Giving TPN With a CADD Solis Pump

The doctor has discharged your child, but TPN is needed until your child can eat normal meals. The medical team has arranged for a home infusion pharmacy to deliver the following items to the place you are staying:

• TPN 
• Multivitamins
• Other additives
• Tubing
• Supplies  

Your child will need a new TPN bag every day.  

Storage

Your child’s TPN and the multivitamins need to be stored on a clean refrigerator shelf or in a clean refrigerator drawer. Do not store any food in the same area as your child’s TPN. 

The temperature in the refrigerator should be 36 degrees F to 46 degrees F (2 degrees C to 8 degrees C). 

Other additives such as ranitidine, L-cysteine, or levocarnitine need to be stored at room temperature as written on the label.

Preparing to use the TPN bag

Check the TPN bag

You must get the bag ready before you attach it to your child’s pump. Follow these steps:

• Take the TPN out of the refrigerator at least 1 hour before you need to attach a new bag. It needs to warm up. Do not warm the TPN in the microwave.
• Check the TPN label for the following:
  • For your child’s name and the correct medical record number, if available.
  • For the name of the TPN ordered by the doctor.
  • For the correct amount Compound volume (also known as Reservoir volume) and the Order volume (also known as Infusion volume).
  • For the amount of time the infusion will take and possible Taper-Up and Taper-Down time.
  • For the expiration date.
  • For storage instructions.
  • For leaks, squeeze the TPN bag gently to check.
  • Make sure the liquid in the TPN bag is clear – not cloudy, discolored, or specked.

If the TPN bag is leaking, damaged or the liquid in the TPN bag is cloudy, discolored, or speckled do not infuse the liquid. Throw the bag and liquid away in the regular trash and contact your home infusion nurse right away. This would be the person who gave you the medicine.

Remember that your child’s TPN bag has 50 to 100 ml more liquid than the amount on the prescription. For example, if the doctor prescribes 1200 ml of TPN over 24 hours, the pharmacy puts 1250 to 1300 ml in your child’s bag. But if the label does not look right, please call the pharmacy.

Getting ready to give TPN

• Clean your work area with an alcohol prep pad or other disinfectant.
• Clean your hands with soap and water and dry well, or use an alcohol-based liquid or foam hand cleaner. 
• Gather these supplies and place them on the clean work area.

Supplies needed

• CADD Solis pump
• Bag of TPN
• IV tubing  
• Multivitamins (Vial 1 and Vial 2)
  • The infusion nurse told you which multivitamins your child should get — pediatric or adult.
• Other additives (such as ranitidine, or L-cysteine). Check the labels for:
  • The name of the medicine on the vial 
  • The expiration date on the vial is still in the future 
  • Storage instructions 
• A 3, 5, or 10 ml syringe for each additive 
• 1 syringe of sterile sodium chloride (saline for IV use). Check label for:
  • The name “0.9% Sodium Chloride Injection” on the syringe 
  • 5 mls of liquid in the syringe 
  • An expiration date on the syringe that is still in the future 
• 2 Site Scrubs® (If you do not have Site Scrubs, you may use 2 alcohol prep pads)
• 3–6 alcohol prep pads for cleaning multivitamins, other additives, and injection ports
• 4 AA batteries
• Medical tape, if needed to secure the line
• X-span® mesh (use as a onesie if your child is a baby or T-shirt if your child is a toddler)

All supplies and IV fluids must be used only 1 time and should be thrown away in the regular trash after use.

Preparing your child’s TPN bag

• Clean your hands with soap and water and dry well, or use an alcohol-based liquid or foam hand cleaner.  
• Remove the caps from the additives and clean the tops with an alcohol prep pad for 10 seconds and let dry. You will use a new alcohol prep pad for each of the additives.
• Remove the silver foil from the inject port on the TPN bag. Wipe the rubber port of the TPN bag with an alcohol prep pad for 10 seconds and let dry. Do not fan or blow on the port to dry it.
• With the syringe and needle, withdraw the amount of vitamins that the nurse taught you to use. You will use 2 vials of multivitamins for each bag. You will add the multivitamins to your child’s TPN each day.  
• Inject (stick) the needle for the multivitamins into the rubber port of the TPN bag and empty the syringe. Squeeze the bag gently a few times to mix the vitamins with the TPN.
• Repeat steps for other additives such as ranitidine or L-cysteine as needed.
• If you accidentally poke the needle through the TPN bag when you add vitamins or additives, throw the bag away. Do not use it because the bag is now dirty. Start over with a new bag if you have one, or call the pharmacy for a new bag right away. Make sure the pharmacy knows you are out of TPN. Your child should never miss a day of TPN unless the doctor says so.
• After you inject the additives, throw away the needle and syringe in a sharps container.  
• Twist the seal off the large middle port found at the bottom of the TPN bag, as you were shown by your infusion nurse.
• Remove the white cap from the spike on the IV tubing. Insert the spike into the large middle port on the TPN bag by applying pressure and twisting back and forth. This is called spiking the bag. Be careful not to touch the spike while inserting it into the bag.
• Lift the bag to prime (fill) the tubing with fluid. Remember that the pharmacy puts in extra TPN so you have enough to fill the tubing this way. Do not remove the blue clip from the cassette.
• If you see air bubbles in the tubing, let some TPN run into the sink to remove the air. Do not take the cap off the end of the tubing. You will still have enough TPN for your child’s needs.

Attaching infusion cassette

1. Clean your hands with soap and water and dry well, or use an alcohol-based liquid or foam hand cleaner.

2. Turn on the pump by pressing the gray button on the right side of the pump. Check the battery indicator on the screen, top right corner. If low, change batteries.

3. Lower cassette arm into the open position.

4. Remove the blue clip from the cassette, if present. Then insert the cassette hooks into the hinge pins on the bottom of the pump.

5. Swing the cassette up into the latch position.

6. Place the pump upright on a firm, flat surface. Press down so the cassette fits tightly against the pump. You will hear a click.

7. Lift the cassette arm up to the closed position.

8. Once the cassette is in place, the display will ask if you want to reset the reservoir volume. If the reservoir volume does not match what was prescribed for your child, please call your doctor, nurse practitioner, or home infusion nurse right away. If it is after normal clinic hours, please call the Infusion Center at 901-595-2441 or the home infusion nurse.

9. If the reservoir volume is correct press the button located under the word “Yes” at the bottom right of the screen.

10. The display will then say “Prime tubing?”  Press the button located under the word “No” at the bottom left of the screen unless taught otherwise by a member of your child’s care team.

11. The display will now say “Start pump?” Follow the directions below to start the infusion.

12. Check the program numbers on your child’s pump. Looking at the label on the TPN bag, make any changes to the pump program as needed.

If you have questions about the pump program or the numbers you see, call your home infusion nurse.

Connecting the TPN

• Put your child in a safe place where you can easily reach the central line and the TPN bag.
• Clean your hands for 15–20 seconds with soap and water or an alcohol-based hand cleaner. Use paper towels to dry your hands. Then, use the paper towels to turn off the faucets.
• Take off the old X-span mesh and untape the central line as needed.

1. Prepare the saline syringe

• Remove the cap from the saline syringe as you were taught without touching the inside of the cap or the tip of the syringe. Set the cap down so the inside is facing up.
• Holding the syringe upright, pull back on the plunger of the syringe. Look for any large air pockets, and thump out the bubbles. Slowly, push the air out of the syringe and stop when the top of the plunger is at the 5ml mark. 
• Place the cap back on the syringe. Be careful not to touch the inside of the cap or the tip of the syringe. The saline flush can now be laid down on the table and is ready to use.
• Disconnect tubing from the previous TPN bag or remove the disinfectant cap from the end of the connector.

2. Clean the connector

• Open 2 Site Scrubs.
• Using a Site Scrub, scrub with a back and forth motion for 10 seconds and let dry for 5 seconds. If using an alcohol pad, wipe the end of the connector 8 seconds on the top and 8 seconds around the rim in the grooves and let dry for 15 seconds.
• Do not blow on or fan the connector.
• After the connector is clean, do not lay it down.

3.   Flush the line with saline

• With your free hand, pick up the saline syringe and remove the cap as you were taught without laying down the connector.
• Attach the saline syringe to the connector. Unclamp the central line, and flush with saline with a pulsing motion as you were taught. 
• Re-clamp the line. Remove the syringe.

4.   Clean the connector again

• Using a Site Scrub, scrub with a back and forth motion for 10 seconds and let dry for 5 seconds. If using an alcohol pad, wipe the end of the connector 8 seconds on the top and 8 seconds around the rim in the grooves and let dry for 15 seconds.
• Do not blow on or fan the connector.
• After the connector is clean, do not lay it down.

5.   Start the infusion

• Remove the cap from the end of the TPN tubing and connect to the cleaned connector.
• Unclamp the TPN tubing and unclamp the central line to start giving your child the TPN. It will start going into your child’s line as soon as the pump is running.
• Start the pump following the steps in “How to Program a CADD Solis Pump: TPN.”
• Place the TPN bag and CADD Solis pump in a backpack.
• Throw away needles and syringes in the sharps container. 
• All other supplies and TPN are a one-time use and must be thrown away in the regular trash.

6.   Check urine for glucose

Check your child’s urine glucose (sugar level) as you were taught by the home infusion nurse. Write down the numbers you get from the urine test and bring the results to the clinic on your next visit.

Medicine side effects

All medicines, including TPN, have side effects. Some are mild and some are more severe. Please read the Patient Medication sheets you received when your child’s medicines were first delivered. If you have questions or concerns that your child might be having an allergic reaction, stop the infusion and call the Infusion Center at 901-595-2441.

Call 911 if your child has a medical emergency and needs help right away.

Disconnecting your child from TPN

• Put your child in a safe place where you can easily reach the central line and the TPN bag.
• Clean your work area with an alcohol prep pad or other disinfectants.
• Clean your hands with soap and water and dry well, or use an alcohol-based liquid or foam hand cleaner. 
• Gather your supplies and place them on your clean work area.

Supplies needed

• 1 syringe of sterile sodium chloride (saline for IV use). Check label for:
  • The name “0.9% Sodium Chloride Injection” on the syringe 
  • 5 mls of liquid in the syringe 
  • An expiration date on the syringe that is still in the future 
• 1 syringe of heparin 10 units/ml for IV use. Check label for:
  • The name “Heparin Lock Flush 10 USP units/ml” on the syringe 
  • 3 mls of liquid in the syringe 
  • An expiration date on the syringe that is still in the future 
• 1 disinfectant cap
• 3 Site Scrubs (If you do not have Site Scrubs, you may use 3 alcohol prep pads)
• X-span® mesh (use as a onesie if your child is a baby or a T-shirt if your child is a toddler)
• Medical tape, if needed to secure the line

1.   Prepare the saline syringe

• Remove the cap from the saline syringe as you were taught without touching the inside of the cap or the tip of the syringe. Set the cap down so the inside is facing up.
• Holding the syringe upright, pull back on the plunger of the syringe. Look for any large air pockets, and thump out the bubbles. Slowly, push the air out of the syringe and stop when the top of the plunger is at the 5ml mark. 
• Place the cap back on the syringe. Be careful not to touch the inside of the cap or the tip of the syringe. The saline syringe can now be laid down on the table. It is ready to use.

2.   Prepare the heparin syringe

• Remove the cap from the heparin syringe as you were taught without touching the inside of the cap or the tip of the syringe. Set the cap down so the inside is facing up.
• Holding the syringe upright, pull back on the plunger of the syringe. Look for any large air pockets, and thump out the bubbles. Slowly, push the air out of the syringe and stop when the top of the plunger is at the 3ml mark. 
• Place the cap back on the syringe, being careful not to touch the inside of the cap or the tip of the syringe. The heparin syringe can now be laid down on the table. It is ready to use.

Ending the Infusion

When the Infusion Volume has been given, the pump will beep 9 times and change to a KVO rate. The pump will read “Infusion Complete.” Press Acknowledge. 

Remember that your child’s TPN bag has 50 to 100 ml more liquid than the amount on the prescription, so the TPN bag will not be empty. The screen will continue to say “Running” while in KVO mode. 

• Open 3 Site Scrubs and place them on the clean work area.
• Press stop/start key to stop the pump. “Stop the Pump?” will appear on the pump screen, Press Yes.
• Close the clamp on the TPN tubing.
• Clamp your child’s central line.
• Clean your hands with soap and water and dry well, or use an alcohol-based liquid or foam hand cleaner. 
• Remove the TPN tubing from the connector on your child’s line.

1.   Clean the connector

• Using a Site Scrub, scrub with a back and forth motion for 10 seconds and let dry for 5 seconds. If using an alcohol pad, wipe the end of the connector 8 seconds on the top and 8 seconds around the rim in the grooves and let dry for 15 seconds.
• Do not blow on or fan the connector.
• After the connector is clean, do not lay it down.

2.   Flush the line

• With your free hand, pick up the saline syringe and remove the cap as you were taught without laying down the connector.
• Attach the saline syringe to the connector. Unclamp the central line, and flush with saline with a pulsing motion as you were taught.
• Clamp the line. Remove the saline syringe.

3.   Clean the connector again

• Using a Site Scrub, scrub with a back and forth motion for 10 seconds and let dry for 5 seconds. If using an alcohol pad, wipe the end of the connector 8 seconds on the top and 8 seconds around the rim in the grooves and let dry for 15 seconds.
• Do not blow on or fan the connector.
• After the connector is clean, do not lay it down.

If your child is getting TPN over 24 hours, you will connect the new TPN bag to your child’s line at this time.

If your child is getting TPN over 23 hours or less you will flush the line with heparin because your child will be disconnected for an extended period of time.

4.   Flush with heparin

• With your free hand, pick up the heparin syringe and remove the cap as you were taught without laying down the connector.
• Attach the syringe to the connector. Unclamp the central line, and flush the line with most of the heparin. When the plunger reaches the 1ml mark on the syringe, do a steady push to finish the flush, while holding pressure on the plunger, clamp the central line. This helps keep the line open and free from blood.
• Remove the heparin syringe.

5.   Clean the connector again

• Using a Site Scrub, scrub with a back and forth motion for 10 seconds and let dry for 5 seconds. If using an alcohol pad, wipe the end of the connector 8 seconds on the top and 8 seconds around the rim in the grooves and let dry for 15 seconds.
• Do not blow on or fan the connector.
• After the connector is clean, do not lay it down.

6.   Cap the line

• Remove the cover from the disinfectant cap and attach the cap to the connector. Alcohol will spill from the cap and your hand may get wet when you attach the cap to the connector. This is OK. You may now lay down the line.
• Loop the line, and put on X-span mesh if your child is an infant or toddler.
• Throw the empty TPN bag and syringes into the regular trash.
• Clean your hands again.

Problems and troubleshooting

• Stop the infusion and call the Infusion Center or your home infusion nurse right away if:
• The TPN or tubing begins to leak during the infusion 
• The infusion stops before the ordered infusion volume is given 
• The IV site becomes red or swollen 
• You see leaking or drainage from the IV site 

Changing the batteries

If a message on the screen says “Battery low, replace battery,” you will need to replace the batteries as soon as you can.

To change the batteries, follow these steps:

1. Press the stop/start key.
2. “Stop Pump?” displays. Press “Yes.”
3. Turn the knob on the battery door counter-clockwise and open the battery door.
4. Remove the 4 used batteries.
5. Insert 4 new AA batteries following the diagram inside the battery compartment.
6. Close the battery door, turn the knob on the battery door clockwise to lock.
7. Press the power switch to turn on the pump.
8. The screen displays “Do you want to start a new patient?” Press “No.”
9. Press stop/start key to start the pump.
10. “Start Pump?” displays. Press “Yes.”
11. If you do not change the batteries while they are low, the alarm will sound and the orange light will no longer flash. Change the batteries as described above.

Questions?

If you have questions about giving TPN with a CADD Solis pump, please call your child’s home infusion nurse. If you are using the St. Jude Home Infusion Service, call 901-595-7464. If you are outside the Memphis area, call toll-free at 1-855-466-3799. You may also call your child’s doctor, nurse, or pharmacist. In the local area, call 901-595-3300. If you are outside the Memphis area, dial toll-free 1-866-278-5833.