ASPEN Self-Assessment: Parenteral Nutrition Flashcards
Stress-induced hyperglycemia in acutely ill and septic patients often develops from what 4 factors?
- Insulin resistance
- Increased gluconeogenesis (glucose generation)
- Increased glycogenolysis (glycogen breakdown)
- Suppressed insulin secretion
What are the 3 components of basal-bolus insulin therapy?
- Basal insulin
- Nutritional component prior to meals
- Correctional insulin
What form of glutamine supplementation improves physical compatibility and stability for admixture in PN solutions?
Glutamine dipeptide.
(TRUE/FALSE for each)
Free glutamine is unstable in PN solutions.
Enteral glutamine is protein-bound and is difficult to determine the exact glutamine content.
L glutamine powder is used in enteral supplements.
TRUE
TRUE
FALSE - oral nutrition supplements
What are the ASPEN/SCCM recommendations for calories in critically ill obese patients with BMI of greater than 30?
BMI > 50?
11 to 14 kcal/kg ACTUAL body weight (BMI 30-50)
22 to 25 kcal/kg IBW (BMI >50)
What are the ASPEN/SCCM recommendations for protein in critically ill obese patients with BMI 30-40? BMI > or equal to 40?
Greater than or equal to 2.0 g/kg IBW (BMI 30-40)
Up to 2.5 g/kg IBW (BMI > or equal to 40)
(TRUE/FALSE)
There is no safe concentration of iron dextran in any TNA.
TRUE.
-Iron dextran has the greatest risk of destabilizing the ILE in a TNA (total nutrient admixture) (a trivalent cation)
- Na & K are the least disruptive to the emulsifier (monovalent cations)
- Ca & Magnesium are medium disruptive (divalent cations)
Has to do with excess of cations. So the higher the cation valence, the greater the destabilizing power.
What are common factors associated with the majority of PN prescribing errors?
- Inadequate knowledge regarding PN therapy
- Certain patient characteristics (age, impaired renal function, etc)
- Miscalculation of PN dosages
- Specialized PN dosage formulation characteristics
- Prescribing nomenclature
According to the ASPEN PN Safety Consensus Recommendations, which is the best method to express the dextrose content on the label of a PN formulation in order to avoid misinterpretation?
Grams per 24-hour nutrient infusion (ie: 200 g/day)
- PN ingredients shall be ordered in amounts per day for adults and amounts per kg for peds and neonatal patients
- This limits the confusion from amounts per liter, percent concentration, or volume
According to the ASPEN PN Safety Consensus Recommendations, what is considered mandatory for the PN order form? What is recommended, not required?
- Complete patient identifiers (birth date/age, allergies)
- Height and dosing weight
- Diagnosis/diagnoses
- Indication for PN
- Administration route/vascular access device
- Contact info for prescriber
- Date & time order submitted
- Administration date & time
- Volume and infusion rates
- Infusion schedule (continuous or cyclic)
- Type of formulation (TNA vs. dextrose/AA with separate ILEs)
PN Ingredients shall be ordered as follows:
- Amounts per day
- Electrolytes as a complete salt form
- Full generic name for each ingredient (using Joint Comm approved abbreviations and avoiding ISMP error-prone abbreviations)
- Dose for each macronutrient and electrolyte
- Dose for vitamin (including MVI)
- Dose for trace elements
- Dose for each non-nutrient medication
**The addition of recommended lab monitoring for PN order forms is strongly recommended, but NOT required
According to the ASPEN PN Safety Consensus Recommendations, how are electrolytes to be expressed on an PN order form?
As complete salt forms, NOT individual ions
According to the ASPEN PN Safety Consensus Recommendations, what should be included on the PN label?
- Two patient identifiers
- Patient location or address
- Dosing weight in metric units
- Administration date & time
- Beyond use date & time
- Route of administration
- Prescribed volume and overfill volume
- Infusion rate in ml/hr
- Duration of infusion (continuous vs. cyclic)
- Size of in-line filter (1.2 or 0.22 micron)
- Completer name of all ingredients
- Barcode
- All ingredients shall be listed in the same sequence and sam units of measure as PN order
- Name of institution or pharmacy
15, Institution or pharmacy contact information (including phone number)
When ILE is infused separately, what must the ILE label include?
- Two patient identifiers
- Patient location or address
- Dosing weight
- Admin date & time
- Route of admin
- The prescribed amount of ILE and volume required to deliver that amount
- Infusion rate in ml/hr
- Duration of infusion (not longer than 12 hours)
- Complete name of ILE
- Beyond use date & time
- Name of institution or pharmacy
- Institution/pharmacy contact info (including phone number)
One mL of 20% ILE is equal to how many calories?
2 kcals
How many grams of fat per mL does 20% ILE provide?
20 grams fat / 100 mL
So 225 mL of 20% ILE provides: 45g fat and 450 kcals
How many mLs is considered high for fistula output?
> 500 mL/day
This is considered an indication for PN
(TRUE/FALSE)
Severely malnourished patients may benefit from preoperative nutrition support.
TRUE
Note that significant reductions in perioperative complications are achieved when receiving more than 7 days of preoperative PN.
A common complication of central venous catheters inserted at the bedside is what?
Catheter misplacement, including pneumothorax.
(TRUE/FALSE)
PN solutions can be started immediately if the catheter was inserted with the use of fluoroscopy.
TRUE
(TRUE/FALSE)
Routinely replacing central venous catheters, PICCs, HD catheters, or pulmonary artery catheters prevent catheter-related infections and CRBSI.
FALSE
The CDC recommends:
- Only removing the PICC line if it is suspected or known to be the source of infection
- PICCs and CVCs should not be removed based on fever alone.
According to ASPEN, what is the maximum osmolarity that can be safely infused peripherally?
900 mOsm/L
The lower concentrated dextrose solutions (5%, 10%) and AA solutions (3%) are most often used for peripheral administration:
- Osmolarity of 10% dextrose = 500 mOsm/L
- Osmolarity of 3% AA = 300 mOsm/L
What reduces the risk of calcium phosphate precipitation in PN?
Increased AA concentration
- By forming soluble complexes with calcium, thereby reducing the free calcium ions available to form insoluble dibasic calcium phosphate precipitates.
- Also, higher [AA] may lower the pH of the PN formulation, which improves calcium phosphate solubility.
When compounding PN, it is important to add the [calcium/phosphate] first and then add the [phosphate/calcium] near the end of compounding to utilize the maximum volume of PN formulation to dilute the salts.
Phosphate, first
Calcium, near the end
In a patient with hepatobiliary disease, which two trace elements should be withheld or require a dosage reduction when prescribing PN?
Copper and Manganese, due to impaired excretion
Reduction or removal of copper and manganese from the PN solution is recommended for patients with decreased liver function.
(TRUE/FALSE)
Manganese is a contaminant found within the PN solution components, thus patients will likely receive small doses of manganese even if eliminated from the PN trace element prescription.
TRUE
What trace element toxicity presents as Parkinson-like symptoms in long-term PN patients?
Manganese
Symptoms: tremor, involuntary movements, and rigidity
Patients with abnormal liver function are at an increased risk for toxicity due to manganese being primarily excreted via bile
When compared to the DRIs for fat-soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are:
- Lower
- Equal
- Higher
EQUAL
When compared to the DRIs for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are:
- Lower
- Equal
- Higher
HIGHER, parenteral doses are 2 to 2.5 x higher than the RDA or AI because of increased requirements due to malnutrition, baseline vitamin deficiencies, and increased urinary excretion of water-soluble vitamins when used intravenously.
Compounding of PN using manual or automated devices during which there are multiple injections, detachments, and attachments of nutrient source products to the device or machine to deliver all nutritional components to a final sterile container is classified as?
Medium-Risk
Compounding that involves using nonsterile ingredients or nonsterile devices prior to terminal sterilization, is considered what risk?
High Risk
L-glutamine for supplementation in PN formulation
Transfer, measuring, and mixing manipulations with closed or sealed packaging systems that are performed promptly and attentively are considered what risk?
Low Risk
(TRUE/FALSE)
ACDs (automated compounding devices) ensures an error free process.
FALSE
~22% when automated and 37% when manually prepared
When is manual PN compounding indicated?
When the volume of a PN component is less than the ACD can accurately deliver, OR
When there is an interaction between a PN component and ACD component, OR
When chemical reactions between PN components cannot be mitigated by sequencing the addition of ingredients, OR
As part of a conservation effort during drug shortages
Creaming of a TNA (total nutrient admixture) appears as?
A translucent band at the surface of the emulsion separate from the remaining TNA dispersion
Cracking of a TNA appears as? What does cracking refer to?
Cracking = terminal state of emulsion destabilization:
- Yellow-brown droplets at or near the TNA surface
- A continuous layer of yellow-brown liquid at the surface of the TNA
- Marbling or streaking of the oil throughout the TNA
Why is hyperglycemia a common complication when transitioning a critically ill patient from PN to EN?
Patients may receive nutrients in excess during the overlap of therapy leading to hyperglycemia.
Appropriate adjustments to limit total CHOs intake to no greater than 4 mg/kg/min can prevent this metabolic complication in many of these patients.
How can rapid infusion of phosphate result in tetany?
Due to an abrupt decrease in serum [Ca2+]
Tetany = intermittent muscular spasms
While receiving PN, your patient develops metabolic acidosis. Which serum electrolyte level needs to be monitored closely?
Potassium
What is considered to be the most serious complication of significant hyperphosphatemia?
Soft tissue and vascular complications
Occurs when serum phosphorus levels exceed 55 mg/dL
Additional consequences: secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia.
What biochemical evidence indicates EFAD?
A triene to tetrene ratio > 0.2
Can occur within 1 to 3 weeks of adults receiving PN without ILEs
How much linoleic acid should be given to prevent EFAD?
2 to 4% of daily energy requirements
How much alpha-linolenic acid should be given to prevent EFAD?
0.25 to 0.5% of energy
(TRUE/FALSE)
When serum TG levels exceed 400 mg/dL, ILE infusion should be decreased to levels that prevent EFAD?
TRUE
The FDA currently recommends that daily intake of parenteral aluminum not exceed what amount?
5 mcg/kg/day
When should PN be cycled? Why?
For patients at risk for liver dysfunction (because continuous PN can result in hyperinsulinemia and hepatic fat deposition, thereby increasing the risk for liver complications), OR
Long-term TPN patients that are stable and active
