Block 2: Parenteral Nutrition

Question 1

What are the types of PN?

Answer 1

CPN and PPN

Question 2

PN is classified as a ___ medication

Answer 2

High alert

Question 3

2-in-1 PN

Answer 3

Dextrose, amino acids, electrolytes, vitamins, and minerals in one PN bag, ILE administered separately

Question 4

3-in-1 PN

Answer 4

Total nutrient admixture (TNA) and all-in-one: all PN macronutrients (amino acids, dextrose, and ILE) as well as other PN ingredients in same PN bag

Question 5

Continuous PN?

Answer 5

PN infused over 24 hr

Question 6

Cyclic PN

Answer 6

PN infused over < 24 hours (usually 8–18 h)

Question 7

MCB

Answer 7

Multichambered bags

Question 8

What are the indications for PN?

Answer 8

1. Impaired absorption, loss of nutrients via the GIT, EN can worsen infection
2. Mechanical bowel obstruction
3. Restrict PO intake or EN for bowel rest
4. Motility disorders
5. Inability to achieve or maintain enteral access or EN

Question 9

What patients would used PN?

Answer 9

1. Patient with GI problems
2. Pancreatitis
3. Cancer
4. Critical patients with malnutrition
5. Hyperemesis gravidarum
6. Eating disorders

Question 10

What is the goal of TPN?

Answer 10

1. Provide 100% of nutritional needs
2. Avoid complications
3. Facilitate transition to PO/enteral

Question 11

What is come of the points when prescibing PN?

Answer 11

1. If the gut works, use it via EN
2. Individualize therapy and don’t overfeed leading to FLS, hypertriglyceridemia, hyperglycemia
3. Titrate
4. Trasition to PO to prevent GI decay, nutrient def, FLS

Question 12

When should you initiate PN

Answer 12

1. After 7 days in patients who are weel nourished and stable
2. After 3-5 days in those who are nutritionally at risk
3. As soon as feasible in patients with baseline moderate- severe malnutrition
4. After 7-10 days if unable to meet > 60% of energy
5. after 7-10 days if unable to meet > 60% of energy

Question 13

What are the most common nutritional screening?

Answer 13

NRS and NUTRIC

Question 14

What are the main principles of Nutritional screening?

Answer 14

1. What is the condition now: BMI
2. Is the condition stable: assess rectent weight loss (>5% in 3 months is significant)
3. Will the condition worsen – has food intake decreased; bowel obstruction
4. Will the disease process accelerate nutritional deterioration?

Question 15

When do you initiate NUTRIC screening?

Answer 15

If “Yes” to any”
1. BMI < 20.5 kg/m2
2. Weight loss within 3 months
3. Reduced dietary intake in the last week
4. ICU patient

Question 16

When do you use the NUTRIC score?

Answer 16

1. Critically ill

Score of 0-5 indicates low risk
Score of 6-10 indicates high risk

Question 17

What is pharmacist job in regards the PN?

Answer 17

1. Nutrition support team
2. Evaluate the PN prescription
3. Clinical review

Question 18

What are the types of macronutrients?

Answer 18

1. AA
2. Carbs
3. Lipids

Question 19

Who manny kcal does 1 g aa provide?

Answer 19

4 kcal

10-20% total kcal

Question 20

Who manny kcal does 1 g lipid provide?

Answer 20

9kcal

10% IVFE: 1.1 kcal/mL
20% IVFE: 2 kcal/mL
30% IVFE: 3 kcal/mL
Should provide 15-30% of total non-protein kcal

Question 21

Who manny kcal does 1 g carb provide?

Answer 21

3.4 kcal

Should provide 45-60% total kcal

Question 22

What are the drugs that contain lipids?

Answer 22

1. Propofol: 1.1 kcal/mL
2. Clevidipine: 2 kcal/mL
3. Amphotericin B

take them into account of fat calories if patient is on it

Question 23

What are the micronutrients?

Answer 23

1. Vitamins
2. Trace elements
3. Electrolytes

Question 24

What are you multivitmins? Volume?

Answer 24

10mL:
1. Vitamins A, B1, B2, B6, B7, B9, B12, C, K, niacinamide, dexpanthenol

Question 25

What are trace elements? Volume?

Answer 25

1 mL 1. Zince sulfate 2. Copper 3. Sulfate 4. Manganese 5. Chromium 6. Chloride 7. Selenium

Question 26

What are your electrolyte the additives?

Answer 26

1. NaCl 2. Soidum acetate 3. Sodium phosphate 4. KCl 5. Potassium acetate 6. Potassium phosphate 7. Calcium gluconate 8. Mg sulfate

Question 27

Daily requirement for Ca, Mg, P, Na, K?

Answer 27

Ca: 10-15 mEq Mg: 8-20 mEq P: 20-40 mmol Na: 1-2 mEq/kg K: 1-2 mEq/kg

Question 28

What is the difference between chloride and acetate salts?

Answer 28

**Chloride:** acidifier for metabolic alkalosis **Acetate:** alkalinizer for metabolic acidosis

Question 29

What the indications of PPN?

Answer 29

1. Lower risk of infections, metabolic, and tech complications 2. Mild-moderate stressed patients from whom central access is unavailbale or undesirable

Question 30

What is the indication of CPN?

Answer 30

1. Risks associated with catheter insertion and care of the site, greater potential for infection and catheter-induced trauma 2. Larger blood vessels with higher blood flow rates quickly dilute hypertonic solutions

Question 31

What is the max of PPN?

Answer 31

900 mOsm/L

Question 32

With osmolarity is too high in PN how should you lower macronutrients?

Answer 32

**Amino Acid:** 10 X grams of amino acid/liter **Dextrose:** 5 X grams of dextrose/liter **Lipid emulsion (20%):** 1.3 mOsm x g

Question 33

What are the benefits and limitations of P IV?

Answer 33

**Benefits:** Fast access, can be started by nurses and phlebotomist **Limitations:** Infiltration, phlebitis, or catheter obstruction can interrupt therapy * Osmolarity > 900 mOsm/L must be given via central line

Question 34

What are examples of long term Central IV therapies?

Answer 34

1. **Peripheral Inserted Central Catheter (PICC)** 2. Tunneled cantral venous catheter 3. Non tunneled 4. **Ports central venous cath (oncology)**

Question 35

What are the steps to calculate TPN?

Answer 35

1. Calculate TEE 2. Calculate protein needs 3. Calculate lipid needs 4. Calculate carbs need 5. Calculate sterile water

Question 36

What is the distribution of total calories?

Answer 36

Question 37

How do you calculate lipid needs?

Answer 37

1. 10-30% of non-protein calories = in kcal 2. Lipid in gram = total mL x % (the strength of AA you use) **Lipid do not need to be given daily esp. in high TG:** * Lipid infusion * If lipid given alone: hang over 12 hours, * If 3 in one: 24 hours * With 1.2-micron filter

Question 38

How do you calculate carb needs?

Answer 38

1. Total carb cal=total calories-protein calories - lipid calories 2. Calculate total g dx: * Dextrose monohydrate: 3.4 kcal/g * Complex: 4 kcal/g * Dextrose in PN: 70%, 50%, 30%, 20% 3. Calculate total of DX: * Total g dx x %

Question 39

How do you calculate PN fluid needs?

Answer 39

1. Total fluid needs (when weight > 20 kg) =1500 mL + (20 mL) x (weight in Kg – 20) 2. Sterile water (mL) = total fluid needs (mL) – protein (mL) – lipid (mL) – DX (mL)

Question 40

What are the steps to calculate TPN?

Answer 40

1. Calculate total kcal/day 2. Calculate protein dose in grams, kcal and mL 3. Determine fat dose in grams, kcal and mL 4. Subtract protein and fat kcal from total kcal to get carbohydrate kcal [total kcal – protein kcal – fat kcal = CHO kcal] * Convert CHO kcal to grams, get mL 5. Sterile water volume: * Determine total fluid volume * Sterile water added = total fluid volume - the volume from (protein + lipid + CHO)

Question 41

Describe the interaction between ca and P?

Answer 41

1. Add potassium or sodium phosphate early and calcium gluconate nearly last 2. Use calcium gluconate (NOT chloride) 3. When both values are high, risk of precipitation occurs Cal (mEq/L) x Phosphate (mEq/L) > 55-60 results in precipitation and deposition of complexes in the vasculature

Question 42

What are the complications of PN?

Answer 42

**GI:** GI atrophy, cut bacterial overgrowth **Metabolic/nutritional:** FLD, HTG, HPG, refeeding **Mechanical:** pump failure, problems with tubing, clogging **Infectious:** Line infection

Question 43

What is refeeding syndrome?

Answer 43

1. Starvation/malnutrition – catabolism * [glucagon] increases and [Insulin] decrease * rapid conversion of glycogen stores to glucose, gluconeogenesis, fat metabolism 2. Refeeding (switch to anabolism) * (When feeding) Shift from fat to carbohydrate metabolism * insulin release -> increased cellular uptake of glucose, phosphate, potassium, magnesium, and water

Question 44

What are the risk facotrs of reffeding syndrome?

Answer 44

1. not been fed for 7-10 days with evidence of stress and depletion 2. Prolonged fasting and massive weight loss in obese patients 3. Anorexia 4. Oncology patients

Question 45

How do we start and stop TPN?

Answer 45

1. Start at 1/2 the goal rate -> increase as tolerated 2. Decrease by 1/2 current rate -> discontinue no sooner than 4 hours later

Question 46

What monitoring parameters are we looking at in PN?

Answer 46

1. Body weigh 2. Inputs and outputs 3. Vitals 4. Blood glucose 5. Serum electrolytes 6. TG 7. Kidney: BUN/SCr Liver function tests Nutrition status: Albumin, prealbumin