Ch: 17 Complications of Parenteral Nutrition Flashcards
What causes prerenal azotemia?
Dehydration, excess protein, and/or inadequate energy from other nonprotein sources
To reduce risk of hypertriglyceridemia, how should ILE be given/infused
ILE should be restricted to <30% of total energy or 1 g/kg/d; also, if ILE is administered separately, it should provide slowly over at least 8-10 hours
What is the most common complication of PN administration?
Hyperglycemia
How much phosphorus does APSEN recommend be put in PN?
20-40 mmol/d
The FDA establishes labeling requirements for ______ contamination or large volume, small volume, and pharmacy bulk packages used in PN compounding?
Aluminum
To avoid metabolic acidosis, what should be added to TPN in adequate amounts?
Acetate
When should patients/caregivers add MVI to their PN
just prior to administration of the PN
How should PN be initiated?
At ½ of the estimated energy needs or approximately 150 to 200 g dextrose for the first 24 hours. Delivery of less dextrose (~100 g) may be warranted if pt has low BMI or poor glycemic control
What generally causes osteomalacia?
Vit D deficiency
How much vitamin K is included in the 13 vitamin preparation for PN?
150 mcg; this interacts with warfarin and can cause treatment failure
How much calcium does ASPEN recommend in PN to offset higher ca urinary losses?
10-15 mEq calcium gluconate from PN formula
In acutely ill patients, CHO administration should not exceed what?
Rate of 4-5 mg/kg/min or 20-25 kcal/kg/d in acutely ill patients
How much vit D is contained in a PN adult MVI prep?
200 IU of vit D (ergocalciferol or cholecalciferol)
What are the three types of hepatobiliary disorders?
Steatosis (more common in adults), cholestasis (more common in childern), and gallbladder sludge/stones
How is risk of hypoglycemia in PN patients reducted
To reduce risk of hypoglycemia, 1-2 hour taper down of the infusion or half the infusion rate may be necessary
What are some clinical manifestations of a EFAD?
Alopecia, hepatomegaly, thrombocytopenia, fatty liver, and anemia
What kind of insulin should be added to PN
Regular insulin
What insulin regimen is common in adding insulin to PN
In initial insulin regimen of 0.05-0.1 units per gram of dextrose in the PN is common, or 0.15 to 0.2 units per gram of dextrose may be used in patients who are already hyperglycemic
Can ILE be given to a patient with pancreatitis?
ILE is considered safe for use in patients with pancreatitis without hypertriglyceridemia
What is the primary factor that causes steatosis?
excessive energy intake
In patients with hepatobiliary disease, which trace elements should clinicians consider reducing/removing?
manganese and copper
What are some stratagies to manage PN related hepatobiliary complications?
Rule out non PN etiologies (hepatoxic meds), consider PN modifications (decreasing dex or ILE, cyclic infusion), maximize enteral intake, prevent/treat bacterial overgrowth, prescribe meds (ursodiol, cholestyramine)
What is a prominent manifestation of a magnesium deficiency?
Hypocalcemia should be related with magnesium supplementation b/c it is often refractory to calcium therapy alone. Magnesium deficiency can also lead to hypophosphatemia b/c of increased phos excretion
What is the prime indicator for diagnosing cholestasis?
An elevated serum conjugated bili (greater then 2 mg/dL is considered the prime indicator for cholestasis
Aside from PN, what are some other risk factors for developing cholestasis?
include bacterial/fungal infections, sepsis, SIBO, massive intestinal resection and small bowel remnant < 50 cm have been associated w/ chronic cholestasis
What should be given to all adult patients receiving PN?
A standard daily dose of PN MVI
Chronic metabolic acidosis is associated with what?
Hypercalciuria and metabolic bone disease
Excess chloride, diarrhea and acute renal failure are also common causes of metabolic acidosis.
A long-term PN patient presents with involuntary movements, tremor, and rigidity. What etiology may explain these symptoms?
Manganese toxicity
Catheter related thrombosis caused by fibrin build up within blood vessels adhering to a central venous catheter is called
Mural thrombus
The best approach to prevent PN-induced cholelithiasis is what?
Early initiation of oral or enteral feeding, even in small amounts, to stimulate cholecystokinin secretion, bowel motility and gallbladder emptying. Injections of CCK-OP to induce gall bladder contractions and reduce biliary sludge have yielded mixed results and caused gastrointestinal intolerance in some patients
What is most likely responsible for elevated serum bicarbonate levels in a home parenteral nutrition (PN) patient?
Excess acetate salts in the PN
An elevated serum bicarbonate level is one of the markers of metabolic alkalosis. Metabolic alkalosis may be caused by nasogastric suctioning, volume depletion and diuretic use. In a PN patient, excess use of acetate, which is metabolized to bicarbonate, may precipitate a metabolic alkalosis.
What feature of a Groshong® Central Venous Catheter reduces the risk of catheter occlusion?
Pressure sensitive three-way valve
What is the only FDA-approved thrombolytic agent for CVAD occlusions?
Cathflow (Alteplase)
The most common route of infection for a tunneled central venous access device (CVAD) is what?
Contamination of the catheter hub
The most common route of infection for a nontunneled CVAD is what?
Extraluminal colonization of the catheter or intraluminal colonization of the hub and lumen of the CVAD.
What is pinch off syndrome?
Pinch-off syndrome occurs when the catheter is being compressed between the first rib and the clavicle, causing intermittent compression and pinching.
This can lead to intermittent occlusion of infusion and aspiration and an increased risk of catheer fracture. Changes in the patient’s position can widen or narrow the angle between the rib and clavicle, usually by raising or lowering the arm, which can relieve occlusion of the catheter
How is superior vena cava syndrome characterized?
Superior vena cava syndrome is characterized by shortness of breath, dyspnea, cough, cyanosis of face, neck, shoulder and arms, and distended chest or neck veins.
Rapid intravenous infusion of potassium phosphate may result in what
thrombophlebitis; Infusion rates of phosphate should not exceed 7 mmol/h because faster infusion rates can often cause thrombophlebitis (ie, potassium phosphate) and metastatic calcium-phosphate deposition with potential resultant organ dysfunction.
In a patient with hepatobiliary disease, which trace elements should be withheld or requires a dosage reduction when prescribing parenteral nutrition?
Copper and manganese
When compared to the Dietary Reference Intakes (DRIs) for fat- soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are _____
Equal
When compared to the Dietary Reference Intakes (DRIs) for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are ____
Higher
According to United States Pharmacopeia (USP) Chapter 797, a PN solution prepared from 8.5% amino acid solution with electrolytes and 70% dextrose, with multivitamins, trace elements, and famotidine added would be classified as ____ risk
Medium
How does creaming of a TNA appear?
a translucent band at the surface of the emulsion separate from the remaining TNA dispersion.
In general, light creaming is a common occurrence and not a significant determinant of infusion safety except in extreme cases.
Rapid intravenous infusion of sodium or potassium phosphate may result in what?
Tetany; Rapid infusion of phosphate can result in tetany due to an abrupt decrease in serum calcium concentration.
