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Master Deck > Chapter 14: Overview of PN > Flashcards

Chapter 14: Overview of PN Flashcards

1
Q

What are ILEs?

A

Lipid injectable emulsions

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2
Q

What determines osmolarity of PN formulation?

A

Dextrose, AA, and electrolyte content

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3
Q

How much osmolarity does dextrose contribute to PN formulations?

A

5 mOsm/g

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4
Q

How much osmolarity does AA contribute to PN formulations?

A

10 mOsm/g

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5
Q

How much osmolarity do electrolytes contribute to PN formulations?

A

1 mOsm/g of individual electrolyte additive

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6
Q

What is the maximum osmolarity tolerated by a peripheral vein?

A

900 mOsm/g; anything higher requires CPN

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7
Q

What does CPN stand for?

A

Central PN, aka TPN

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8
Q

How is CPN safe?

A

The glucose, AA and electrolyte content provides a hyperosmolar formulation (1300 to 1800 mOsm/g) that must be delivered into a large-diameter vein, such as the superior vena cava adjacent to the right atrium. The rate of blood flow in these large veins rapidly dilutes the hypertonic parenteral feeding formulation to that of body fluids, maximizing the risk of complications associated with an IV infusion of hypertonic solutions.

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9
Q

How long can central venous access be maintained?

A

weeks to years

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10
Q

(TRUE/FALSE)

Large fluid volumes must be administered with PPN to provide energy and protein doses comparable to those of CPN.

A

TRUE.

Thus, making it an undesirable option for those with fluid restriction because concentrating the solution to meet their fluid requirements frequently results in a hyperosmolar solution that is NOT suitable for peripheral administration. Use CPN in this situation.

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11
Q

(TRUE/FALSE)

PPN is an undesirable option for patients with fluid restriction.

A

TRUE.

Concentrating the solution to meet their fluid requirements frequently results in a hyperosmolar solution that is not suitable for peripheral administration.

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12
Q

(TRUE/FALSE)

PPN may be used in patients to provide partial or total nutrition support.

A

TRUE

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13
Q

How long is PPN typically used for?

A

Short periods (up to 2 weeks) because patients’ tolerance is limited and because there are few suitable peripheral veins.

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14
Q

(TRUE/FALSE)

PPN is generally indicated in malnourished patients requiring longer period of nutrition support.

A

FALSE.

PPN is NOT generally indicated… Only short periods (up to 2 weeks).

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15
Q

What are the two criteria, that must be met, for PPN.

A
  1. Must have good peripheral venous access AND 2. Should be able to tolerate large volumes of fluid (2.5 to 3.0 L/day). Also, they should require at least 5 days but no more than 2 weeks of partial or total pN.
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16
Q

(T/F) ILE may be used to increase the energy density of the peripheral parenteral feeding formulation without increasing the osmolarity, and it has been reported to improve peripheral vein tolerance of PPN.

A

TRUE

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17
Q

Name some contraindications for PPN (6).

A

-Significant malnutrition -Severe metabolic stress -Large nutrient or electrolyte needs (potassium is a strong vascular irritant) -Fluid restriction -Need for prolonged PN (> 2 weeks) -Renal or liver compromise

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18
Q

Define permissive underfeeding.

A

A concept relevant to critically ill patients who do not tolerate nutrition, especially PN, well. This approach is intended to minimize complications of PN delivery by providing only 80% of estimated energy requirements until the patient’s condition improves.

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19
Q

Define hypocaloric feeding.

A

Used in both EN and PN therapy for obese patients to meet protein requirements but provide less energy than the estimated requirement. This approach is also designed to minimize the metabolic complications of PN while improving N balance. It is used for patients with a BMI greater than 30, unless weight loss is not intended. Note very little research is available for long-term (greater than 30 days) use of this approach.

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20
Q

Define supplemental feeding.

A

An approach designed to minimize the energy deficit that accumulates during periods of no nutrition or undernutrition. It is used in those circumstances where EN is insufficient to meet energy needs.

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21
Q

(TRUE/FALSE)​

PN has been shown to benefit patients with moderate-to-severe malnutrition who have no or inadequate oral or EN for prolonged periods.

A

TRUE.

This is particularly relevant to the following populations: -Patients receiving perioperative support -Patients with acute exacerbations of Crohn’s disease, GI fistulas, or extreme short bowel syndrome -Critical care -Cancer patients

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22
Q

**What are the indications for PN use:

A

**ASPEN Recommendation:**

-PN may be appropriate for patients who are unable to meet nutrition requirements with EN. These patients are already or have the potential to become malnourished.

  • PPN may be used in selected patients to provide partial or total nutrition support for up to 2 weeks when those patients cannot ingest or absorb oral or enteral tube-delivered nutrients, OR when CPN is not feasible.
  • CPN support is necessary when PN is indicated for longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or FR is required, and the benefits of PN outweigh the risks.
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23
Q

**What are the indications for CPN use:

A

**ASPEN Recommendation:**

  • The patient has failed the EN trial with appropriate tube placement (post-pyloric)
  • EN is contraindicated or the GI tract has a severely diminished function because of the underlying disease or treatment. Specific applicable conditions are as follows:
    • Paralytic ileus
    • Mesenteric ischemia
    • SBO
    • GI fistula, except when enteral access may be placed posterior to the fistula or volume of output (less than 200 ml/day), support a trial of EN.
  • The exact duration of starvation that can be tolerated without increased morbidity is unknown, as can occur in postoperative nutrition support. Expert opinion suggests that wound healing will be impaired if PN is not started within 5 to 10 days postoperatively for patients who cannot eat/tolerate EN.
  • The patient’s clinical condition is considered in the decision to withhold or withdraw therapy. Conditions where nutrition support is poorly tolerated and should be withheld until the condition improves are:
    • Severe hyperglycemia
    • Azotemia (elevation in BUN > 100 mg/dL and [Cr] levels)
    • Encephalopathy and Hyperosmolarity
    • Severe fluid and electrolyte disturbances
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24
Q

**What is the recommendation for initiating PN in critically ill patients with normal nutrition risk or no malnutrition?

A

**Initiate PN when patient has been NPO/Inadequate intake x 7 days, with normal nutrition risk.

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25
Q

**What is the recommendation for initiating PN when patients are malnourished or have high nutrition risk?

A

**PN is indicated when EN is not feasible.

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26
Q

**What is the recommendation for initiating PN in other conditions that preclude the use of the GI tract?

A

**More than 7 to 10 days.

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27
Q

(TRUE/FALSE)

Bowel rest is no necessary to achieve remission in Crohn’s disease.

A

TRUE.

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28
Q

(TRUE/FALSE)

GI or bowel rest and PN no longer have a role in pancreatitis.

A

TRUE.

Recent reviews highlight the importance of maintaining GI integrity with EN as a means to avoid complications from pancreatitis and improve outcomes from the disease.

PN is unlikely to benefit patients with mild, acute or chronic relapsing pancreatitiswhen the conditions last for less than 1 week.

PN should be avoided unless EN is not feasible because of GI ileus, SBO, or the inability to properly place an enteral feeding tube.

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29
Q

What are the recommendations for initiating PN when needed in treatment of pancreatitis?

A

PN energy administration should not exceed 25 to 35 kcal/kg/d and glucose be adequately maintained.

Consider glutamine supplementation to minimize the effect of being NPO on GI integrity.

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30
Q

Define perioperative PN.

A

Reserved for patients with severe malnutrition at baseline, in whom the risk of surgery would outweight any benefit because of the high risk of postoperative complications.

Maximal benefit is derived in severly malnourished patients who receive PN for more than 7 to 10 days.

PN is still reserved for when other nutrition options (GI feeding) is not feasible.

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31
Q

Define critical illness.

A

Characterized by a catabolic state that is generally the result of systemic inflammatory response to infectious or traumatic result.

Gut failure is common because of preferential blood supply to vital organs

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32
Q

Define mesenteric ischemia.

A

It is poor circulation in the vessels supplying blood flow to your mesenteric organs: your stomach, liver, colon and intestine. With poor circulation, blockages can form and compromise the function of these organs.

Results from hemodynamic compromise and the use of vasopressors

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33
Q

**ASPEN/SCCM Recommendation**

What are the recommendations for nutrition support in the ICU?

A

**ASPEN/SCCM Recommendation**

Recommend the enteral route as the preferred means of nutrition support in the critically ill. The greatest benefit derived in patients started on enteral feedings within 24 to 48 hours of ICU admission.

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34
Q

**ASPEN Recommendation**

What are the recommendations for the provision of nutrition support in adult patients receiving anticancer therapy?

A

**ASPEN Recommendation**

Recommends a thorough assessment of the patient’s nutrition status and the use of PN ONLY in those who are malnourished and likely to be unable to ingest and absorb adequate nutrients for a period of 7 to 14 days.

EN always preferred with functional GI tract. Also, preferred in patients undergoing hematopoietic cell transplant because glycemic control is better during EN than PN.

Consider immune-enhancing EN formulas.

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35
Q

What are the indications for home PN?

A
  • Duration of PN is prolonged (more than 2 weeks)
  • Medicare requires documentation that:
    • The patient’s GI tract is nonfunctional (“artificial gut”), AND
    • The condition is permanent (at least 90 days of therapy is needed), AND
    • Must have documented evidence of inability to tolerate EN (malabsorption, obstruction)
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36
Q
A
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37
Q

Stress-induced hyperglycemia in acutely ill and septic patients often develops from what 4 factors?

A
  1. Insulin resistance
  2. Increased gluconeogenesis (glucose generation)
  3. Increased glycogenolysis (glycogen breakdown)
  4. Suppressed insulin secretion
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38
Q

What are the 3 components of basal-bolus insulin therapy?

A
  1. Basal insulin
  2. Nutritional component prior to meals
  3. Correctional insulin
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39
Q

What form of glutamine supplementation improves physical compatibility and stability for admixture in PN solutions?

A

Glutamine dipeptide.

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40
Q

(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.

A

TRUE

TRUE

FALSE - oral nutrition supplements

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41
Q

What are the ASPEN/SCCM recommendations for calories in critically ill obese patients with BMI of greater than 30?

BMI > 50?

A

11 to 14 kcal/kg ACTUAL body weight (BMI 30-50)

22 to 25 kcal/kg IBW (BMI >50)

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42
Q

What are the ASPEN/SCCM recommendations for protein in critically ill obese patients with BMI 30-40? BMI > or equal to 40?

A

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)

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43
Q

(TRUE/FALSE)

There is no safe concentration of iron dextran in any TNA.

A

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.

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44
Q

What are common factors associated with the majority of PN prescribing errors?

A
  • Inadequate knowledge regarding PN therapy
  • Certain patient characteristics (age, impaired renal function, etc)
  • Miscalculation of PN dosages
  • Specialized PN dosage formulation characteristics
  • Prescribing nomenclature
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45
Q

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?

A

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
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46
Q

According to the ASPEN PN Safety Consensus Recommendations, what is considered mandatory for the PN order form? What is recommended, not required?

A
  1. Complete patient identifiers (birth date/age, allergies)
  2. Height and dosing weight
  3. Diagnosis/diagnoses
  4. Indication for PN
  5. Administration route/vascular access device
  6. Contact info for prescriber
  7. Date & time order submitted
  8. Administration date & time
  9. Volume and infusion rates
  10. Infusion schedule (continuous or cyclic)
  11. Type of formulation (TNA vs. dextrose/AA with separate ILEs)

PN Ingredients shall be ordered as follows:

  1. Amounts per day
  2. Electrolytes as a complete salt form
  3. Full generic name for each ingredient (using Joint Comm approved abbreviations and avoiding ISMP error-prone abbreviations)
  4. Dose for each macronutrient and electrolyte
  5. Dose for vitamin (including MVI)
  6. Dose for trace elements
  7. Dose for each non-nutrient medication

**The addition of recommended lab monitoring for PN order forms is strongly recommended, but NOT required

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47
Q

According to the ASPEN PN Safety Consensus Recommendations, how are electrolytes to be expressed on an PN order form?

A

As complete salt forms, NOT individual ions

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48
Q

According to the ASPEN PN Safety Consensus Recommendations, what should be included on the PN label?

A
  1. Two patient identifiers
  2. Patient location or address
  3. Dosing weight in metric units
  4. Administration date & time
  5. Beyond use date & time
  6. Route of administration
  7. Prescribed volume and overfill volume
  8. Infusion rate in ml/hr
  9. Duration of infusion (continuous vs. cyclic)
  10. Size of in-line filter (1.2 or 0.22 micron)
  11. Completer name of all ingredients
  12. Barcode
  13. All ingredients shall be listed in the same sequence and sam units of measure as PN order
  14. Name of institution or pharmacy
    15, Institution or pharmacy contact information (including phone number)
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49
Q

When ILE is infused separately, what must the ILE label include?

A
  1. Two patient identifiers
  2. Patient location or address
  3. Dosing weight
  4. Admin date & time
  5. Route of admin
  6. The prescribed amount of ILE and volume required to deliver that amount
  7. Infusion rate in ml/hr
  8. Duration of infusion (not longer than 12 hours)
  9. Complete name of ILE
  10. Beyond use date & time
  11. Name of institution or pharmacy
  12. Institution/pharmacy contact info (including phone number)
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50
Q

One mL of 20% ILE is equal to how many calories?

A

2 kcals

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51
Q

How many grams of fat per mL does 20% ILE provide?

A

20 grams fat / 100 mL

So 225 mL of 20% ILE provides: 45g fat and 450 kcals

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52
Q

How many mLs is considered high for fistula output?

A

> 500 mL/day

This is considered an indication for PN

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53
Q

(TRUE/FALSE)

Severely malnourished patients may benefit from preoperative nutrition support.

A

TRUE

Note that significant reductions in perioperative complications are achieved when receiving more than 7 days of preoperative PN.

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54
Q

A common complication of central venous catheters inserted at the bedside is what?

A

Catheter misplacement, including pneumothorax.

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55
Q

(TRUE/FALSE)

PN solutions can be started immediately if the catheter was inserted with the use of fluoroscopy.

A

TRUE

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56
Q

(TRUE/FALSE)

Routinely replacing central venous catheters, PICCs, HD catheters, or pulmonary artery catheters prevent catheter-related infections and CRBSI.

A

FALSE

The CDC recommends:

  1. Only removing the PICC line if it is suspected or known to be the source of infection
  2. PICCs and CVCs should not be removed based on fever alone.
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57
Q

According to ASPEN, what is the maximum osmolarity that can be safely infused peripherally?

A

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
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58
Q

What reduces the risk of calcium phosphate precipitation in PN?

A

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.
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59
Q

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.

A

Phosphate, first

Calcium, near the end

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60
Q

In a patient with hepatobiliary disease, which two trace elements should be withheld or require a dosage reduction when prescribing PN?

A

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.

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61
Q

(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.

A

TRUE

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62
Q

What trace element toxicity presents as Parkinson-like symptoms in long-term PN patients?

A

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

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63
Q

When compared to the DRIs for fat-soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are:

  • Lower
  • Equal
  • Higher
A

EQUAL

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64
Q

When compared to the DRIs for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are:

  • Lower
  • Equal
  • Higher
A

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.

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65
Q

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?

A

Medium-Risk

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66
Q

Compounding that involves using nonsterile ingredients or nonsterile devices prior to terminal sterilization, is considered what risk?

A

High Risk

L-glutamine for supplementation in PN formulation

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67
Q

Transfer, measuring, and mixing manipulations with closed or sealed packaging systems that are performed promptly and attentively are considered what risk?

A

Low Risk

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68
Q

(TRUE/FALSE)

ACDs (automated compounding devices) ensures an error free process.

A

FALSE

~22% when automated and 37% when manually prepared

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69
Q

When is manual PN compounding indicated?

A

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

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70
Q

Creaming of a TNA (total nutrient admixture) appears as?

A

A translucent band at the surface of the emulsion separate from the remaining TNA dispersion

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71
Q

Cracking of a TNA appears as? What does cracking refer to?

A

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
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72
Q

Why is hyperglycemia a common complication when transitioning a critically ill patient from PN to EN?

A

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.

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73
Q

How can rapid infusion of phosphate result in tetany?

A

Due to an abrupt decrease in serum [Ca2+]

Tetany = intermittent muscular spasms

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74
Q

While receiving PN, your patient develops metabolic acidosis. Which serum electrolyte level needs to be monitored closely?

A

Potassium

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75
Q

What is considered to be the most serious complication of significant hyperphosphatemia?

A

Soft tissue and vascular complications

Occurs when serum phosphorus levels exceed 55 mg/dL

Additional consequences: secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia.

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76
Q

What biochemical evidence indicates EFAD?

A

A triene to tetrene ratio > 0.2

Can occur within 1 to 3 weeks of adults receiving PN without ILEs

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77
Q

How much linoleic acid should be given to prevent EFAD?

A

2 to 4% of daily energy requirements

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78
Q

How much alpha-linolenic acid should be given to prevent EFAD?

A

0.25 to 0.5% of energy

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79
Q

(TRUE/FALSE)

When serum TG levels exceed 400 mg/dL, ILE infusion should be decreased to levels that prevent EFAD?

A

TRUE

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80
Q

The FDA currently recommends that daily intake of parenteral aluminum not exceed what amount?

A

5 mcg/kg/day

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81
Q

When should PN be cycled? Why?

A

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

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82
Q

When solely on PN how fast can essential fatty acid deficiency occur

A

2-4 weeks without linoleic or alpha linolenic acid

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83
Q

Symptoms of essential fatty acid deficiency

A

Dry scaly rash, impaired wound healing, increased infection risk, immune dysfunction, alopecia

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84
Q

The Holman Index

A

Triene to Tetraene ratio to test for essential fatty acid deficiency

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85
Q

EFAD can develop faster in lipid free PN secondary to

A

Insulin levels in PN are increased as there is typically a high dextrose dose which prevents lipolysis of adipose tissue which would be the fail safe for releasing EFAs that would be stored

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86
Q

TPN in the critical care unit should initially be

A

hypocaloric and lipid free

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87
Q

Should PN be started in the acute phase of severe sepsis with elevated triglycerides

A

No

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88
Q

Alpha Linolenic Acid is the precursor for

A

DHA and EPA (omega 3 fatty acids)

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89
Q

Contents of the Injectable Lipid Emulsion (ILE)

A

An oil in water emulsion, 1 triglyceride, glycerol and phospholipid emulsifier, vitamin E, K phytosterols and cholesterols

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90
Q

Which vitamins are in ILE’s

A

vitamin E and K

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91
Q

Long chain fatty acids require ____ to be oxidized for energy

A

L-Carnitine

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92
Q

What are needed to prevent essential fatty acid deficiency?

A

alpha linolenic acid and linoleic acid (Omega 3’s)

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93
Q

What percentage of calories is needed of alpha linolenic acid to prevent EFAD

A

0.25-0.5% omega 3 (alpha linolenic acid)

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94
Q

What percentage of calories is needed of linoleic acid to prevent EFAD?

A

1-4% omega 6 (linoleic acid)

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95
Q

In which type of oils are the highest concentration of linoleic acid found

A

Soybean and Corn Oil (Omega 6)

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96
Q

In which type of oils are the highest concentration of alpha linolenic acids found in?

A

Soybean and Canola Oil (Omega 3)

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97
Q

How much ILE is needed weekly to prevent EFAD

A

500mL/week

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98
Q

Maximum PN ILE infusion daily

A

2.5 g/kg/day

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99
Q

If a patient is critically ill, don’t exceed ____ amount of lipids IV a day

A

1g/kg/day

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100
Q

When using 100% soybean oil IV, hold lipids x _____ unless there is a concern for EFAD, then give _____

A

For 1 week, OR

100grams/week

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101
Q

Give IVFE at no more than _____ rate to avoid toxicity of rapid infusion (fat overload syndrome)

A

0.11 g/kg/hr

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102
Q

Why does PPF (10% ILE) lead to hypertriglyceridemia

A

10% ILE’s contain lipoprotein X which competes with triglycerides for lipoprotein lipase which is responsible for the breakdown of TCG’s, therefore they build up and cause hypertriglyceridemia

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103
Q

What should happen if serum triglycerides exceed 400mg/dL

A
  1. Decrease fat emulsion or hold
  2. Monitor serum TCGs 2x/week
  3. Remove lipids if also on PPF
  4. Try to start a patient on trophic enteral feeding
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104
Q

Omega 9 fatty acids

A

Olive Oil/Oleic acid used to lower cholesterol and triglycerides without lipid peroxidation often used in EN formulas

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105
Q

What is the suspected role of omega 3 fatty acids in parenteral nutrition

A

it contains fish oil which may cause LESS inflammation. Limited evidence is available at this time to be recommended.

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106
Q

Should omega 3 fatty acid ILEs be used in PN per ASPEN?

A

Limited Evidence by ASPEN

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107
Q

How can plant based ILEs lead to the development of liver dysfunction related to PN

A

phytoserols in plant based ILE’s are structurally similar to cholesterol which interferes with bile synthesis, transport of bile, increased lipid peroxidation causing free radical damage to the liver

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108
Q

typical IV dose of calcium

A

10-15 mEq/day (calcium gluconate) (also add magnesium)

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109
Q

typical IV dose of magnesium

A

5-8 mEq/L, or 80-20 mEq/day (magnesium sulfate)

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110
Q

how often should patients get MVI in PN

A

every day unless toxicity is suspected

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111
Q

what is added to PN that have demonstrated therapeutic effects in bone marrow transplants

A

glutamine supplementation

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112
Q

normal calcium requirements for PN with normal renal function

A

15mEq/day

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113
Q

what is the suggested adult PN thiamine daily dose

A

3 mg

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114
Q

when is PN recommended for burn patients

A

when EN is contraindicated or unlikely to meet nutritional needs (shouldn’t be the first route)

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115
Q

TPN terminates in the ____________ which can tolerate high osmolarity

A

superior vena cava

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116
Q

a central line should be placed if TPN is suspected for ___to ____ days in the hospital setting

A

7-14 days

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117
Q

PPN is indicated for _____ term use. Less than ______

A

short term use, <2 weeks

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118
Q

PPN is generally not recommended for malnutrition because

A

it cannot provide enough calories

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119
Q

what are 2 parameters for being a candidate for PPN

A
  1. good peripheral venous access

2. ability to tolerate large volumes o fluid 2.5-3 L

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120
Q

PPN should only be considered when PO or EN is not possible to meet a person’s nutrition needs for > than _____ days

A

5 days

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121
Q

You would consider PPN vs TPN when only indicated for use between ____ and ____ days

A

5-12

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122
Q

significant malnutrition, severe metabolic disturbance, marked nutrient needs, fluid restriction, and renal/liver compromise, and need for <2 weeks are contraindications to this type of PN

A

PPN

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123
Q

Thrombophlebitis can be caused by

A

high PN osmolarity or potassium

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124
Q

the term for providing up to 80% of energy needs until a patient’s condition improves, usually in the ICU

A

permissive underfeeding

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125
Q

the term for providing EN/PN of 60-75% of energy needs and high protein needs for the obese with BMI >30

A

hypocaloric feeding

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126
Q

this type of PN minimizes the energy deficit that accumulates during periods of no nutrition or undernutrition when EN is insufficient to meeting energy needs

A

supplemental PPN

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127
Q

indications for starting PN

A
  1. unable to meet nutrition requirements from EN
  2. when a patient cannot ingest or absorb oral or EN tube feedings
  3. paralytic ileus
  4. bowel obstruction
  5. GI fistula except when EN access can be placed posterior to the fistula,
  6. unable to use the gut for 7-10 days
  7. when EN access is contraindicated/failed attempts
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128
Q

when should PN be held off from starting

A
  1. azotemia
  2. severe hyperglycemia
  3. severe fluid/electrolyte imbalances
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129
Q

in the critically ill PN should not be considered until after ____ days when the patient has normal nutrition or no risk of malnutrition

A

7 days

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130
Q

when deciding to start PN be careful when blood sugar is over

A

300 mg/dL

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131
Q

when deciding to start PN, be careful when the patient is azotemic which means BUN is > than

A

100 mg/dL

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132
Q

when deciding to start PN, be careful when the patient is hypernatremic with a sodium > than

A

150 mEq/L

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133
Q

when deciding to start PN, be careful when the patient is hyperchloremic with metabolic acidosis with a chloride > than or hypochloremic with metabolic alkalosis with chloride

A

115 mEq/L , 85 mEq/L

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134
Q

Is PN recommended over EN for pancreatitis

A

no

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135
Q

if PN is indicated in pancreatitis what is important to manage, what are the kcal needs

A

25-35 kcal/kg, glucose control, consider glutamine to help minimize effect of GI integrity

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136
Q

PN can be used in the pre-operative phase in _______ _______ and should be at least ____ to ____ days for maximum benfit

A

severe malnutrition, 7-10 days

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137
Q

who in critical illness are appropriate for starting PN

A

malnourished at baseline, not able to ingest/absorb significant nutrition in 7-10 days, have adequate resuscitation from any hemodynamic compromise with paralytic ileus acute GIB or complete bowel obstruction

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138
Q

is PN clinically indicated in cancer

A

no; chemo/radiation can cause infectious complications, no improvement clinically

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139
Q

ASPEN recommendation for when to start PN in cancer

A

only when malnourished AND unlikely to ingest/absorb adequate nutrition in 7-14 days

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140
Q

is PN preferred for hematopoietic cell transplant

A

No

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141
Q

successful PN depends on these factors.

A
  1. adequate ordering transcribing, compounding, dispensing and administration of PN and interdisciplinary care/nutrition support team
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142
Q

Errors of PN

A
  1. infection of IV catheter
  2. over/under feeding
  3. errors during Rx, transcription or prep
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143
Q

Most errors that occur from PN occur from

A

prescribing PN order

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144
Q

What can help decrease errors in PN

A
  1. create nutrition guidelines
  2. multi step double check process
  3. verify electronically transcribed order against actual written order
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145
Q

if a patient who is critically ill and previously well nourished ins PN recommended

A

no

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146
Q

in severely malnourished patients in the ICU when is PN indicated

A

when unable to use GI tract in 7 days

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147
Q

other indications to start PN (precluding the use of the GI tract)

A
  1. unable to meet estimated nutrition needs with EN alone or at high risk of malnutrition
  2. TPN when needed for > 2 weeks and PPN when needed <2 weeks
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148
Q

patients with significant hyperglycemia, azotemia, encephalopathy, or severe fluid/electrolyte abnormalities should not start _____ until resolved

A

PN

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149
Q

patients with theses issues may not tolerate large volumes with PN

A

CHF, renal failure, liver failure with ascites

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150
Q

when providing high fluid in PN what should be monitored

A

pulmonary edema, blood pressure, pulse

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151
Q

what should initially be monitored when PN reaches goal rate

A

fluid status, renal status, routine blood glucose monitoring, LFT/TCGs periodically, serum visceral proteins weekly, nitrogen balance/urine output with functioning kidneys

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152
Q

periodically monitor triglycerides levels if ____ given

A

lipids

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153
Q

goal of parenteral nutrition

A

maintain a patient’s nutrition status until some form of EN is tolerated

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154
Q

how can rebound hyperglycemia be prevented when stopping PN

A

taper down for 1-2 hours before stopping

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155
Q

if a patient is on TPN and EN does TPN need to be tapered before stopping

A

no

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156
Q

Dextrose in TPN contains _____ kcal/kg

A

3.4 kcal/kg

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157
Q

ranges of dextrose concentrations available for PN

A

2.5-70%

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158
Q

pH of dextrose solutions in pN

A

3.5-6.5

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159
Q

why are concentrations of dextrose for peripheral PN usually <8%

A

concentrations >10% can cause phlebitis in peripheral veins

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160
Q

Standardized Commercially Available PN (SCAPN)

A

PN that contains glycerol/glycerine as their sugar alcohol providing 4.3 kca/kg, created for peripheral administration which has less of an insulin response

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161
Q

Protein provided in PN solutions come from _______ amino acids

A

crystalline

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162
Q

16% nitrogen + ___ g amino acids and ____ g nitrogen

A

6.25 g amino acids, 1 gram nitrogen

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163
Q

standard amino acid solutions in PN contain ___- and ___ amino acid

A

essential and nonessential

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164
Q

concentrations of PN amino acids range from

A

3-20%

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165
Q

amino acid formulations used for special disease states are called

A

modified amino acids

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166
Q

amino acid formulations made for hepatic encephalopathy contain

A

increased BCAAs and decreased aromatic amino acids

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167
Q

altered protein metabolism in liver failure increases the transport of ______ amino acids which cross the blood brain barrier and create neurotransmitters that cause altered mental status _____ amino acids do not cross the blood brain barrier reducing this effect

A

aromatic amino acids (bad), branched chain amino acids (good)

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168
Q

amino acid formulations made for stress, trauma and thermal energy contain

A

BCAAs, increased leucine, isoleucine and valine to improve nitrogen balance

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169
Q

amino acids made for _____ are highly concentrated between 15-20% amino acids

A

fluid restriction

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170
Q

20% Injectable Lipid Emulsions (ILE’s) contain 100%

A

soybean oil (long chain fatty acids)

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171
Q

100% soybean ILE’s contain these fatty acids

A

linoleic acid (omega 6) , oleic acid, alpha linolenic acid, stearic acid, and palmitic acid

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172
Q

30% ILE’s provide ____ kcal/mL and are only available for _____ PN

A

3 kcal/mL, TNA mixtures

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173
Q

10% ILE’s are found in ______ and have a higher phospholipid/triglyceride concentration than 20% ILE’s, increasing free phospholipids interfering with lipoprotein lipase clearance causing _______

A

propofol, hypertriglcyeridemia

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174
Q

the only other form of lipid approved by the FDA for PN use to reduce the amounts of omega 6 fatty acids are

A

SMOF lipid

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175
Q

SMOF lipid contains sources of fatty acids from

A

Soybean, mCt’s, olive oil and fish oil as well as EPH and DHA

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176
Q

SMOF lipid is a ______% concentration

A

20%

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177
Q

contraindications to using SMOF lipid

A

Egg, soybean, fish or peanut allergies

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178
Q

when is the use of SMOF considered for PN

A

if a patient cannot tolerate soy bean oil with metabolic stress or in carnitine deficiency as the medium chain triglycerides don’t require carnitine to transport into the mitochondria which will reduce risk of essential fatty acid deficiency

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179
Q

IV lipids contain ____ as an emulsifier

A

egg

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180
Q

how many mmols of phos to ILE’s contain

A

15 mmol

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181
Q

what is the pH range of ILE’s

A

6-9

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182
Q

what is the maximum infusion rate of ILE administration

A

0.11 g/kg/hour

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183
Q

high rate of ILE infusion can lead to hypertriglyceridemia and infection called

A

fat overload syndrome

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184
Q

headaches, seizures, fever, jaundice, abdominal pain, and shock are all symptoms of

A

fat overload syndrome

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185
Q

ILE’s should not exceed total energy of _____g/kg/day

A

2.5 g/kg/day

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186
Q

per ASPEN recommendations for ILE’s in the ICU

A

withhold soybean based oil ILE or limit to 100 g during the first week if the patient is at risk for EFAD

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187
Q

lipids that are lab derived made up of chemically altered triglycerides with specific fatty acids at the 3 binding sites

A

structured lipids

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188
Q

Are structured lipids used in the US

A

no, they are not commercially available in the US

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189
Q

Fish oil ILE’s contain more _____ which is thought to decrease inflammation

A

omega 3

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190
Q

are just fish oils recommended for PN use

A

no, they can lead to EFAD as they are low in arachidonic and alpha linolenic acid

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191
Q

Clinolipid contains ____ oil and is enough to protect against EFAD

A

olive oil (contains at least 20% omega 6 fatty acids)

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192
Q

what are the preferred cations for calcium and magnesium which will produce the least incompatibilities in PN

A

Calcium Gluconate

Magnesium Sulfate

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193
Q

electrolyte requirements for sodium per day in PN

A

1-2 mEq/kg/day

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194
Q

requirements for potassium IV per day in PN

A

1-2mEq/kg/day

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195
Q

chloride and acetate are added _____ for acid base balance

A

as needed

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196
Q

calcium requirements for PN per day

A

10-15 mEq

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197
Q

magnesium requirements for PN per day

A

8-20 mEq

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198
Q

phosphate requirements for PN per day

A

20-40 mmol

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199
Q

single IV vitamins for PN are not available for

A

biotin, panthothenic acid, riboflavin, vitamin A, D or E

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200
Q

MVI’s in PN come in ____ vitals

A

10mL

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201
Q

how many micrograms of vitamin K are in 10mL IV MVI

A

150 mcg

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202
Q

what make up the trace elements in PN (multi trace)

A

zinc, copper, manganese, selenium, iron (ferric chloride), iodine, molybdate, fluoride, chromium

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203
Q

only iron ____ is approved for addition to PN and are contraindicated with the use of ______

A

dextran, lipids

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204
Q

role of glutamine in PN

A

intestinal integrity, immune function, protein synthesis during stress

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205
Q

is glutamine added to regular crystalline amino acids

A

NO

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206
Q

there is no FDA approved IV form of ___ for the critically ill due to lack of mortality benefit

A

glutamine

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207
Q

a quaternary amine needed for transport and metabolism of long chain fatty acids into the matrix of the mitochondria for beta oxidation

A

carnitine

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208
Q

carnitine deficiency can lead to

A

impaired fatty acid oxidation increasing the chance hepatic steatosis

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209
Q

is carnitine available in IV form for PN

A

no but IV L-Carnitine is available for carnitine deficiency esp. for neonates

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210
Q

10% amino acid solutions for PN should only be used for

A

fluid restriction patients

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211
Q

reserve IV MVI for

A

patients ONLY getting PN as sole nutrition or medical need

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212
Q

Liquid MVI contains sorbitol which can cause ______

A

diarrhea

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213
Q

if in a shortage of IV MVI how should MVI be rationed

A

50% or 3 times a week

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214
Q

12-MVI doesn’t contain

A

vitamin K

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215
Q

the typical form of IV MVI is

A

13-MVI

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216
Q

In shortage if 13-MVI occurs 12-MVI should be given, what needs to be separately

A

vitamin K 150 mc/day or 5-10 mg/week

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217
Q

if there is a shortage of calcium gluconate (the preferred form) what should be done?

A

eliminate from PN, order/monitor a serum ionized calcium and monitor fore evidence of calcium deficiency

218
Q

if in a shortage calcium chloride needs to be infused for low calcium/calcium deficiency what should be done

A

infuse it SEPERATLY in a separate IV as it will cause precipitation if mixed w/ PN

219
Q

what is one of the most dangerous PN incompatabilities

A

formation/infusion of calcium phosphate precipitates using calcium chloride which is less soluble than calcium gluconate

220
Q

when providing 2 in 1 + piggy backed lipids what should be the hang time for ILE

A

12 hours

221
Q

desired dextrose in a TNA TPN solution is

A

> 10 %

222
Q

desired amino acid in a TNA TPN solution is

A

> 4%

223
Q

a desired glucose concentration of >10% and and amino acid concentration >4 % in a TNA mixture is to prevent

A

lipid destabalization

224
Q

Advantages of TNA 3:1 TPN solutions

A

aseptically compounded, more efficient for the pharmacy, less manipulation which decreased chance of bacterial contamination, more cost effective, easier to store at home

225
Q

Disadvantages of TNA 3:1 TPN solutions

A

large particle sizes for the filter, less stable and prone to separation of lipids, more sensitive to destabilization of divalent/monovalent electrolytes, patients may be unstable for a low final concentration of ILE, the bag is opaque 2/2 the lipids which makes it difficult to observe destablation, less stable over time

226
Q

who’s role is it to ensure that PN is prepared safely

A

pharmacist

227
Q

as part of the National Standards for Compounded Sterile Preparations, what is an essential part of the compounding process

A

compound an accurate formulation free of microbes/particulate matter

228
Q

USP

A

a private non profit company that sets standards for drug purity/safety

229
Q

Compounding TPN in a closed system with aseptic transfer is considered ____Risk per USP standards

A

low

230
Q

Reconstitution of several sterile products for transfer into several small volume or large volume PN preparation is considered ____ risk per USP standards

A

medium

231
Q

Preparation from bulk, non=sterile ingredients exposed to ISO standard class 5; no particles, 0.5 micr mols or larger or 100 particles by cubic inch is considered ____ risk per USP standards

A

high

232
Q

PN becomes _____ risk when L glutamine is compounded from non-sterile powder

A

high

233
Q

ACD stands for

A

Automated Compounding Decice

234
Q

PN that is compounded under computerized control is called

A

an ACD

235
Q

Why were ACD’s created for PN compounding

A

helped streamline the manufacturing sequence for multiple ingredient preparations such as PN

236
Q

advantages of ACD compounding

A

enhanced accuracy
can create unique volumes
more easily tailored to patient’s needs
reduces potential of contamination

237
Q

disadvantages of ACD compounding

A

tubing must be changed daily
your facility should be using PN often in order to be cost effective
large

238
Q

If PN using an ACD is made for adults, pedi and neonates PN should be infused ____ for each population

A

separately

239
Q

what is the best method to reduce transcription errors during the PN ordering process

A

the PN order should be electronically integrated without requiring re entry of data

240
Q

as part of quality control of the PN process the pharmacist should visually _______ each PN for physical defects, phase separation, package integrity

A

visually inspect

241
Q

_____ determines whether PN formulations have been compounded properly, using refractive index of dextrose/amino acids

A

Refractometry

242
Q

if refractive measures differs from ____ values in refractometry, the formula could be improperly admixed

A

predicted values

243
Q

_____ _____ must be developed to ensure that PN is not exposed to extremes in temperature or light

A

written procedures

244
Q

2-in-1 or 3-in-1 TPN solutions that are kept in internal membrane that separates the macronutrients into different chambers and is broken so the components can be mixed just before administration are called

A

Standardized Commercially Available PN Formulations (SCAPN)

245
Q

SCAPNs require addition of ______ injection before administration because they are not stable for >24 hours

A

MVI

246
Q

SCAPN bags contain procal amino acid/glycerol based product which does not undergo the Maillard reaction and precludes the heat of sterilization so they must be protected form ______ until admin

A

the light

247
Q

the degradation of nutritional components that changes their original characteristics or the ability o PN additives to maintain their chemical integrity/pharmacological activity is definition of the ____ of PN

A

stability

248
Q

overtime when exposed to light, IV dextrose and amino acids in PN will form a brown color is known as

A

the maillard reaction

249
Q

Photodegradation from light exposure results in the loss of some vitamins including

A

B12, folic acid, pyridoxine, riboflavin, thiamin and retinol

250
Q

_____ of PN involves evaluating the formation of precipitates in PN

A

compatibility

251
Q

what are 2 possible precipitates of PN

A

solid/crystalline precipitates

phase separation of oil and water

252
Q

addition of iron dextran to ILE’s will cause ______ ___ of the ILE component, which is an example of incompatibility of PN

A

phase separation

253
Q

Medications should not be added to PN formulations unless clear evidence from

A

literature

254
Q

fat molecules over ____ micrometers will make the emulsion unstable

A

1 micrometer

255
Q

if fat droplets in PN become too large it is unsafe as they could dislodge and cause

A

pulmonary compromise

256
Q

what factors alter the charge of lipids

A

reduced pH
addition of electrolyte salts
additives with a low pH below 5 or above 10 can crack the emulsion

257
Q

what is the favorable range of pH for ILE’s

A

6-9

258
Q

yellow streaks or an amber oil layer on top of a TPN bag can indicate

A

oil phase separation (cracked emulsion)

259
Q

amino acids with a concentration above ____% may cause TPN instability

A

15%

260
Q

TNA’s should be avoided with this type of PN because the concentrations of dextrose and amino acids would be too low and cause TNA instability

A

PPN (due to osmolarity restrictions only can use 8% dex and 3% amino acids)

261
Q

optimal concentration of ILE for TNA is

A

20% ILE

262
Q

low osmolarity PN increases the risk of _______ precipitations

A

calcium/phosphate

263
Q

to prevent lipid destabilization, divalent cations should be provided between ____ to ____ mEq/L

A

16-20

264
Q

final concentration of dextrose and amino acids should be above ____ in a 3 in 1 TPN

A

> 10% dex, > 4% amino acids, >20% ILE

265
Q

______ _____ precipitates can cause respiratory distress or microvascular pulmonary emboli

A

calcium phosphate

266
Q

what are the 2 factors that influence calcium and phosphate solubility in PN

A

increased calcium phos precipitation and increased calcium phosphate solubility

267
Q

what increases the risk of calcium phosphate precipitation

A

increased calcium concentration, increased phosphate, calcium chloride instead of CaGluconate and increased temperature

268
Q

what can help increase calcium phosphate solubility

A
  • increased amino acid concentrations
  • increased dextrose concentration
  • lower pH
269
Q

____ primarily dictates the solubility of calcium/phosphate

A

pH

270
Q

____ pH favors the presence of mono basic calcium phos which is more soluble

A

lower pH

271
Q

an ____ in pH increases the amount of di-basic phosphate to bind with free calcium ions, increasing the chance of precipitation

A

increase

272
Q

for PN in neonates ____ is added to lower the PH of TPN to increase calcium/phos solubility as they need higher amounts of calcium and phos for bone growth

A

L cysteine hydrochloride

273
Q

L-cysteine, a semi-essential amino acid for neonates in PN are added to lower the pH which is bad for the ILE environment and should not be used in _____ PN solutions

A

TNA

274
Q

_________ ________ are used to check the solubility of calcium and phos before compounding TPN

A

calcium/phosphorous solubitliy curves

275
Q

________ ______ provide the best guidance in determining calcium phosphate solubility

A

solubility curves

276
Q

this organ regulates the elimination of aluminum

A

kidneys

277
Q

in 1994 the FDA required the addition of _____ due to high instance of calcium phosphate precipitates

A

filters

278
Q

large pore filters are considered ____ micromoles which can remove CaPhos precipitates and plastic fragments from the PN bag

A

5 micromoles

279
Q

Filters are a good substitute for good compounding practices true or false

A

False

280
Q

______ micrometer filters can remove pathogenic microorganisms from PN

A

0.22 micrometers

281
Q

use a ____ micromolar filter for TNAs and separately infused ILE’s, but this wont filter out staph epidermis or E.coli

A

1.2

282
Q

use a _____ micromolar filter for 2 in 1 dextrose/amino acid admix with a SEPERATE infusion of ILE

A

0.22

283
Q

ILE’s filter size should be

A

1.2 micromoles

284
Q

how often should PN filters be exchanged for dextrose-amino acid solutions

A

every 24 hours or new infusion

285
Q

how often should PN filters be exchanged for lipids

A

every 10-12 hours for separately infused ILE’s

286
Q

0.22 micron filters cannot be used for ____ forms of TPN

A

3 in 1, not suitable for the ILE

287
Q

tubing and PN containers should be ________ and kept away from _____

A

refrigerated, away from light exposure

288
Q

when transitioning from PN to EN , the most common complication is

A

hyperglycemia (limit GIR to <4 mg/kg/min)

289
Q

47 year old female admit with recurring GI problems has had a 8.4 kg wt loss, 11% wt loss in 35 days, eating <25% of estimated nutrition needs, her abdominal scan demonstrated bowel obstruction with pockets of fluid collections consistent with intra abdominal abscess what type of feeding would be appropriate

A

PN

290
Q

critically ill patients with normal nutrition/no risk of malnutrition should avoid PN for

A

7 days

291
Q

is PN recommended as the first line of nutrition therapy in acute Chron’s or Ulcerative Colitis flare

A

no

292
Q

peri operative PN can be used in ____ with a risk assessment

A

severe malnutrition

293
Q

most errors when ordering PN happened during these steps in the process

A

transcription, prescription and administration

294
Q

a patient’s clinical condition should lead decision of whether to start or withhold therapy in these settings

A

hyperglycemia, azotemia, encephalopathy, hyperosmolality, severe fluid/electrolyte abnormalities

295
Q

once PN is infusing at goal rate in the hospital, what should be monitored

A

fluid ,electrolyte/renal status, daily BG, TCG/LFT periodically , visceral protein weekly, urine output

296
Q

this type of amino acid PN formulation is used for hepatic encephalopathy

A

branched chain amino acids and decreased aromatic amino acids

297
Q

patients under metabolic stress, trauma, thermal energy have increased needs for these types of amino acids

A

branched chain, essential

298
Q

patients with severe fluid restriction may need this special amino acid formula with ___ to ___ % acids

A

15-20%

299
Q

this type of lipid formulation for PN may be able to reduce risk of PNALD

A

SMOF

300
Q

ILE provide ___mmol/L of phosphorous

A

15

301
Q

this type of ILE has 100% fish oil

A

Omegaven

302
Q

single IV vitamin products are not available in these micronutrients

A

biotin, pantothenic acid, riboflavin, vitamin A,D or E

303
Q

a typical 10mL dose of MVI contains this much vitamin K

A

150 mcg

304
Q

single entity or multi trace elements provide ____ mg of zinc

A

3-6.5 mg

305
Q

single entity or multi trace elements provides ___ mg of copper

A

1-1.3

306
Q

single entity or multi trace elements provides ____ mcg of selenium

A

0-60 mcg

307
Q

per ASPEN recommendations when multiple ____ products are inappropriate for PN use ____ products should be used to meet a patient’s needs

A

element

single entity

308
Q

when using single entity copper reduce the amount to

A

0.3-0.5 mg/day

309
Q

trace element contamination in PN formulas can be limited to < ____ mg/day of copper and _____ mcg of manganese to reduce organ accumulation of copper, manganese, and chromium

A

0.1 mg, 40mcg

310
Q

only iron ____ is approved for addition to PN and should only be considered for dextrose amino acid formulations because ILE formulations are disrupted by iron

A

dextran

311
Q

PN _____ is no longer recommended for critically ill patients due to lack of infectious/mortality benefit or even high mortality rates when IV is gen

A

glutamine

312
Q

there is currently no form of IV glutamine because

A

not FDA approved, poor solubility/stability

313
Q

carnitine only comes in the form of _____ in parenteral nutrition for those with carnitine deficiency such as neonates and infants

A

L-carnitine

314
Q

in the setting of ILE shortage who should be prioritized

A

long term TPN needed for > 2 weeks, high risk for essential fatty acid deficiency, critically ill patients NOT on propofol, pregnant patients, severely malnourished, glucose intolerant

315
Q

in the setting of IV MVI shortage who should be prioritized

A

patients only on IV nutrition, medical need

316
Q

if there is a shortage of MVI, what alternatives are there

A
  1. consider oral/enteral MVI when EN or PO intake is started
  2. avoid liquid MVI as can cause GI upset
  3. Ration IV MVI to 50% 3x/week
  4. If MVI-13 not available, use MVI 12 (no vit K) and give separate IV vitamin K 150mcg/d or 5-10 mg/ week
317
Q

how much vitamin K IV is needed a day/week

A

150mcg/day

5-10 mg/week

318
Q

_____MVI’s should never be substituted for adults MVI

A

Pediatrics

319
Q

Adult IV MVI should be given to neonates because

A

they have propylene glycol, polysorbate and aluminum which can be toxic to neonates

320
Q

During an IV MVI shortage reserve electrolytes for _____ PN patients or patients with ______ need

A

sole

medical

321
Q

consider oral/enteral electrolytes when a patient is on enteral feeding or po diet during an IV MVI or trace element shortage excluding those with

A

malabsorption or non functioning GI tract

322
Q

if a multi mineral/trace element formula for IV is not available, use ____ formulations

A

single IV

323
Q

withhold IV adult multi trace elements for the first month to _____ adult PN patients who are not critically ill or have pre existing deficits

A

newly initiated

324
Q

if calcium chloride is given in substitute for calcium gluconate in PN during a shortage, what must be taken into consideration

A

calcium chloride is much more INSOLUBLE that calcium gluconate and should be given in a separate IV line to avoid PN compatibility issues.

325
Q

the desired dextrose concentration for a TNA TPN solution is > ____ and >___% for amino acids to prevent ______destabilization

A

10% dextrose,
4% amino acids
lipid

326
Q

who’s responsibility is it to ensure that PN is prepared safely

A

Pharmacy

327
Q

an essential part of the PN compounding process is to create

A

a compound with an accurate formulation, free of microbes and particulate matter

328
Q

Review Current USP guidelines for PN safety/purity

A
  1. enforced for compounding sterile preparations
  2. assigns low, med, high risk
  3. Low risk - closed system aseptic transfer, medium risk = reconstitution of several sterile products that transfer into several small volume PN preparations or large volume PN preps
329
Q

trace elements can lead to contamination from these 6 substances

A 
aluminum
arsenic
chromium
zinc
manganese
copper
330
Q

the amount of contamination in PN depends on these 3 factors

A

manufacturer
vial size
concentrations

331
Q

The 2004 federal regulation state that _______ content must be labeled in large volume PN formulations, pharmacy bulk packaging and small volume PN formulas

A

aluminum

332
Q

the max amount of aluminum per liter allowed in Large Volume PN is

A

25mcg/L

333
Q

Storage of PN products in _____ which a high affinity for aluminum should instead by stored in ______ to decrease aluminum contamination

A

Don’t store in glass

STORE in plastic

334
Q

less than ___% of aluminum is absorbed by the GI tract

A

<1 %

335
Q

this organ is an effective barrier for aluminum

A

the lungs

336
Q

Extra aluminum during toxicity will deposit in these 4 areas

A

Lungs
Bones
Liver
Brain

337
Q

Which patients are at the highest risk for aluminum toxicity in PN

A 
Renal Dysfunction (cannot excrete)
High intake of PN products
Iron deficiency (transferrin assist with excretion)
Infants/Pedi patients
338
Q

what are the signs/symptoms of an aluminum toxicity

A

encephalopathy, osteomalacia, reduced PTH secretion, erythropoietin resistant microcytic anemia

339
Q

the FDA defines the upper limit of aluminum to be ___ and requires a ____ in the manufactures product

A

4-5mcg/kg/day; requires a warning statement

340
Q

to decrease post op complications of severely malnourished patients who require surgery, they should receive pre operative PN for a minimum of how many days

A

7-10 (perioperatively)

341
Q

the threshold for starting PN in an elderly person is ____ than a younger adult because of age related decrease in muscle mass and organ function with diminished reserves as well as impaired compensatory mechanisms

A

lower

342
Q

name 2 absolute indications for the use of PN

A

high output fistula especially if over 500mL/day and GI obstruction limiting po intake >1 week

343
Q

routine use of perioperative PN is indicated for severely malnourished patients to prevent preoperative complications when used for

A

> 7 days

344
Q

in a home PN patient TNA TPN, what should added immediately before infusion

A

multivitamin

345
Q

what are the recommended maximum PN components for fluid, g/kg carb, g/kg fat and g/kg protein

A

30-40mL/kg fluid
7g/kg carb
2.5 g/kg/day fat
2 g/kg protein (depending on the disease)

346
Q

the best way to express the dextrose content in PN to avoid misinterpretation

A

grams per 24 hour infusion

347
Q

max lipid infusion rate to avoid infusion complications

A
  1. 11 g/kg/hour lipid

1. 1 g/kg/day

348
Q

provide at least ___ to __% of linoleic acid to avoid EFAD

A

2-4%

349
Q

provide at least 0.25 to 0.5 % _____ to avoid EFAD

A

alpha linolenic acid

350
Q

avoid providing IVFE if serum triglycerides exceed

A

400mg/dL

351
Q

avoid infusion of >_____g/kg/hour of fat to a void hypertriglyceridemia

A

0.125 g/kg/hour

352
Q

when 2 oils are mixed together into an emulsion this is known as a ___ mixture

A

physical

353
Q

medium chain fatty acids and long chain fatty acids that are created through hydrolysis of triglycerides and go through transesterification of fatty acid to make TCG molecules

A

structured lipids

354
Q

what is the primary advantage of using structured lipids in TPNA

A

lowers serum triglyceride levels because they are utilized at a slower rate

355
Q

how many milliliters per liter of fat emulsion are needed to provide a final concentration of 5% when using 20% Intralipid as a stock solution

A

5% means 5 grams in 100mL. 1 L = 1000mL so in 1000mL , there will be 50 grams of fat (5 x 10). There are 10kcal per gram of fat, so 10 kcal x 50 grams, gives you 500 kilocalories. There are 2kcals per mL of lipids in IVFE so 500/ 2 is 250 mL of ILE

356
Q

these 2 amino acids are synthesized primarily in the intestines. When PN is started, there is an alteration to intestinal metabolism impairing the synthesis of these amino acids and they become conditionally essential, they are

A

glutamine and arginine

357
Q

this amino acid has shown to provide the benefit of reducing length of stay and post operative infection rates when added and is conditionally essential

A

arginine

358
Q

the most appropriate PN amino acid solution for the non-dialysis patient with acute renal failure contains

A

a balance of essential and non essential amino acids

359
Q

metabolic alkalosis is PN is mostly likely contributed by

A

amino acids; they have large amounts of endogenous acetate which metabolizes into excess bicarbonate

360
Q

the addition of______ to PN has the benefit of unaltered GI permeability

A

glutamine diphosphate

361
Q

the disadvantage of adding glutamine to PN is it can cause

A

hyperammonemia

362
Q

renal parenteral formulas have higher amounts of ____ compared to the standard

A

essential amino acids

363
Q

the addition of glutamine may be contraindicated in

A

hepatic failure

364
Q

Glutamine diphosphate can be added into PN as long as it is added within ___ hours compounding

A

48 hours

365
Q

this is a non-essential amino acid that is the primary fuel for the small bowel

A

glutamine

366
Q

A patient with an ileostomy getting TPN is likely to need supplemental

A

sodium, potassium and acetate (loss of bicarb through stool)

367
Q

what PN additive may cause throbocytopenia

A

heparin

368
Q

_____ is added to adult MVI preparations and IV fat emulsion solutions for PN, therefore when a patient is on Coumadin and starting or ending PN _____ should be monitored

A

INR

369
Q

_____ time should be monitored regularly in adults getting IV fat emulsions and who are on Coumadin/Warfarin with PN as they contain ______ in the emulsion

A

vitamin K

370
Q

____ cannot be added to IVFE as it has the highest risk over time destabilizing the fat emulsion due to phase separation and liberation from oil due to high cation valence. There is NO safe concentration of this in any TNA for this reason.

A

Iron dextran

371
Q

the higher the ___ of an element, the higher the destabilizing power

A

valence

372
Q

the DRI for PN ____ vitamins provided in PN are less than the DRI’s for ___ vitamins orally, given that there is no loss from the GIT when given intravenously

A

fat soluble vitamins

373
Q

DRI for PN _____ vitamins are given in higher concentrations than oral supplementation as patients are in a state of high stress and may require a greater intake

A

water soluble vitamins

374
Q

increased endogenous insulin levels that don’t adjust to the decrease in dextrose infusion following the discontinuation of PN is called

A

rebound hypoglycemia

375
Q

after stopping PN, blood glucose should be monitored for how long to prevent rebound hypoglycemia

A

30 minutes-1 hour

376
Q

patients with hypothyroidism are at increased risk of _____ when PN is stopped as the thyroid controls metabolism associated with glucose control. T3 and T4 hormones, directly impact glucose homeostasis

A

rebound hypoglycemia

377
Q

Are parenteral feeding formulations hypotonic, isotonic, or hypertonic to body fluids?

A

Hypertonic

378
Q

The osmolarity of a parenteral feeding formulation is primarily dependent on:

A

The dextrose, amino acid, and electrolyte content

379
Q

List the approximate mOsm contributed by dextrose, amino acids, and electrolytes

A

Dextrose = 5 mOsm/g
Amino acids = 10 mOsm/g
Electrolytes = 1 mOsm per mEq of individual electrolyte additive

380
Q

What is the maximum osmolarity tolerated by a peripheral vein?

A

900 mOsm/L

381
Q

How must a hyperosmolar formula be delivered into the body and why?

A

Into a large diameter vein (ex. superior vena cava). The rate of blood flow in larger vessels rapidly dilutes the hypertonic parenteral feeding formulation to that of body fluids, minimizing the risk of complications

382
Q

CPN is preferred in patients who will require PN support for longer than what time frame?

A

7-14 days. CPN can ultimately be maintained for weeks to years

383
Q

What is the dextrose dose in peripheral parenteral nutrition (PPN)?

A

150-300 gm/day (5-10% of the final concentration

384
Q

What is the amino acid content of PPN?

A

50-100 gm/day (3% of final concentration)

385
Q

Why is PPN an undesirable option for patients with a fluid restriction?

A

Large fluid volumes must be administered with PPN. Concentrating the solution to meet their fluid requirements frequently results in a hyperosmolar solution that is not suitable for peripheral administration

386
Q

What 2 criteria must patients meet to be considered for PPN?

A
  1. They must have good peripheral venous access
  2. They should be able to tolerate large volumes of fluid (2.5-3 L/day)
387
Q

What time frame is PPN appropriate?

A

Patients should require at least 5 days but no more than 2 weeks of partial or total PN

388
Q

List the contraindications to PPN

A

Significant malnutrition
Severe metabolic stress
Large nutrient or electrolyte needs (potassium is a strong vascular irritant)
Fluid restriction
Need for prolonged parenteral nutrition (>2 weeks)
Renal or liver compromise

389
Q

What is the usual osmolarity of CPN?

A

1300-1800 mOsm/L

390
Q

What is the usual osmolarity of PPN?

A

600-900 mOsm/L

391
Q

Why is the use of midline catheters recommended in patients needing PPN for more than 6 days?

A

The catheter’s length and lower probability of dislodging compared with other peripheral cannulas. Midline catheters however do not eliminate the risk of thrombophlebitis

392
Q

How often might a peripheral IV site need to be rotated when using PPN?

A

At least every 48-72 hours

393
Q

Define permissive underfeeding and its intent when used with PN

A

Concept relevant to critically ill patients who do not tolerate nutrition, especially PN, well. Intended to minimize complications of PN delivery by providing only 80% of estimated energy requirements until the patient’s condition improves

394
Q

Define hypocaloric feeding and its intent

A

Used in both EN and PN for obese patients to meet protein requirements but provide less energy than the estimated requirement. Designed to minimize the metabolic complications of PN while improving nitrogen balance. Used for patients with BMI >30, unless weight loss is not intended. May be used in critically ill and other hospitalized patients. Little data on its use for >30 days

395
Q

Define supplemental PN

A

Approach designed to minimize the energy deficit that accumulates during periods of no nutrition or undernutrition. Used in circumstances where EN is insufficient to meet energy needs

396
Q

PN has been shown to benefit patients with moderate to severe malnutrition who have no or inadequate oral or EN for prolonged periods, particularly for which populations?

A

Patients receiving perioperative support; acute exacerbations of Crohn’s, GI fistulas, or extreme short bowel syndrome; critical care and cancer patients

397
Q

List the considerations for PN use

A

May be appropriate for patients who are unable to meet nutrition requirements with EN, are already or have the potential of becoming malnourished.
PPN may be used in selected patients to provide partial or total nutrition support for up to 2 weeks when those patients cannot ingest or absorb oral or enteral tube-delivered nutrients, or when CPN is not feasible.
CPN support is necessary when PN is indicated for longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or fluid restriction is required, and the benefits of PN outweigh the risks

398
Q

List situations during which CPN should be used

A

Patient has failed EN trial with appropriate tube placement (postpyloric)
EN is contraindicated or GI tract has severely diminished function because of the underlying disease or treatment
Wound healing will be impaired if PN is not started within 5-10 days post-op for patients who cannot eat or tolerate EN

399
Q

When is PN indicated?
Practice scenario: 47 y/o F with recurring GI problems; 8.4 kg wt loss (11% wt change over 35 days; consuming <25% estimated needs. Abd scans show bowel obstruction with pockets of fluid collections consistent with intra-abdominal abscess. At surgery, found to have complete bowel obstruction, multiple adhesions, recurrence of Crohn’s, large suprapubic abscess. Surgical procedure consisted of ex lap, LOA, small bowel resection to remove disease-affected bowel, drainage of abdominal abscess. NG placed to suction, removed 1500-2000 ml post-op day 1

A

Patient is at high risk of developing post-op complications such as wound dehiscence, wound infection, pneumonia, and renal failure. Problems with GI tract not expected to resolve in 7-10 days, PN is indicated.

400
Q

Parameters under which PN indication is dependent

A

Severity of patient’s malnutrition
Length of time the patient will not be able to use the enteral route for nourishment
Influence of the underlying clinical condition on the safety and efficacy of therapy.

401
Q

What is the length of time a patient can endure inadequate oral nutrition and semi- or complete starvation before there is an impact on clinical outcomes?

A

The length of time is not known. For cancer patients, more than a week without adequate oral intake is indicative of PN. For critically ill patients with normal nutrition risk or no malnutrition, PN should be avoided for up to 7 days

402
Q

List clinical (biochemical) conditions that warrant cautious use of PN and the suggested criteria

A

Hyperglycemia (BG >300 mg/dL)
Azotemia (BUN >100 mg/dL)
Hyperosmolality (serum osmolality >350 mOsm/kg)
Hypernatremia (Na >150 mEq/L)
Hypokalemia (K <3 mEq/L)
Hyperchloremic metabolic acidosis (Cl >115 mEq/L)
Hypophosphatemia (P <2 mg/dL)
Hypochloremia metabolic alkalosis (Cl <85 mEq/L)

403
Q

True or false: PN has been shown to improve patient outcomes as the primary management of acute exacerbations of Crohn’s or ulcerative colitis

A

False

404
Q

What is the role of PN in pancreatitis?

A

Unlikely to benefit patients with mild, acute, or chronic relapsing pancreatitis when the conditions last for less than 1 week. Should be avoided unless EN is not feasible because of GI ileus, SBO, or the inability to properly place an enteral feeding tube.

405
Q

PN kcal and any special nutrient recommendations when used with pancreatitis?

A

Recommended PN energy administration not exceed 25-35 kcal/kg/day and glucose be adequately controlled. Also recommended to consider glutamine to minimize the effects of being NPO on GI integrity (provide 0.3 gm alanyl-glutamine [Ala-Glb] dipeptide per kg)

406
Q

What are the effects of the stress of surgical procedures?

A

Produces an abundance of proinflammatory cytokines, which increase metabolic rate and cause catabolism, resulting in a depletion of lean body mass and aberrations in glycemic control

407
Q

List the 2 main benefits of EN use in critical illness

A
  1. Positive impacts on the immune barrier and decreasing the permeability of the GI tract to enteric organisms, which can contribute to the overall detrimental systemic inflammatory response
  2. The low risk of mesenteric ischemia when introducing EN
408
Q

List the criteria that critically ill patients usually meet to warrant the use of PN

A
  1. Malnourished at baseline
  2. Will not reliably ingest or absorb significant amounts of EN for a period of greater than 7-10 days
  3. Have been adequately resuscitated from any hemodynamic compromise
409
Q

What is routine PN use in patients receiving chemo or radiation associated with?

A

Increased infectious complications and no improvement in clinical response, survival, or toxicity to chemotherapy

410
Q

Conditions warranting caution when initiating PN in the home

A

Medical conditions: DM, CHF, pulmonary disease, severe malnutrition, hyperemesis gravidarum
Electrolyte disorders: Hypernatremia, hypokalemia, hyperchloremic metabolic acidosis, hypophosphatemia, hypochloremic metabolic alkalosis

411
Q

Why is EN preferred over PN in cancer patients undergoing hematopoietic cell transplant?

A

Glycemic control is better during EN than PN

412
Q

What are the requirements set forth by Medicare before home PN costs are reimbursed?

A

Requires documentation that the patient’s GI tract is nonfunctional (“artificial gut”), and this condition is permanent (at least 90 days of therapy is needed). Must also have documented evidence of inability to tolerate enteral feeding (malabsorption, obstruction)

413
Q

Abnormalities in carbohydrate, protein, and fat metabolism are characterized in the stressed patient as:

A

Hyperglycemia, insulin resistance, uremia, encephalopathy, hyperosmolality, and hypertriglyceridemia

414
Q

How should PN be initiated in the following patient scenario?
Scenario: PN is to be initiated in 53 y/o M w/ chronic disease related malnutrition and complete bowel obstruction. Nutrition-related and metabolic parameters are as follows: Na 135, K 4.1, Cl 103, Bicarb 24, BUN 6, Cr 1.1, Glucose 234, Mg 1.8, Ca 9.8, Phos 1.5, Prealbumin 2, weight loss 20 kg in 45 days (14% wt change)

A

PN should be initiated at a low rate (100g dextrose per day) with a supplemental dose of phosphorus prior to the start of PN and an increased dose of phos in PN. A favorable clinical response to PN may be delayed by the patient’s catabolic state. Glucose and phos problems should be corrected before PN is initiated. Then, PN should be initiated slowly, beginning with a low energy dose. This pt is severely malnourished and at significant risk of developing refeeding syndrome.

415
Q

When can PN be advanced to the goal infusion rate in the following scenario?
Scenario: PN is initiated in 61 y/o F w/ h/o T2DM. PN started at low dose and the following morning pt’s BG is 210-240. BP and other vital signs are WNL

A

PN should be advanced only when the following criteria are met: stable BP, pulse, and respiration rates; normal phos, potassium, and glucose concentration. Best practice is is to control BG before advancing the rate of PN to its goal rate. Reasonable goal for BG is 140-180.

416
Q

Why might patients with limited cardiac function not tolerate a PN infusion?

A

Because PN contributes significantly to the fluid intake of the patient. Patients should be assessed for signs and symptoms of congestive heart failure and pulmonary edema

417
Q

Once PN is infusing at its goal rate, what approach to monitoring should be taken in the following scenario?
Scenario: PN is advanced to goal rate in a pt w/ normal renal function but a GI fistula draining 800 ml/d. Labs are normal after acute replacement of K and Mg and a correction of metabolic acidosis

A

Initially, fluid, electrolyte, and renal status should be monitored daily. Routine BG monitoring should also be conducted daily. Metabolic parameters (TG and LFTs) should be obtained periodically. The effectiveness of PN may be further assessed by measuring serum visceral proteins on a weekly basis and determining nitrogen balance in pts with functioning kidneys and adequate urine output.

418
Q

How often should electrolytes (Na, K, Cl, CO2, Mg, Ca, Phos, BUN, Cr) be checked on initiation of PN? During critical illness? In stable patients?

A

On initiation check daily x3
Critical illness check daily
Stable patients check 1-2x per week

419
Q

How often should serum triglycerides be checked on initiation of PN? During critical illness? In stable patients?

A

On initiation check on day 1
Critical illness check weekly
Stable patients check weekly

420
Q

How often should capillary glucose be checked on initiation of PN? During critical illness? In stable patients?

A

On initiation check as needed
Critical illness check 3x or more each day until consistently <150
Stable patients check as needed

421
Q

How often should LFTs (ALT, AST, ALP, total bilirubin) be checked on initiation of PN? During critical illness? In stable patients?

A

On initiation check on day 1
Critical illness check weekly
Stable patients check monthly

422
Q

When and how should PN therapy be discontinued in the following scenario?
Scenario: PN initiated in 65 y/o F s/p surgical procedure for bowel obstruction and drainage of intra-abdominal abscess. Post-op day 8 NG output dramatically declines, pt has bowel sounds and a BM. NG is removed and OG feeds are initiated.

A

PN may be discontinued when the patient can meet and tolerate an adequate percentage of their estimated energy and protein needs via enteral route.

423
Q

How can rebound hypoglycemia be prevented when PN therapy is discontinued?

A

PN may be tapered over 1-2 hours. If PN needs to be stopped emergently, a 10% dextrose in water solution should be infused at either the same rate as the PN or at a rate of at least 50 ml/hr. Cyclic PN at home usually requires some form of tapering during the last 2 hours of the cycle

424
Q

What has been demonstrated in the use of PN in malnourished patients?

A

Improvements in body composition.
Outcomes comparable with those of EN when contemporary doses of energy and protein are used.
Improved quality, safety, and utilization when PN is managed by nutrition support teams.
Positive PN outcomes in long-term patients.
Improved PN performance measures.
Better quality of life for some patients

425
Q
A
426
Q

for a pregnant patient with hyperemesis gravidarium presenting with fluid/electrolyte imbalances, ketonuria and dehydration, what would be the first line of therapy

A

IV fluid, additional B vitamins such as B12 and B6 as well as thiamine

427
Q

for a patient with severe hyperemesis gravidarum with little to no po intake, what should be supplemented to prevent Wernicke’s encephalopathy and neural tube defects

A

Thiamine

Folic Acid

428
Q

what is the second line of therapy for hyperemesis gravidarum

A

hold oral intake, start antiemetic

429
Q

if a patient with hyperemesis gravidarum is unable to take oral feedings after 24-48 hours of supportive therapy (IV fluid, anti emetic, vitamins) what should be started as far as nutrition support

A

enteral feedings

430
Q

when should PN be considered for hyperemesis gravidarum

A

if a patient fails EN due to exacerbated nausea, vomiting, diarrhea, significant gastric residuals or tube displacement, and clinically significant weight loss >5% of body weight

431
Q

Rapid IV infusion of potassium phosphate can cause

A

thrombophlebitis

432
Q

infusion rates of IV phosphate should not exceed ___mmol/hr because it can cause ________ and metastatic ___ deposition/organ dysfunction

A

7 mmol/hr
thrombophlebitis
calcium phosphate deposition

433
Q

the most common complication associated with PN

A

hyperglycemia

434
Q

hyperglycemia is the most common complication associated with PN due to

A

stress associated hyperglycemia in sepsis/acutely ill causing insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion

435
Q

what is the glycemic BG target for the majority of critically ill patients

A

140-180mg/dL (American Association of Clinical Endocrinologists and American Diabetes Association)

436
Q

a target BG below ____ is not recommended in the ICU due to the adverse effects of hypoglycemia

A

<110mg/dL

437
Q

What is the preferred approach for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus

A

basal, bolus insulin.

(basal insulin is given for hepatic glucose output and bolus insulin regularly scheduled is used for meal times) as well as correctional insulin

438
Q

what form of glutamine supplementation improves physical compatibility and stability for admix in PN solutions

A

glutamine dipeptide (L-alanyl, Lglutamine, Glycl L glutamine)

439
Q

___glutamine supplementation is more beneficial than enteral supplementation

A

parenteral

440
Q

IV glutamine supplements are _____ available in the U.S.

A

not

441
Q

free ____ is unstable in PN solutions

A

glutamine

442
Q

a critically ill obese patient with a BMI of 33.4

should be recommended for this range of calories/body weight/day per SCCM and ASPEN

A

11-14 kg/ABW/day

443
Q

for all classes of obesity where BMI >30 kg/m2, the goal PN regiment shouldn’t exceed ___ to ___ total energy requirements as measured by indirect calorimetry

A

65-70%

444
Q

If indirect calorimetry isn’t available, the weight based equation of _______ should be used for patients with a BMI of 30-50 kg/m2 to predict energy needs

A

11-14 kcal/kg/ABW

445
Q

If IC isn’t available, the weight based equation of ___ should be used for patients with a BMI >50 kg/m2 to predict energy needs

A

22-25 IBW

446
Q

protein should be provided in a range > or equal to ____ g/kg _____ a day for patients with a BMI of 30-40 kg/m2

A

2.0 g/kg IBW day

447
Q

protein should be provided in a range up to ____g/kg ____ a day for patients with a BMI greater than or equal to 40

A

2.5 g/kg IBW /day

448
Q

the majority of PN complications that increase PN Prescription errors happen when

A

inadequate knowledge of PN therapy, certain pt characteristics related to PN such as renal function, calculation of PN doses are incorrect, specialized PN dosage formulation characteristics and lack of knowledge of prescribing nomenclature

449
Q

According to ASPEN , what is the best way to express dextrose content on the PN label to avoid misinterpretation

A

total grams within 24 hours (ie 255 grams/day)

450
Q

On the PN label, PN ingredients are ordered in ____ for adults and ______ for pediatrics and neonates

A

amounts per day for adults

amounts per kg for neonates/peds

451
Q

On the PN label, macronutrients should be expressed in

A

grams per day

452
Q

On the PN label, micronutrients should be measured in

A

mEq,mmol,mcg,mg per day (units)

453
Q

Mandatory items on a PN ORDER FORM per ASPEN

A 
patient identifiers (birthdate or age)
patient allergies
Height, Weight
Diagnosis (es)/ indication for PN
Administration route/venous access device (periph vs. central)
Prescriber contact info
order date/time
administration date/time
volume infusion rate
infusion schedule (continuous vs cyclic)
type of formulation (TNA vs 2 in1 + ILE) 
PN ingredients (amt per day or per kg)
electrolytes in complete salt form 
full generic name for each ingredient
joint commission approved abbreviations
dose of vitamins, trace elements, on nutrients medication
454
Q

electrolytes on the PN order form and label should be expressed in

A

complete salt form

455
Q

Mandatory inpatient PN label should contain

A 
electrolytes in complete salt forms
2 patient identifiers
patient location
dosing weight in kg
administration date and time
route of administration
prescribed volume
overfill volume
infusion rate in mL/hr
duration of infusion (continuous or cycled)
size of the in line filer
all ingredients with barcode
same sequence as PN order
name of institution or pharmacy
contact info for above
456
Q

if ILE is hung separately, the mandatory PN label should also contain

A 
2 patient identifiers
patient location
patient dosing weight in kg
administration time/date
route of administration
prescribed amount of ILE
volume of ILE
infusion rate
duration of infusion
complete name of the ILE
beyond use date and time, name of the institution/pharmacy with contact#
457
Q

A patient’s PN order is 2400mL, 300 grams of dextrose, 90 grams of protein and 225mL of IL20%. How many total kcals and grams of fat are provided

A 
1830 kcal and 45 grams of fat
300 g dextrose x 3.4 kcal = 1020 kcal
90g protein x 4 kcal = 360 kcal
225mL IL20% x 2kcal/mL = 450 kcal
450kcal of lipid /10 kcal = 45 grams
1020 + 360 +450 = 1830
458
Q

A patient who weighs 75 kg is getting 2: in 1 PN with piggy back ILE 20% at 65mL/hr. with 117 grams of protein, 273 grams of dextrose. What is the total daily caloric content per kg of body weight

A

117 g protein x 4 kcal = 468 kcal
273 g dextrose x 3.4 kcal = 928 kcal
250mL x 2kcal= 500 kcal
468+928+500 kcal = 1896 kcal/75 kg = 25.3 g/kg

459
Q

A critically ill obese patient has a BMI >33.4 kg/m2, how much protein is recommended per SCCM and ASPEN

A

greater than or equal to 2.0 g/kg IBW

460
Q

Which of the following is an indication to start PN

high output fistula, Chron’s disease, pancreatitis, hyperemesis gravidarum

A

high output fistula

461
Q

When is PN indicated in severe burn patients

A

when EN is contraindicated or unlikely to meet nutritional needs. Studies have found that use of PN in burn patients has been associated with increased mortality

462
Q

The routine use of preoperative PN is indicated for patients with a non functioning GI tract who are ____ to decrease perioperative complications

A

severely malnourished when used for >7 days pre op

463
Q

An adult patient with an abdominal tumor resulting in an unresolved SBO for over 7 days is a candidate for PN true or false

A

true

464
Q

Any adult with a GI obstruction that precludes oral intake for at least 1 week is a candidate for PN true or false

A

true

465
Q

Palliative use of nutrition support in terminal ill patients is ______ indicated

A

rarely

466
Q

patients who are scheduled for surgery and are _______ are recommended for PN if PN can continue for 7-10 days

A

severely malnourished

467
Q

When should PN be used in Chron’s

A

only after failure to tolerate EN (studies have found no advantage of PN over the use of EN)

468
Q

EN should only be used in patients with Chron’s requiring

A

nutrition support therapy

469
Q

peri operative specialized nutrition support is indicated in patients with IBD who are ___ and surgery can be safely postponed

A

severely malnourished

470
Q

In a TNA ILE is stable at room temperature for ______ and stable refrigerated for ________

A 
24 hours (room temp)
9 days  (refrigerated)
471
Q

Prolonged exposure to light of an ILE can cause

A

degradation

472
Q

ILE is most stable at a pH of ____ and adding _____ can cause instability

A

6-9 pH

acidic dextrose

473
Q

ILE administration via Piggy Back separate from dextrose and protein has a max hang time of

A

12 hours

474
Q

ILE administration via piggy back separate from dextrose and protein tubing/filters should be changed

A

with each new infusion

475
Q

_____ micron filters should be used to stop fat emboli, air emboli, microorganisms, or particulate matter from the patient

A

1.2 micron

476
Q

what is the most appropriate distal catheter tip placement at a peripherally inserted central catheter

A

superior vena cava

477
Q

a catheter inserted via peripheral vein (cephalic or basilic) whose distal tip lies in the vena cava

A

PICC line

478
Q

central or peripheral access is defined by

A

position of the distal tip

479
Q

disadvantages of PICC lines

A

limited self care ability
limited mobility
high rate of malposition or coiling
long lines increase risk of occlusion

480
Q

advantages of PICC lines

A

NO risk of pneumothorax of puncture of carotid/subclavian arteries
NO repeated skin punctures
comes in single, double or triple lumens

481
Q

When is it most appropriate to start a PN infusion in a patient with a new central venous catheter inserted at the bedside without fluoroscopy

A

AFTER chest x-ray confirms correct cath tip placement

482
Q

one of the most common complication(s) of central venous catheters inserted at the bedside

A

misplacement/pneumothorax

483
Q

fluoroscopy for central line insertion allows

A

immediate repositioning of catheter tip

484
Q

The CDC recommends to ______ routinely replace CVC’s, PICCs, HD catheters or pulmonary artery catheters to prevent catheter related infections

A

NOT

DON’T Recommend to routinely replace

485
Q

The CDC recommends ______ remove the CVC/PICC based on fever alone

A

DON’T remove the line based on fever alone

486
Q

______ should be used to determine appropriateness of catheter removal if infection is evidenced from another site or non infectious cause

A

clinical judgement

487
Q

Catheter insertion over a guidewire during bacteremia should ______ due to a source of infection/colonization of the skin to the insertion site

A

SHOULD NOT BE DONE

488
Q

Which of the following additives has the greatest risk of destabilizing a lipid injectable emulsion in a total nutrient admixture (TNA) (sodium chloride, calcium acetate, iron dextran or potassium phosphate)

A

iron dextran

489
Q

Phase separation and liberation from free oil from the destabilization of TNAs can result over time with an excess of ____ added to a formula

A

cations

490
Q

The ____ the cation valence, the greater the destabilizing power of a TNA with oil (ILE)

A

greater the valence, the more disruptive

491
Q

A PICC line should only be removed if

A

it is suspected or known to be the source of infection

492
Q

the LEAST favorable place for a PN catheter is

A

femoral

493
Q

Evidenced based interventions for patients with IV catheters that should be implemented together for the best outcomes is known as

A

the institute for health care improvement central line bundle

494
Q

what are the two principles of the central line bundle

A
  1. optimal cath selection

2. avoid of CV access in places at high risk for infection (femoral catheters, when alternative access is available

495
Q

what are the max percentages of dextrose and amino acids appropriate for peripheral PN

A

10% dextrose

3% amino acids

496
Q

osmolarity up to _______ mOsm/L can be safely infused peripherally

A

900 mOsm/L

497
Q

high concentrations of ____ increases calcium phosphorous precipitation in PN

A

amino acids

498
Q

the increase of temperature of PN bags increases the dissociation of ____ salts

A

calcium

499
Q

storage of PN in the refrigerator decreases the risk of _____ precipitation

A

calcium phosphate

500
Q

when compounding PN, always add _____ first then ______

A

PHOS FIRST

then calcium

501
Q

what type of parenteral amino acids should be used in a hospitalized adult with acute kidney injury requiring PN (standard, branched chain , essential amino acids, or renal specialty amino acids

A

standard

502
Q

patients with acute renal insufficiency have a decreased ability to synthesize ____ amino acids, no research has proven the benefit of branched chain amino acids or renal specialty formulas to be more beneficial than the standard

A

non essential amino acids

503
Q

Branched Chain Amino Acid PN formulations are the most appropriate for

A

a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources, despite optimal pharmacotherapy

504
Q

APSEN recommends the use of _______ amino acid formulas for critically ill patients with acute and chronic liver disease

A

standard amino acid formulations

505
Q

Failure to provide linoleic and alpha linolenic acids with PN will most likely result in

A

essential fatty acid deficiency

506
Q

to prevent EFAD in adults, provide at least ___ to____ total calories as linoleic and ____ to _____ of alpha linoleic acid. In infants provide at least ___ to ___ g/kg/day of lipids to prevent EFAD

A

2-4% total calories linoleic acid

  1. 25-0.5% total calories alpha linoleic acid
  2. 5 to 1 gram/kg/day
507
Q

what is a lipid injectable emulsion produced by the transesterification of fatty acids to form a composite triglyceride molecule?

A

a structured lipid

508
Q

what is the purpose of using a structured lipid for an injectable lipid emulsion

A

to slow the rate or release and utilization of medium chain fatty acids

509
Q

in a patient with hepatobiliary disease, which trace elements should be withheld or require a dose reduction when prescribing PN

A

manganese and copper due to impaired excretion in liver disease

510
Q

what parts of PN are a major source of aluminum exposure 2/2 contamination of raw materials and byproducts

A

calcium salts, phosphate salts, calcium gluconate and potassium phosphate

511
Q

The FDA mandates all manufacturers to measure and report the maximum content of ______ in their products

A

aluminum

512
Q

per the FDA, large volume PN products should contain less than _____ mcg/L of aluminum

A

25 mcg/L

513
Q

per the FDA, small volume PN products should label the amount of aluminum________

A

at the time of product expiration

514
Q

a long term PN patient begins to experience Parkinson’s like symptoms; which trace element toxicity is most likely to present these symptoms

A

manganese

515
Q

excess manganese accumulates in the _____ when not excreted through bile appropriately

A

the brain

516
Q

What are the Parkinson’s like symptoms from hypermagnesemia

A

rigidity
involuntary movement
tremors

517
Q

what patients are at risk for manganese toxicity

A

patients who are on TPN and have liver failure and elevated LFT’s because bile excretion is limited

518
Q

patients with chronic liver disease should get ____ free TPN

A

manganese free

519
Q

when compared to the DRIs for fat soluble vitamins given orally, the DRIs for parenterally administered fat soluble vitamins are ____ even though the amounts in PN are higher than PO. Fat soluble vitamin needs increase 2/2 malnutrition & metabolic changes from chronic illness. No toxicities have been reported

A

equal

520
Q

when compared to the DRIs for water soluble vitamins given orally, the DRI’s for parenterally administered water soluble vitamins are

A

higher

521
Q

PN water soluble doses are 2-2.5x____ than the RDA or AI 2/2 increased requirements from malnutrition, baseline vitamin deficiencies, increased urinary excretion of water soluble vitamins when used IV (rare toxicity)

A

greater than

522
Q

according to the United States Pharmacopeia (USP) chapter 797, a PN solution prepared from 8.5% amino acid with electrolytes, 70% dextrose with MVI, trace elements and famotidine added would be classified as ____ risk

A

medium (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)

523
Q

according to the United States Pharmacopeia (USP) chapter 797, PN solutions are categorized as low, medium and high risk corresponding with the probability of

A

microbial contamination, chemical or physical contamination

524
Q

according to the United States Pharmacopeia (USP) chapter 797, PN high risk solutions involve

A

NONSTERILEE ingredients and devices

525
Q

Automated Computed Devices for compound TPN are _____ error free

A

NOT ERROR FREE, errors can still occur

526
Q

Error rates of ACD devices compared to manual compounding are ____% and ___% respectively

A

22% ACD

39% Manual

527
Q

There should be established ____ limit warnings and _____ based limits in the pharmacy and ACD systems

A

dose limit warnings

weight based limits

528
Q

_____ should develop monitoring and surveillance plans for PN compounding

A

pharmacies

529
Q

when is manual compounding appropriate to use over ACD’s when preparing PN

A
  1. when the volume of PN are less than the ACD can accurately provide
  2. when chemical interactions between PN components cannot be mitigated by sequencing
  3. conservation during drug shortages
530
Q

_______ all healthcare providers should have the ability to override soft and hard limit alerts from ACDs

A

NOT ALL

531
Q

the preparation of compounded sterile preparations (CSPs) for all patient populations should be _____ for each population, with ________ strategies

A

separate, separate

532
Q

a translucent band at the surface of the emulsion separate from the remaining TNA dispersion is called

A

creaming

533
Q

when TNA has creaming, this is the ____ phase of an emulsion and the lipid droplets are preserved. Light creaming is a _____ occurrence and _____ spose a significant risk unless in extreme cases

A

Initial phase
common occurrences
Doesn’t (little clinical risk)

534
Q

when a TNA develops yellow/brown oil droplets near or at the TNA surface, marbling/streaking of oil all throughout the TNA or a continuous layer of yellow brown liquid at the surface of TNA this is known as

A

Cracking (terminal state of emulsion destabilization)

535
Q

Cracking of a TNA solution is the _____ phase of emulsion destabilization and can cause a ____ risk of clinical danger

A

terminal phase of emulsion destabilization

high risk of clinical danger

536
Q

what complication is most likely to occur when transitioning a critically ill patient from PN to EN and why. how can this be limited?

A

hyperglycemia because there may be an overlap in excess nutrients given when transitioning. This can be limited by keeping GIR < 4 mg/kg/min

537
Q

rapid infusion of IV Na or KPhos may result in ____ from an abrupt decrease in ________

A

tetany from abrupt decrease in serum calcium

538
Q

potassium phosphate in PN is _____ in nature, acid base wise

A

acidic/acidifying

539
Q

while getting PN, your patient develops metabolic acidosis. What serum electrolyte level needs to be monitored most closely

A

potassium

540
Q

during metabolic acidosis and tissue catabolism, there is an extracellular shift in ____ to maintain electroneutrality. Correcting metabolic acidosis will treat this.

A

potassium

541
Q

what is considered the most serious complication of significant hyperphosphatemia?

A

soft tissue and vascular complications 2/2 calcification when serum calcium multiplied by serum phos exceeds >55mg/DL

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