your infusion system clean and that you do not talk while in a position that is directly over the connection points during assembly of the system
  • that you exchange the respective component part of screw connection parts if they get touched by accident.

Please allocate the task of local care to yourself or to someone else. You will be trained according to a particular care standard by one of our Care Managers.

The TransCare team will be happy to help you find trained nursing staff should you plan to endorse the help of a nursing service for further care. The team will take care to ensure that the nursing service works according to generally accepted rules.

In general, bathing and showering are allowed during infusion-free periods.
Waterproof bandages (Askina® soft waterproof, Askina® Derm) are available for all catheter types when it comes to covering the catheter exit site (puncture site with port catheters).
These enable you to take a shower without the catheter exit site getting wet. The part of the infusion hub that extrudes from the bandage is best wrapped in a gauze swab and fixed separately with a large piece of transparent bandage. 

Important patient notice

The transparent bandage is generally not suitable for bathing as it can sometimes come loose from the skin.
You are able to shower or to take a bath without any risk and without further precaution if you have had a port catheter without connecting port needle and your wound has healed.

As a general rule, your attending doctor will decide as to how often your bandage needs to be renewed. The decision will mainly depend on the state of the catheter exit site, that is to say, on the state of the puncture site.

The Robert Koch Institute in Germany recommends the following: *

  • the bandages should be inspected on a daily basis. The catheter exit site/puncture site should be inspected for pressure pain and the gauze-pad bandage and bandagesshould be intact (pain is often an initial indicator that an infection is developing)
  • the gauze-pad bandages should be changed on a daily basis if the patient is restricted in terms of cooperativeness (disturbance of consciousness, respiration) or if the patient shows a lessened sensitivity to pain
  • the bandages should be removed and the catheter exit site/puncture site should be inspected if signs of pressure pain, fever unclear symptoms in the patient with unknown cause or sepsis appear
  • transparent bandages should be changed on a routine basis at the latest after every 7 days
  • the bandages should be changed immediately if they have become dirty, wet or soaked, are starting to loosen or if infection is suspected
  • the procedure of changing bandages should be carried out in an aseptic way


*http://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Kommission/Downloads/Gefaesskat_Rili.html

Important patient notice
Please take care of your oral hygiene even if you are being fed via infusions only.

Saliva keeps the mucous membranes of our mouths moist. Only moist mucous membranes are able to function properly and fight off any germs in our environment.


Your salivation will be significantly decreased because of no longer taking in food via the mouth. What’s more, there are several types of medication that cause extra dryness of the oral mucous membranes.

Your oral hygiene program should include the following steps:

  • brushing your teeth on a daily basis (soft toothbrushes)
  • using a mouth wash that contains, for example, Glandomed®
  •  if you have a dry mouth, moisten the inside of your mouth with soaked swabs
    (e.g. lemon glycerine swabs) or with artificial saliva (Glandosane®).

Your doctor has created a nutritional regime that is especially suited to your daily energy, nutrient and fluid needs. To make your parenteral nutrition therapy at home as easy and safe as possible you will use so-called ‘all-in-one’ systems that get mixed up just before use, that are contained in one bag, and that contain all nutritional elements (amino acids, carbohydrates, lipids, electrolytes, trace elements and vitamins).

Using only one infusion line, you will receive everything that your body needs on a daily basis in terms of nutrition.


This system, with its multi-chambers (2 or 3-chamber bags) and an individual mixing bag component (compounding), offers a wide spectrum of all-in-one systems that is ideal for parenteral nutrition therapy at home.


Three-chamber bags contain amino acids with/without electrolytes, glucose and fat all in individual chambers. The individual chambers are mixed by applying gentle pressure. An additional lipid emulsion gets added via the use of a special transfer set in the case of two-chamber bags. Individually produced mixing bag systems contain all the necessary macro- nutrients in exactly defined gram dosages and come in a mixed state.

There are different means by which parenteral nutrition can be administered to the body.

This depends largely on the composition of the infusion solution and on the duration foreseen for parenteral nutrition, and on whether you are administered nutrition via a small vein in your arm (peripheral-venous administration) or via a larger blood vessel near the heart (central venous administration).


Your doctor has given you a line that is special to your personal situation.

Peripheral-venous line
A peripheral-venous line gets placed into a small vein in your forearm or into the back of your hand via a small puncture. A small plastic tube - about 5 cm long - remains in your blood vessel. This type of access line can only be used for a limited amount of time. It can only be used to administer infusion solutions that in their composition are suited to peripheral-venous line types of access.
This is why most parenteral nutrition solutions get administered directly into a larger blood vessel. There are several types of access lines into these larger types of blood vessel:

Central venous lines

  • non-implanted central-venous catheter
  • one or multi-lumen catheter
  •  implanted central-venous catheter
  •  Hickman or Broviac catheter
  • port catheter (double-chamber port)

With non-implanted central-venous catheters, a thin plastic catheter is inserted and forwarded though a blood vessel via a puncture through to a vein in the arm or neck until it reaches a position close to the heart area. These non-implanted catheters also have a limited time of usage.

This is why, instead - and in the case of a longer period of nutrition or use at home - a central-venous catheter is implanted via a small operative procedure under local anaesthesia.

Hickman-Broviac vein catheter types are placed into a blood vessel close to the heart area and run along and between the nipple and sternum, where it also exits. The tunnel under the skin acts as a certain kind of protection against infection. The end of the catheter is equipped with a plastic cuff (Dacron cuff) with which the catheter is firmly fixed to the body. As a result, this type of catheter can remain in place for a longer period of time.

The implantation of a port system can be carried out as an inpatient or outpatient procedure. In either case, the system is positioned under local anaesthesia.

Post implantation you will only see and notice a small elevation just under the skin that is easy to feel with the fingers. No one else will notice that you are wearing a port.

The system can be used right after implantation. You should however avoid any physical activities during the first few days.

 

The implantation of a port system can be carried out as an inpatient or outpatient procedure. In either case, the system is positioned under local anaesthesia.

Post implantation you will only see and notice a small elevation just under the skin that is easy to feel with the fingers. No one else will notice that you are wearing a port.

The system can be used right after implantation. You should however avoid any physical activities during the first few days.

Normally, you receive your infusion from your doctor or nursing staff.
Using sterile gloves, the skin over the port is first of all disinfected. The port is then located by hand and fixed in a hold position with two fingers without actually touching the disinfected puncture point itself.

The skin and the silicone membrane of the port system is then punctured with a port cannula. You will only feel a small needle prick. The parenteral nutrition infusion or other can now be administered.

After the infusion is finished, the cannula simply gets withdrawn. Permanent bandages are not necessary.

Please regularly check the skin area covering the port. Please inform and immediately show your attending doctor any reddening or swelling.

You will not feel or notice your port after it has been implanted. Once the incision area has healed you can resume with your usual way of life. You are free to move about freely, to take a bath, shower and, to do sports.

The port passport that is given to you whilst you wear your port is of utmost importance. It contains information such the personal details of the wearer, the implant doctor, port specifications (manufacturer, model, size and batch number), position of the port chamber, position of the catheter, and instructions in case of emergency. Patients wearing a port should please carry their port passport with them at all times. This can be vital in case of an emergency.

Using a pump allows a better control over the infusion rate and dosage.

The infusion pump (e.g. Space Infusomat® or a mobile pump) can be adjusted to suit the infusion duration that has been calculated especially for you.

Glossary

aseptic free of germs
dosage  determination of the recommended daily amount and necessary amount per time unit
enteral into the intestinal tract 
Groshong catheter  central venous catheter that has a valve in the tip of the catheter that only opens if there is a difference in pressure of the catheter lumen and surrounding blood. The valve remains closed if the catheter is not in use and thus hinders any blood getting into the catheter
Hickman-Broviac catheter  implanted central venous catheter that is tunnelled under the skin. It exits between the nipple and sternum
hygiene cleanliness 
infusion administration of fluids and medication directly into the bloodstream
infusion duration  the time needed to administer and to infuse nutrients directly into a blood vessel
catheter a thin plastic tube 
Luer-Lock the most frequently used connection of infusion lines in medicine and used for injections and cannulae
parenteral  a process whereby nutrients are delivered directly into the bloodstream thus bypassing the intestinal tract
peripheral-venous  an access line that goes into a small vein in the forearm or back of the hand
port  completely implanted central-venous catheter
tube feeding  artificial feeding via a probe in the intestinal tract
transfer devices  plastic transfer lines used to transport nutrition out of a container into the catheter
venous line access a line that goes into a blood vessel 
central-venous line a line that goes into a larger blood vessel that is closer to the heart