Table 71Parenteral nutrition (PN) route of access: CVC vs peripheral

Bibliographic referenceStudy TypeEvidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments (including source of funding)
Couse et al 199370RCT49 patients randomised

Peripheral : n=23
4 withdrawn

Central: n=26
3 withdrawn
Total analysed: n= 42

Peripheral: n= 19

Central: n= 23
Gastroenterological patients who required total parenteral nutrition.

Age (mean +/− SD):
Peripheral: 63 +/− 16
Central: 61 +/− 18

Gender (M/F):
Peripheral: 7/16
Central: 8/18

Indications for TPN: Inflammatory bowel disease, enterocutaneous fistulae, acute pancreatitis, postoperative major surgery, failed enteral support, miscellaneous
Peripheral parenteral nutrition administered through a suitable forearm vein using an 18 gauge teflon IV cannula. The line was established using strict aseptic technique and covered with an occlusive transparent dressing. The infusion site was inspected daily. At the first appearance of thromboflebitis, the cannula was removed and PPN was continued through a re-sited cannula in the contralateral arm.

TPN was discontinued in all cases on the resumption of oral feeding.
All nutrient solutions infused into the superior vena cava through a 14 gauge silicone catheter inserted using a standard infracalvicular subclavian approach. Catheters were removed if there was any suspicion of catheter-related sepsis which was confirmed if pyrexia settled on removal of the catheter and there were matching positive blood and catheter tip cultures.

TPN was discontinued in all cases on the resumption of oral feeding.
Until resumption of oral feedingMedian duration of PPN (days)Peripheral: n= 19

Central: n= 23

Peripheral: 8.5 +/− 4.2 (6 converted to CPN)
Central: 12 +/− 7
(2 converted to PPN) [Not significant]
MorbidityPeripheral:

Severe phlebitis was not encountered and no patient required any active therapy specifically for phlebitis Central: Catheter related sepsis was confirmed in one patient. Two patients developed small apical pneumothoraces
Kohlhardt et al 1994189RCT1+46 patients

Peripheral IVN: n=23

Central IVN: n=23
Surgical inpatients requiring IVN

Gender (M/F):
Peripheral IVN: 16/7
Central IVN: 14/9

Mean age(yrs):
Peripheral IVN: 61
Central IVN: 61

P IVN group;
Postoperative gut rest: Pancreatic surgery =7
C IVN group:
Patients with Postoperative gut rest:
Pancreatic surgery =4

P IVN group; Oesophageal surgery =7 C IVN group:
Oesophageal surgery =4

P IVN group;
Gastric surgery =2
C IVN group: Gastric surgery =7

P IVN group;
Other:
Inflammatory bowel disease =2
C IVN group:
Other:
Inflammatory bowel disease =0

P IVN group;
Pancreatitis =0
C IVN group:
Pancreatitis =2

P IVN group;
Fistula =3
C IVN group:

Fistula =4

P IVN group;
Other =2
C IVN group:
Other =2

Excl: Patients who received IVN treatment in ICU and those who required multiple-lumen venous access.
Peripheral IVN group: a paediatric fine-bore silicone catheter with an internal dia=0.3mm and external dia=0.6mm was inserted asceptically 10–15cm into the deep median basilic vein. Catheters inserted percutaneously with local anaesthesia and tourniquet- assisted venous distension. Catheters not tunnelled subcutaneously or sutured to the skin for fixation. Nutrient solutions were prepared daily under aseptic conditions in the hosp. pharm from Vamin 18, Intralipid 20% and dextrose 50%. Electrolyte additions were adjusted on the basis of daily biochemical profiles and the anticipated special needs of individual patients. Vitamin and trace elements were added as recommended. Heparin 1 unit/ml was routinely added as recommended. The peripheral IVN solution provided approximately 100 kcal (0.42 MJ) per gN, with between 65 and 75 per cent of the non-protein calories supplied as lipid. Delivered continuously over 24h.Central IVN group: single-lumen silicone catheters of internal dia=1.3mm and external dia=1.67mm were used. CVC inserted with strict asepsis using the Seldinger technique via an infraclavicular subclavian approach. All catheters were sutured to the skin for fixation.

Central IVN solutions were a selection of standard amino acid and dextrose nutrient solutions, prepared aseptically in the hospital pharmacy. Synthamin and Vamin products comprised the nitrogen source with all non-protein calories supplied as glucose. These solutions provided between 100 and 150 kcal (0.42 and 0.63 MJ) per gN. A fat premix solution with 500 ml Intralipid 20% was administered twice weekly to each patient. Patients received between 0.2 and 0.4 gN per Kg per day with 35–45 kcal (150–190 kJ) per kg per day. Vitamins and trace elements were added as recommended. Insulin (20–40 units/l) was added to the solutions of patients with significant glucose intolerance.
Study was terminated when the accumulated period of treatment for both groups was at least 2yrs. Mean total patient treatment period for both groups was 365 days.

Single catheter use ranged from 4 to 40 days with peripheral and 0 to 29 days with central venous lines. The total treatment period for patients receiving peripheral IVN was 426 days and for central IVN 322 days.
Peripheral: n=23
CVC: n=23
Small sample size may not have allowed adequate stats power for significance to be demonstrated.

Patients who received peripheral IVN may have been subject to greater surgical insult, undergoing more oesophageal and pancreatic ops then those who received central IVN who had gastric procedures.

Two patients in the CVC group developed early infection-site infection and central lines were converted to peripheral IVN until enteral feeding was resumed.

Funding: Royal Australasian College of Surgeons
Problems with venous accessPeripheral: 0
CVC: 1
Num. catheters usedPeripheral: 25
CVC: 30
Spontaneous catheter retractionPeripheral: 3
CVC: 0
Chemical infusion thrombophlebitisPeripheral: 4
CVC: 0
Catheter related bacteraemiaPeripheral: 0
CVC: 3
Incidence density of complicationsPeripheral: 0.016
CVC: 0.025
- RR incidence density ratio (95% CI)0.66 (0.24–1.82) [Not significant]
Probability of complication-free system function with time[Not significant] [p= 0.14]
May et al 1993221RCT1+49 patients

Peripheral: n= 23
Central: n= 26
GI patients requiring PN

Patients were well matched with regards to age, sex and indication for TPN. Data not provided
Peripheral PN. Patients received their nutritional support through a suitable forearm vein using a standard 18 gauge cannula. The cannula was inserted under aseptic conditions on the ward and the site converted by an occlusive transparent dressing. PPN fluid was then infused continuously over 24 hours with an infusion pump and the infusion site was assessed daily for phlebitis by the nutrition nurse and recording to a modified Maddox scale.CVC PN. The superior vena cava was cannulated with a 14 gauge silicon catheter via standard infraclavular approach to the right subclavian vein. Nutrition solution was also infused continuously over 24 hours by an infusion pump.Until resumption of oral feedingCVC: n= 26
Peripheral : n= 23
Patients successfully finished PN in their allocated groupCVC: n= 21 (80%)
Peripheral: n= 13 (56%)
Line feversCVC: n= 6
Peripheral: n= 3
PneumotoraxCVC: n= 2
Peripheral: n=0

From: Appendix Four, Evidence Tables

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).
Copyright © 2006, National Collaborating Centre for Acute Care.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Collaborating Centre for Acute Care to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.