ASPEN Self-Assessment: Complications of PN

Question 1

What contributes to metabolic bone disease in PN-dependent patients?

Answer 1

Aluminum toxicity

Question 2

(TRUE/FALSE)

Hyperglycemia causes a shift of water out of the cells into the extracellular space, resulting in dilution of serum sodium

Answer 2

TRUE; resulting in hypertonic hyponatremia

For every 100 mg/dL increase in serum glucose conc above 100 mg/dL, the serum sodium would be expected to DECREASE by approximately 1.6 mEq/L.

Treatment should consist of correction of the underlying hyperglycemia, and NOT changes in sodium and water administration, as this is not a true sodium or water imbalance.

Question 3

Define azotemia

Answer 3

an elevation in BUN and serum creatinine levels

Question 4

(TRUE/FALSE)

If serum TG is above 400 mg/dL, the ILEs should be discontinued.

Answer 4

TRUE.

Provide lipids only to prevent EFAD.

Question 5

Parenteral nutrition should not exceed X mg/kg/min or X to X kcal/kg/day.

Answer 5

Not exceed 5 mg/kg/min OR 20 to 25 kcal/kg/day

Question 6

When fibrin builds up inside the vein and causes the vascular access device to adhere to the vessel wall, what is it called?

Answer 6

Mural thrombus

Question 7

A layer of fibrin that develops around the outside of the CVC (central venous catheter) secondary to aggregation of fibrin from the presence of a CVC within a vein, is?

Answer 7

Fibrin sheath

Question 8

What is fibrin build up on the CVC tip that will allow for infusion through the CVC, but will inhibit withdrawal of blood?

Answer 8

Fibrin tail/flap

Question 9

What is a clot within the catheter lumen and is caused by inadequate flushing and blood reflex?

Answer 9

Intraluminal thrombus

Question 10

0.1N HCl acid is most effective for clearing catheter occlusions due to precipitation of?

Answer 10

Calcium-Phosphate

However, direct infusion of HCl acid into the venous system can be associated with fever, phlebitis, and sepsis

Question 11

What catheter occlusions is sodium bicarbonate been effective in clearing?

Answer 11

Catheter occlusions due to precipitates associated with meds in the high pH range (tobramycin and phenytoin).

Question 12

What is 70% ethanol effective in clearing in catheter occlusions?

Answer 12

Dissolve lipid residue

Question 13

What is the most important contributor to metabolic bone disease?

Answer 13

Negative calcium balance.

Hypocalcemia occurs as a result of decreased calcium intake and/or increased calcium urinary excretion.

Factors that cause:

• Excessive calcium & inadequate phosphorus supplementation
• Excessive protein in PN solutions
• Cyclic PN infusions
• Chronic metabolic acidosis

Question 14

What is the most appropriate intervention for hypercalcemia?

Answer 14

Protein reduction; specifically protein doses for long-term PN should not exceed 1.5 g/kg/day

Question 15

(TRUE/FALSE)

Oral or enteral feeding, even in small amounts, is the best approach to preventing cholelithiasis.

Answer 15

TRUE, (gallstones) as it stimulates cholecystokinin secretion, bowel motility and gallbladder emptying.

Question 16

What is ursodiol?

Answer 16

Used to dissolve gallstones; and shown to improve bile flow

However, it has limited results and is only available in an oral dosage form and its absorption may be limited in patients with intestinal resection.

Question 17

(TRUE/FALSE)

Supplementation of choline has been shown to prevent cholelithiasis.

Answer 17

FALSE

The role of choline in the pathogenesis of cholelithiasis has not been determined

Question 18

Acetate is metabolized to what?

Answer 18

Bicarbonate

So excessive use of acetate may precipitate a metabolic alkalosis.

Question 19

(TRUE/FALSE)

Excess chloride is a common cause of metabolic acidosis.

Answer 19

TRUE

As well as, diarrhea and ARF

Question 20

(TRUE/FALSE)

Severe hypophosphatemia has been reported to cause respiratory failure and seizures?

Answer 20

TRUE

Question 21

What are the recommended maximum amounts of PN components per clinical guidelines for adults?

• mL/kg/day of Fluid
• g/kg/day of CHOs
• g/kg/day of Fat
• g/kg/day of Protein

Answer 21

30 to 40 ml/kg/day of Fluid
7 g/kg/day of CHOs
2.5 g/kg/day of Fat
2 g/kg/day of Protein

Question 22

What are some contraindications for PPN?

Answer 22

• Signification malnutrition
• Severe metabolic stress
• Large nutrient or electrolyte needs
• FR
• Greater than 2 weeks need for PN support
• Liver and Renal compromise

Question 23

What feature of Groshong CVC reduces the risk of catheter occlusion?

Answer 23

A pressure-sensitive three-way valve that restricts blood backflow and air embolism by remaining closed when not in use.

This eliminates the need for heparin flushes to maintain catheter patency, but the CVC should be flushed with NS after med administration or blood aspiration to ensure the valve is in the closed position.

Question 24

What is Alteplase?

Answer 24

Is the only FDA-approved thrombolytic agent for CVAD occlusion

Alteplase 2 mg in a 2-mL volume is injected into the catheter and allowed to dwell for 30 minutes to 4 hours, then aspiration of solution with a syringe is attempted. The process may be repeated, if necessary.

Question 25

(TRUE/FALSE)

Use of heparin 100 units/mL is appropriate for the treatment of CVAD occlusions.

Answer 25

FALSE

Heparin is appropriate for catheter FLUSHING

Question 26

Symptoms of manganese toxicity are associated most commonly with the accumulation of the mineral in which organ?

Answer 26

Brain

Manganese absorption from the GI tract is 6-16% of dietary intake; therefore, when provided through PN there is 100% bioavailability.

Manganese is primarily excreted in the feces via bile

Also, 60-80% of manganese is contained in RBCs.

Question 27

(TRUE/FALSE)

Hypothyroidism is a secondary cause of osteoporosis.

Answer 27

FALSE

HYPERthyroidism

Question 28

What is the prime indicator (lab value) for cholestasis?

Answer 28

Serum conjugated (direct) bilirubin

Question 29

If a patient on long-term PN develops hepatic dysfunction, what two trace elements should be monitored?

Answer 29

Manganese and copper, on a regular basis, and may need to be removed from PN solution if serum levels are elevated

Question 30

Symptoms of SOB, cough, cyanosis of the face, neck, shoulder, and arms, indicates which device complication?

Answer 30

Superior vena cava syndrome

Question 31

Define sentinel event.

Answer 31

A patient safety event of an unexpected occurrence involving death or serious physical/physiological injury, or the risk thereof.

Serious injury specifically includes loss of limb OR function.

Question 32

These are examples of??

• Medication errors
• Wrong-site surgery
• Restraint-related deaths
• Blood transfusion errors
• Preoperative/postop complications

Answer 32

Sentinel events

Question 33

A scientific basis that focuses on a process that leads to a certain outcome, is?

Answer 33

Process measure

Question 34

An evaluation of processes or outcomes of care associated with the delivery of clinical services, is?

Answer 34

Clinical measures

Question 35

Quality measures that emphasize research, proximity, accuracy, and adverse effects in order to result in positive patients outcomes, are?

Answer 35

Accountability

Question 36

(TRUE/FALSE)

Prophylactic use of antibiotic ointment at the catheter exit site is recommended for preventing catheter-associated sepsis?

What about antibiotic prophylaxis during catheter insertion?

Answer 36

FALSE

Abx ointment only encourages the development of resistant flora and should be avoided

FALSE, abx have not been demonstrated to reduce the incidence.

Question 37

What are the 3 research recommendations as primary interventions for reducing risks of CVAD-related infections?

Answer 37

1. Using the maximal barrier technique during catheter insertion
2. Cleansing insertion sites with 2% chlorhexidine preparation
3. Education and training of health care personnel

Question 38

What are 3 signs of a catheter-related bloodstream infection?

Answer 38

1. Bacteremia/fungemia with at least 1 positive blood culture
2. Clinical manifestations, such as fever
3. No apparent source except the catheter

**They often present WITHOUT redness or purulence (pus) at the catheter site

Question 39

What is Malassezia furfur?

Answer 39

A yeast

Classically associated with superficial infections of the skin and associated structures

Occurs most commonly in premature infants and patients receiving PN containing ILE\

Treatment:

• Antifungal
• D/C ILE
• Removal of the intravascular catheter (especially with non-tunneled catheter infections)

Question 40

What are these hallmark symptoms of (arm, shoulder or neck swelling, limb, jaw, or ear pain, and dilated collateral veins over the arm, neck, or chest) typically indicate?

Answer 40

Catheter-related central venous THROMBOSIS