Maximum tolerated osmolarity for peripheral administration of parenteral nutrition in pediatric patients

Limited data support a recommended maximum osmolarity for administration of peripheral parenteral nutrition (PPN). In this retrospective, matched-cohort study, we evaluated the incidence of phlebitis or infiltration associated with administration of PPN with an osmolarity >1000 mOsm/L vs ≤1000 mOsm/L.

Patients ≤18 years old who received PPN in a 2-year period were included in the study. Data related to patient demographics, PPN constituents, and adverse effects were analyzed.

A total of 352 patients met entry criteria. Overall, 139 (40%) patients experienced phlebitis or infiltration. There were no differences between patients who did or did not develop adverse events in terms of age or weight. Administration of PPN with osmolarity >1000 mOsm/L vs ≤1000 mOsm/L significantly increased infiltration (17% vs 7%; odds ratio [OR, 2.47]; 95% confidence interval [CI], 1.24-4.94; P = .01) and the combined composite end point of phlebitis or infiltration (45% vs 34%; OR, 1.65; 95% CI, 1.07-2.54; P = .02). In multivariate analysis, osmolarity >1000 mOsm/L vs ≤1000 mOsm/L was an independent risk factor for developing complications (OR, 1.67; 95% CI, 1.08-2.52; P = .02).

Two of every 5 children experienced phlebitis or infiltration during administration of PPN. These adverse effects were more often observed in those who received PPN with osmolarity >1000 mOsm/L vs ≤1000 mOsm/L. With this high incidence of adverse effects, we recommend that if PPN is used, the osmolarity should not exceed 1000 mOsm/L. More important, PPN should only be used temporarily until central access is obtained.