About the TPN bag... few points first of all...
- bespoke bags come from pharmacy, labelled for the baby, titrated based on their blood results.
- stock bags kept in the NICU, used if needed until bespoke bags are ready.
- they are ran through a plastic line (giving set) into the blood stream, either peripherally (cannula) or centrally (in this case, long line).
- changing bags without changing the giving set is poor practice in neonates.
- moving a bag and line from a peripheral access point (cannula) to a central access point (in this case, long line) is a big no no. High risk of introduction bugs into a central vein.
- however, bags can happily be moved from a central access point to a peripheral.
- TPN contains dextrose (sugar) at a concentration of 10%.
- Dextrose bags can be given separately, at higher concentrations.
Onto the case...
- LL attached a TPN bag to baby's long line on her night shift. This is the one they suspect was contaminated. Let's call it Bag A. It is unclear if this was a bespoke bag or a stock bag.
- 11am. Day staff. LL is off shift. Babies blood sugars are poor. Dextrose is commenced via the long line instead, to fix the low blood sugars. I assume this Dextrose is high concentration. High concentration dextrose MUST be given centrally.
- 11am. Bag A is moved to a peripheral line meantime. It contains other nutrients so cannot be stopped completely. Bag A now cannot be moved back to a long line, as it has been flowing through a peripheral line. Hence the comment, they were inserting a new long line.
- the Dextrose infusion increased baby's blood sugar, but the contaminated TPN (Bag A) counteracted this, as it was still running peripherally.
- 4pm. A new TPN bag arrives from pharmacy. Let's call this Bag B.
- 6pm. Blood sugars remain low. They stop TPN altogether. They replace all fluids with Dextrose only.
- 7.30pm. Blood sugars are finally normal.