Chapter 14: Overview of PN Flashcards
What are ILEs?
Lipid injectable emulsions
What determines osmolarity of PN formulation?
Dextrose, AA, and electrolyte content
How much osmolarity does dextrose contribute to PN formulations?
5 mOsm/g
How much osmolarity does AA contribute to PN formulations?
10 mOsm/g
How much osmolarity do electrolytes contribute to PN formulations?
1 mOsm/g of individual electrolyte additive
What is the maximum osmolarity tolerated by a peripheral vein?
900 mOsm/g; anything higher requires CPN
What does CPN stand for?
Central PN, aka TPN
How is CPN safe?
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.
How long can central venous access be maintained?
weeks to years
(TRUE/FALSE)
Large fluid volumes must be administered with PPN to provide energy and protein doses comparable to those of CPN.
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.
(TRUE/FALSE)
PPN is an undesirable option for patients with fluid restriction.
TRUE.
Concentrating the solution to meet their fluid requirements frequently results in a hyperosmolar solution that is not suitable for peripheral administration.
(TRUE/FALSE)
PPN may be used in patients to provide partial or total nutrition support.
TRUE
How long is PPN typically used for?
Short periods (up to 2 weeks) because patients’ tolerance is limited and because there are few suitable peripheral veins.
(TRUE/FALSE)
PPN is generally indicated in malnourished patients requiring longer period of nutrition support.
FALSE.
PPN is NOT generally indicated… Only short periods (up to 2 weeks).
What are the two criteria, that must be met, for PPN.
- 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.
(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.
TRUE
Name some contraindications for PPN (6).
-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
Define permissive underfeeding.
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.
Define hypocaloric feeding.
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.
Define supplemental feeding.
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.
(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.
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
**What are the indications for PN use:
**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.
**What are the indications for CPN use:
**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
**What is the recommendation for initiating PN in critically ill patients with normal nutrition risk or no malnutrition?
**Initiate PN when patient has been NPO/Inadequate intake x 7 days, with normal nutrition risk.
**What is the recommendation for initiating PN when patients are malnourished or have high nutrition risk?
**PN is indicated when EN is not feasible.
**What is the recommendation for initiating PN in other conditions that preclude the use of the GI tract?
**More than 7 to 10 days.
(TRUE/FALSE)
Bowel rest is no necessary to achieve remission in Crohn’s disease.
TRUE.
(TRUE/FALSE)
GI or bowel rest and PN no longer have a role in pancreatitis.
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.
What are the recommendations for initiating PN when needed in treatment of pancreatitis?
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.
Define perioperative PN.
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.
Define critical illness.
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
Define mesenteric ischemia.
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
**ASPEN/SCCM Recommendation**
What are the recommendations for nutrition support in the ICU?
**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.
**ASPEN Recommendation**
What are the recommendations for the provision of nutrition support in adult patients receiving anticancer therapy?
**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.
What are the indications for home PN?
- 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)
Stress-induced hyperglycemia in acutely ill and septic patients often develops from what 4 factors?
- Insulin resistance
- Increased gluconeogenesis (glucose generation)
- Increased glycogenolysis (glycogen breakdown)
- Suppressed insulin secretion
What are the 3 components of basal-bolus insulin therapy?
- Basal insulin
- Nutritional component prior to meals
- Correctional insulin
What form of glutamine supplementation improves physical compatibility and stability for admixture in PN solutions?
Glutamine dipeptide.
(TRUE/FALSE for each)
Free glutamine is unstable in PN solutions.
Enteral glutamine is protein-bound and is difficult to determine the exact glutamine content.
L glutamine powder is used in enteral supplements.
TRUE
TRUE
FALSE - oral nutrition supplements
What are the ASPEN/SCCM recommendations for calories in critically ill obese patients with BMI of greater than 30?
BMI > 50?
11 to 14 kcal/kg ACTUAL body weight (BMI 30-50)
22 to 25 kcal/kg IBW (BMI >50)
What are the ASPEN/SCCM recommendations for protein in critically ill obese patients with BMI 30-40? BMI > or equal to 40?
Greater than or equal to 2.0 g/kg IBW (BMI 30-40)
Up to 2.5 g/kg IBW (BMI > or equal to 40)
(TRUE/FALSE)
There is no safe concentration of iron dextran in any TNA.
TRUE.
-Iron dextran has the greatest risk of destabilizing the ILE in a TNA (total nutrient admixture) (a trivalent cation)
- Na & K are the least disruptive to the emulsifier (monovalent cations)
- Ca & Magnesium are medium disruptive (divalent cations)
Has to do with excess of cations. So the higher the cation valence, the greater the destabilizing power.
What are common factors associated with the majority of PN prescribing errors?
- Inadequate knowledge regarding PN therapy
- Certain patient characteristics (age, impaired renal function, etc)
- Miscalculation of PN dosages
- Specialized PN dosage formulation characteristics
- Prescribing nomenclature
According to the ASPEN PN Safety Consensus Recommendations, which is the best method to express the dextrose content on the label of a PN formulation in order to avoid misinterpretation?
Grams per 24-hour nutrient infusion (ie: 200 g/day)
- PN ingredients shall be ordered in amounts per day for adults and amounts per kg for peds and neonatal patients
- This limits the confusion from amounts per liter, percent concentration, or volume
According to the ASPEN PN Safety Consensus Recommendations, what is considered mandatory for the PN order form? What is recommended, not required?
- Complete patient identifiers (birth date/age, allergies)
- Height and dosing weight
- Diagnosis/diagnoses
- Indication for PN
- Administration route/vascular access device
- Contact info for prescriber
- Date & time order submitted
- Administration date & time
- Volume and infusion rates
- Infusion schedule (continuous or cyclic)
- Type of formulation (TNA vs. dextrose/AA with separate ILEs)
PN Ingredients shall be ordered as follows:
- Amounts per day
- Electrolytes as a complete salt form
- Full generic name for each ingredient (using Joint Comm approved abbreviations and avoiding ISMP error-prone abbreviations)
- Dose for each macronutrient and electrolyte
- Dose for vitamin (including MVI)
- Dose for trace elements
- Dose for each non-nutrient medication
**The addition of recommended lab monitoring for PN order forms is strongly recommended, but NOT required
According to the ASPEN PN Safety Consensus Recommendations, how are electrolytes to be expressed on an PN order form?
As complete salt forms, NOT individual ions
According to the ASPEN PN Safety Consensus Recommendations, what should be included on the PN label?
- Two patient identifiers
- Patient location or address
- Dosing weight in metric units
- Administration date & time
- Beyond use date & time
- Route of administration
- Prescribed volume and overfill volume
- Infusion rate in ml/hr
- Duration of infusion (continuous vs. cyclic)
- Size of in-line filter (1.2 or 0.22 micron)
- Completer name of all ingredients
- Barcode
- All ingredients shall be listed in the same sequence and sam units of measure as PN order
- Name of institution or pharmacy
15, Institution or pharmacy contact information (including phone number)
When ILE is infused separately, what must the ILE label include?
- Two patient identifiers
- Patient location or address
- Dosing weight
- Admin date & time
- Route of admin
- The prescribed amount of ILE and volume required to deliver that amount
- Infusion rate in ml/hr
- Duration of infusion (not longer than 12 hours)
- Complete name of ILE
- Beyond use date & time
- Name of institution or pharmacy
- Institution/pharmacy contact info (including phone number)
One mL of 20% ILE is equal to how many calories?
2 kcals
How many grams of fat per mL does 20% ILE provide?
20 grams fat / 100 mL
So 225 mL of 20% ILE provides: 45g fat and 450 kcals
How many mLs is considered high for fistula output?
> 500 mL/day
This is considered an indication for PN
(TRUE/FALSE)
Severely malnourished patients may benefit from preoperative nutrition support.
TRUE
Note that significant reductions in perioperative complications are achieved when receiving more than 7 days of preoperative PN.
A common complication of central venous catheters inserted at the bedside is what?
Catheter misplacement, including pneumothorax.
(TRUE/FALSE)
PN solutions can be started immediately if the catheter was inserted with the use of fluoroscopy.
TRUE
(TRUE/FALSE)
Routinely replacing central venous catheters, PICCs, HD catheters, or pulmonary artery catheters prevent catheter-related infections and CRBSI.
FALSE
The CDC recommends:
- Only removing the PICC line if it is suspected or known to be the source of infection
- PICCs and CVCs should not be removed based on fever alone.
According to ASPEN, what is the maximum osmolarity that can be safely infused peripherally?
900 mOsm/L
The lower concentrated dextrose solutions (5%, 10%) and AA solutions (3%) are most often used for peripheral administration:
- Osmolarity of 10% dextrose = 500 mOsm/L
- Osmolarity of 3% AA = 300 mOsm/L
What reduces the risk of calcium phosphate precipitation in PN?
Increased AA concentration
- By forming soluble complexes with calcium, thereby reducing the free calcium ions available to form insoluble dibasic calcium phosphate precipitates.
- Also, higher [AA] may lower the pH of the PN formulation, which improves calcium phosphate solubility.
When compounding PN, it is important to add the [calcium/phosphate] first and then add the [phosphate/calcium] near the end of compounding to utilize the maximum volume of PN formulation to dilute the salts.
Phosphate, first
Calcium, near the end
In a patient with hepatobiliary disease, which two trace elements should be withheld or require a dosage reduction when prescribing PN?
Copper and Manganese, due to impaired excretion
Reduction or removal of copper and manganese from the PN solution is recommended for patients with decreased liver function.
(TRUE/FALSE)
Manganese is a contaminant found within the PN solution components, thus patients will likely receive small doses of manganese even if eliminated from the PN trace element prescription.
TRUE
What trace element toxicity presents as Parkinson-like symptoms in long-term PN patients?
Manganese
Symptoms: tremor, involuntary movements, and rigidity
Patients with abnormal liver function are at an increased risk for toxicity due to manganese being primarily excreted via bile
When compared to the DRIs for fat-soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are:
- Lower
- Equal
- Higher
EQUAL
When compared to the DRIs for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are:
- Lower
- Equal
- Higher
HIGHER, parenteral doses are 2 to 2.5 x higher than the RDA or AI because of increased requirements due to malnutrition, baseline vitamin deficiencies, and increased urinary excretion of water-soluble vitamins when used intravenously.
Compounding of PN using manual or automated devices during which there are multiple injections, detachments, and attachments of nutrient source products to the device or machine to deliver all nutritional components to a final sterile container is classified as?
Medium-Risk
Compounding that involves using nonsterile ingredients or nonsterile devices prior to terminal sterilization, is considered what risk?
High Risk
L-glutamine for supplementation in PN formulation
Transfer, measuring, and mixing manipulations with closed or sealed packaging systems that are performed promptly and attentively are considered what risk?
Low Risk
(TRUE/FALSE)
ACDs (automated compounding devices) ensures an error free process.
FALSE
~22% when automated and 37% when manually prepared
When is manual PN compounding indicated?
When the volume of a PN component is less than the ACD can accurately deliver, OR
When there is an interaction between a PN component and ACD component, OR
When chemical reactions between PN components cannot be mitigated by sequencing the addition of ingredients, OR
As part of a conservation effort during drug shortages
Creaming of a TNA (total nutrient admixture) appears as?
A translucent band at the surface of the emulsion separate from the remaining TNA dispersion
Cracking of a TNA appears as? What does cracking refer to?
Cracking = terminal state of emulsion destabilization:
- Yellow-brown droplets at or near the TNA surface
- A continuous layer of yellow-brown liquid at the surface of the TNA
- Marbling or streaking of the oil throughout the TNA
Why is hyperglycemia a common complication when transitioning a critically ill patient from PN to EN?
Patients may receive nutrients in excess during the overlap of therapy leading to hyperglycemia.
Appropriate adjustments to limit total CHOs intake to no greater than 4 mg/kg/min can prevent this metabolic complication in many of these patients.
How can rapid infusion of phosphate result in tetany?
Due to an abrupt decrease in serum [Ca2+]
Tetany = intermittent muscular spasms
While receiving PN, your patient develops metabolic acidosis. Which serum electrolyte level needs to be monitored closely?
Potassium
What is considered to be the most serious complication of significant hyperphosphatemia?
Soft tissue and vascular complications
Occurs when serum phosphorus levels exceed 55 mg/dL
Additional consequences: secondary hyperparathyroidism, renal osteodystrophy, and hypocalcemia.
What biochemical evidence indicates EFAD?
A triene to tetrene ratio > 0.2
Can occur within 1 to 3 weeks of adults receiving PN without ILEs
How much linoleic acid should be given to prevent EFAD?
2 to 4% of daily energy requirements
How much alpha-linolenic acid should be given to prevent EFAD?
0.25 to 0.5% of energy
(TRUE/FALSE)
When serum TG levels exceed 400 mg/dL, ILE infusion should be decreased to levels that prevent EFAD?
TRUE
The FDA currently recommends that daily intake of parenteral aluminum not exceed what amount?
5 mcg/kg/day
When should PN be cycled? Why?
For patients at risk for liver dysfunction (because continuous PN can result in hyperinsulinemia and hepatic fat deposition, thereby increasing the risk for liver complications), OR
Long-term TPN patients that are stable and active
When solely on PN how fast can essential fatty acid deficiency occur
2-4 weeks without linoleic or alpha linolenic acid
Symptoms of essential fatty acid deficiency
Dry scaly rash, impaired wound healing, increased infection risk, immune dysfunction, alopecia
The Holman Index
Triene to Tetraene ratio to test for essential fatty acid deficiency
EFAD can develop faster in lipid free PN secondary to
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
TPN in the critical care unit should initially be
hypocaloric and lipid free
Should PN be started in the acute phase of severe sepsis with elevated triglycerides
No
Alpha Linolenic Acid is the precursor for
DHA and EPA (omega 3 fatty acids)
Contents of the Injectable Lipid Emulsion (ILE)
An oil in water emulsion, 1 triglyceride, glycerol and phospholipid emulsifier, vitamin E, K phytosterols and cholesterols
Which vitamins are in ILE’s
vitamin E and K
Long chain fatty acids require ____ to be oxidized for energy
L-Carnitine
What are needed to prevent essential fatty acid deficiency?
alpha linolenic acid and linoleic acid (Omega 3’s)
What percentage of calories is needed of alpha linolenic acid to prevent EFAD
0.25-0.5% omega 3 (alpha linolenic acid)
What percentage of calories is needed of linoleic acid to prevent EFAD?
1-4% omega 6 (linoleic acid)
In which type of oils are the highest concentration of linoleic acid found
Soybean and Corn Oil (Omega 6)
In which type of oils are the highest concentration of alpha linolenic acids found in?
Soybean and Canola Oil (Omega 3)
How much ILE is needed weekly to prevent EFAD
500mL/week
Maximum PN ILE infusion daily
2.5 g/kg/day
If a patient is critically ill, don’t exceed ____ amount of lipids IV a day
1g/kg/day
When using 100% soybean oil IV, hold lipids x _____ unless there is a concern for EFAD, then give _____
For 1 week, OR
100grams/week
Give IVFE at no more than _____ rate to avoid toxicity of rapid infusion (fat overload syndrome)
0.11 g/kg/hr
Why does PPF (10% ILE) lead to hypertriglyceridemia
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
What should happen if serum triglycerides exceed 400mg/dL
- Decrease fat emulsion or hold
- Monitor serum TCGs 2x/week
- Remove lipids if also on PPF
- Try to start a patient on trophic enteral feeding
Omega 9 fatty acids
Olive Oil/Oleic acid used to lower cholesterol and triglycerides without lipid peroxidation often used in EN formulas
What is the suspected role of omega 3 fatty acids in parenteral nutrition
it contains fish oil which may cause LESS inflammation. Limited evidence is available at this time to be recommended.
Should omega 3 fatty acid ILEs be used in PN per ASPEN?
Limited Evidence by ASPEN
How can plant based ILEs lead to the development of liver dysfunction related to PN
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
typical IV dose of calcium
10-15 mEq/day (calcium gluconate) (also add magnesium)
typical IV dose of magnesium
5-8 mEq/L, or 80-20 mEq/day (magnesium sulfate)
how often should patients get MVI in PN
every day unless toxicity is suspected
what is added to PN that have demonstrated therapeutic effects in bone marrow transplants
glutamine supplementation
normal calcium requirements for PN with normal renal function
15mEq/day
what is the suggested adult PN thiamine daily dose
3 mg
when is PN recommended for burn patients
when EN is contraindicated or unlikely to meet nutritional needs (shouldn’t be the first route)
TPN terminates in the ____________ which can tolerate high osmolarity
superior vena cava
a central line should be placed if TPN is suspected for ___to ____ days in the hospital setting
7-14 days
PPN is indicated for _____ term use. Less than ______
short term use, <2 weeks
PPN is generally not recommended for malnutrition because
it cannot provide enough calories
what are 2 parameters for being a candidate for PPN
- good peripheral venous access
2. ability to tolerate large volumes o fluid 2.5-3 L
PPN should only be considered when PO or EN is not possible to meet a person’s nutrition needs for > than _____ days
5 days
You would consider PPN vs TPN when only indicated for use between ____ and ____ days
5-12
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
PPN
Thrombophlebitis can be caused by
high PN osmolarity or potassium
the term for providing up to 80% of energy needs until a patient’s condition improves, usually in the ICU
permissive underfeeding
the term for providing EN/PN of 60-75% of energy needs and high protein needs for the obese with BMI >30
hypocaloric feeding
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
supplemental PPN
indications for starting PN
- unable to meet nutrition requirements from EN
- when a patient cannot ingest or absorb oral or EN tube feedings
- paralytic ileus
- bowel obstruction
- GI fistula except when EN access can be placed posterior to the fistula,
- unable to use the gut for 7-10 days
- when EN access is contraindicated/failed attempts
when should PN be held off from starting
- azotemia
- severe hyperglycemia
- severe fluid/electrolyte imbalances
in the critically ill PN should not be considered until after ____ days when the patient has normal nutrition or no risk of malnutrition
7 days
when deciding to start PN be careful when blood sugar is over
300 mg/dL
when deciding to start PN, be careful when the patient is azotemic which means BUN is > than
100 mg/dL
when deciding to start PN, be careful when the patient is hypernatremic with a sodium > than
150 mEq/L
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
115 mEq/L , 85 mEq/L
Is PN recommended over EN for pancreatitis
no
if PN is indicated in pancreatitis what is important to manage, what are the kcal needs
25-35 kcal/kg, glucose control, consider glutamine to help minimize effect of GI integrity
PN can be used in the pre-operative phase in _______ _______ and should be at least ____ to ____ days for maximum benfit
severe malnutrition, 7-10 days
who in critical illness are appropriate for starting PN
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
is PN clinically indicated in cancer
no; chemo/radiation can cause infectious complications, no improvement clinically
ASPEN recommendation for when to start PN in cancer
only when malnourished AND unlikely to ingest/absorb adequate nutrition in 7-14 days
is PN preferred for hematopoietic cell transplant
No
successful PN depends on these factors.
- adequate ordering transcribing, compounding, dispensing and administration of PN and interdisciplinary care/nutrition support team
Errors of PN
- infection of IV catheter
- over/under feeding
- errors during Rx, transcription or prep
Most errors that occur from PN occur from
prescribing PN order
What can help decrease errors in PN
- create nutrition guidelines
- multi step double check process
- verify electronically transcribed order against actual written order
if a patient who is critically ill and previously well nourished ins PN recommended
no
in severely malnourished patients in the ICU when is PN indicated
when unable to use GI tract in 7 days
other indications to start PN (precluding the use of the GI tract)
- unable to meet estimated nutrition needs with EN alone or at high risk of malnutrition
- TPN when needed for > 2 weeks and PPN when needed <2 weeks
patients with significant hyperglycemia, azotemia, encephalopathy, or severe fluid/electrolyte abnormalities should not start _____ until resolved
PN
patients with theses issues may not tolerate large volumes with PN
CHF, renal failure, liver failure with ascites
when providing high fluid in PN what should be monitored
pulmonary edema, blood pressure, pulse
what should initially be monitored when PN reaches goal rate
fluid status, renal status, routine blood glucose monitoring, LFT/TCGs periodically, serum visceral proteins weekly, nitrogen balance/urine output with functioning kidneys
periodically monitor triglycerides levels if ____ given
lipids
goal of parenteral nutrition
maintain a patient’s nutrition status until some form of EN is tolerated
how can rebound hyperglycemia be prevented when stopping PN
taper down for 1-2 hours before stopping
if a patient is on TPN and EN does TPN need to be tapered before stopping
no
Dextrose in TPN contains _____ kcal/kg
3.4 kcal/kg
ranges of dextrose concentrations available for PN
2.5-70%
pH of dextrose solutions in pN
3.5-6.5
why are concentrations of dextrose for peripheral PN usually <8%
concentrations >10% can cause phlebitis in peripheral veins
Standardized Commercially Available PN (SCAPN)
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
Protein provided in PN solutions come from _______ amino acids
crystalline
16% nitrogen + ___ g amino acids and ____ g nitrogen
6.25 g amino acids, 1 gram nitrogen
standard amino acid solutions in PN contain ___- and ___ amino acid
essential and nonessential
concentrations of PN amino acids range from
3-20%
amino acid formulations used for special disease states are called
modified amino acids
amino acid formulations made for hepatic encephalopathy contain
increased BCAAs and decreased aromatic amino acids
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
aromatic amino acids (bad), branched chain amino acids (good)
amino acid formulations made for stress, trauma and thermal energy contain
BCAAs, increased leucine, isoleucine and valine to improve nitrogen balance
amino acids made for _____ are highly concentrated between 15-20% amino acids
fluid restriction
20% Injectable Lipid Emulsions (ILE’s) contain 100%
soybean oil (long chain fatty acids)
100% soybean ILE’s contain these fatty acids
linoleic acid (omega 6) , oleic acid, alpha linolenic acid, stearic acid, and palmitic acid
30% ILE’s provide ____ kcal/mL and are only available for _____ PN
3 kcal/mL, TNA mixtures
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 _______
propofol, hypertriglcyeridemia
the only other form of lipid approved by the FDA for PN use to reduce the amounts of omega 6 fatty acids are
SMOF lipid
SMOF lipid contains sources of fatty acids from
Soybean, mCt’s, olive oil and fish oil as well as EPH and DHA
SMOF lipid is a ______% concentration
20%
contraindications to using SMOF lipid
Egg, soybean, fish or peanut allergies
when is the use of SMOF considered for PN
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
IV lipids contain ____ as an emulsifier
egg
how many mmols of phos to ILE’s contain
15 mmol
what is the pH range of ILE’s
6-9
what is the maximum infusion rate of ILE administration
0.11 g/kg/hour
high rate of ILE infusion can lead to hypertriglyceridemia and infection called
fat overload syndrome
headaches, seizures, fever, jaundice, abdominal pain, and shock are all symptoms of
fat overload syndrome
ILE’s should not exceed total energy of _____g/kg/day
2.5 g/kg/day
per ASPEN recommendations for ILE’s in the ICU
withhold soybean based oil ILE or limit to 100 g during the first week if the patient is at risk for EFAD
lipids that are lab derived made up of chemically altered triglycerides with specific fatty acids at the 3 binding sites
structured lipids
Are structured lipids used in the US
no, they are not commercially available in the US
Fish oil ILE’s contain more _____ which is thought to decrease inflammation
omega 3
are just fish oils recommended for PN use
no, they can lead to EFAD as they are low in arachidonic and alpha linolenic acid
Clinolipid contains ____ oil and is enough to protect against EFAD
olive oil (contains at least 20% omega 6 fatty acids)
what are the preferred cations for calcium and magnesium which will produce the least incompatibilities in PN
Calcium Gluconate
Magnesium Sulfate
electrolyte requirements for sodium per day in PN
1-2 mEq/kg/day
requirements for potassium IV per day in PN
1-2mEq/kg/day
chloride and acetate are added _____ for acid base balance
as needed
calcium requirements for PN per day
10-15 mEq
magnesium requirements for PN per day
8-20 mEq
phosphate requirements for PN per day
20-40 mmol
single IV vitamins for PN are not available for
biotin, panthothenic acid, riboflavin, vitamin A, D or E
MVI’s in PN come in ____ vitals
10mL
how many micrograms of vitamin K are in 10mL IV MVI
150 mcg
what make up the trace elements in PN (multi trace)
zinc, copper, manganese, selenium, iron (ferric chloride), iodine, molybdate, fluoride, chromium
only iron ____ is approved for addition to PN and are contraindicated with the use of ______
dextran, lipids
role of glutamine in PN
intestinal integrity, immune function, protein synthesis during stress
is glutamine added to regular crystalline amino acids
NO
there is no FDA approved IV form of ___ for the critically ill due to lack of mortality benefit
glutamine
a quaternary amine needed for transport and metabolism of long chain fatty acids into the matrix of the mitochondria for beta oxidation
carnitine
carnitine deficiency can lead to
impaired fatty acid oxidation increasing the chance hepatic steatosis
is carnitine available in IV form for PN
no but IV L-Carnitine is available for carnitine deficiency esp. for neonates
10% amino acid solutions for PN should only be used for
fluid restriction patients
reserve IV MVI for
patients ONLY getting PN as sole nutrition or medical need
Liquid MVI contains sorbitol which can cause ______
diarrhea
if in a shortage of IV MVI how should MVI be rationed
50% or 3 times a week
12-MVI doesn’t contain
vitamin K
the typical form of IV MVI is
13-MVI
In shortage if 13-MVI occurs 12-MVI should be given, what needs to be separately
vitamin K 150 mc/day or 5-10 mg/week
if there is a shortage of calcium gluconate (the preferred form) what should be done?
eliminate from PN, order/monitor a serum ionized calcium and monitor fore evidence of calcium deficiency
if in a shortage calcium chloride needs to be infused for low calcium/calcium deficiency what should be done
infuse it SEPERATLY in a separate IV as it will cause precipitation if mixed w/ PN
what is one of the most dangerous PN incompatabilities
formation/infusion of calcium phosphate precipitates using calcium chloride which is less soluble than calcium gluconate
when providing 2 in 1 + piggy backed lipids what should be the hang time for ILE
12 hours
desired dextrose in a TNA TPN solution is
> 10 %
desired amino acid in a TNA TPN solution is
> 4%
a desired glucose concentration of >10% and and amino acid concentration >4 % in a TNA mixture is to prevent
lipid destabalization
Advantages of TNA 3:1 TPN solutions
aseptically compounded, more efficient for the pharmacy, less manipulation which decreased chance of bacterial contamination, more cost effective, easier to store at home
Disadvantages of TNA 3:1 TPN solutions
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
who’s role is it to ensure that PN is prepared safely
pharmacist
as part of the National Standards for Compounded Sterile Preparations, what is an essential part of the compounding process
compound an accurate formulation free of microbes/particulate matter
USP
a private non profit company that sets standards for drug purity/safety
Compounding TPN in a closed system with aseptic transfer is considered ____Risk per USP standards
low
Reconstitution of several sterile products for transfer into several small volume or large volume PN preparation is considered ____ risk per USP standards
medium
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
high
PN becomes _____ risk when L glutamine is compounded from non-sterile powder
high
ACD stands for
Automated Compounding Decice
PN that is compounded under computerized control is called
an ACD
Why were ACD’s created for PN compounding
helped streamline the manufacturing sequence for multiple ingredient preparations such as PN
advantages of ACD compounding
enhanced accuracy
can create unique volumes
more easily tailored to patient’s needs
reduces potential of contamination
disadvantages of ACD compounding
tubing must be changed daily
your facility should be using PN often in order to be cost effective
large
If PN using an ACD is made for adults, pedi and neonates PN should be infused ____ for each population
separately
what is the best method to reduce transcription errors during the PN ordering process
the PN order should be electronically integrated without requiring re entry of data
as part of quality control of the PN process the pharmacist should visually _______ each PN for physical defects, phase separation, package integrity
visually inspect
_____ determines whether PN formulations have been compounded properly, using refractive index of dextrose/amino acids
Refractometry
if refractive measures differs from ____ values in refractometry, the formula could be improperly admixed
predicted values
_____ _____ must be developed to ensure that PN is not exposed to extremes in temperature or light
written procedures
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
Standardized Commercially Available PN Formulations (SCAPN)
SCAPNs require addition of ______ injection before administration because they are not stable for >24 hours
MVI
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
the light
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
stability
overtime when exposed to light, IV dextrose and amino acids in PN will form a brown color is known as
the maillard reaction
Photodegradation from light exposure results in the loss of some vitamins including
B12, folic acid, pyridoxine, riboflavin, thiamin and retinol
_____ of PN involves evaluating the formation of precipitates in PN
compatibility
what are 2 possible precipitates of PN
solid/crystalline precipitates
phase separation of oil and water
addition of iron dextran to ILE’s will cause ______ ___ of the ILE component, which is an example of incompatibility of PN
phase separation
Medications should not be added to PN formulations unless clear evidence from
literature
fat molecules over ____ micrometers will make the emulsion unstable
1 micrometer
if fat droplets in PN become too large it is unsafe as they could dislodge and cause
pulmonary compromise
what factors alter the charge of lipids
reduced pH
addition of electrolyte salts
additives with a low pH below 5 or above 10 can crack the emulsion
what is the favorable range of pH for ILE’s
6-9
yellow streaks or an amber oil layer on top of a TPN bag can indicate
oil phase separation (cracked emulsion)
amino acids with a concentration above ____% may cause TPN instability
15%
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
PPN (due to osmolarity restrictions only can use 8% dex and 3% amino acids)
optimal concentration of ILE for TNA is
20% ILE
low osmolarity PN increases the risk of _______ precipitations
calcium/phosphate
to prevent lipid destabilization, divalent cations should be provided between ____ to ____ mEq/L
16-20
final concentration of dextrose and amino acids should be above ____ in a 3 in 1 TPN
> 10% dex, > 4% amino acids, >20% ILE
______ _____ precipitates can cause respiratory distress or microvascular pulmonary emboli
calcium phosphate
what are the 2 factors that influence calcium and phosphate solubility in PN
increased calcium phos precipitation and increased calcium phosphate solubility
what increases the risk of calcium phosphate precipitation
increased calcium concentration, increased phosphate, calcium chloride instead of CaGluconate and increased temperature
what can help increase calcium phosphate solubility
- increased amino acid concentrations
- increased dextrose concentration
- lower pH
____ primarily dictates the solubility of calcium/phosphate
pH
____ pH favors the presence of mono basic calcium phos which is more soluble
lower pH
an ____ in pH increases the amount of di-basic phosphate to bind with free calcium ions, increasing the chance of precipitation
increase
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
L cysteine hydrochloride
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
TNA
_________ ________ are used to check the solubility of calcium and phos before compounding TPN
calcium/phosphorous solubitliy curves
________ ______ provide the best guidance in determining calcium phosphate solubility
solubility curves
this organ regulates the elimination of aluminum
kidneys
in 1994 the FDA required the addition of _____ due to high instance of calcium phosphate precipitates
filters
large pore filters are considered ____ micromoles which can remove CaPhos precipitates and plastic fragments from the PN bag
5 micromoles
Filters are a good substitute for good compounding practices true or false
False
______ micrometer filters can remove pathogenic microorganisms from PN
0.22 micrometers
use a ____ micromolar filter for TNAs and separately infused ILE’s, but this wont filter out staph epidermis or E.coli
1.2
use a _____ micromolar filter for 2 in 1 dextrose/amino acid admix with a SEPERATE infusion of ILE
0.22
ILE’s filter size should be
1.2 micromoles
how often should PN filters be exchanged for dextrose-amino acid solutions
every 24 hours or new infusion
how often should PN filters be exchanged for lipids
every 10-12 hours for separately infused ILE’s
0.22 micron filters cannot be used for ____ forms of TPN
3 in 1, not suitable for the ILE
tubing and PN containers should be ________ and kept away from _____
refrigerated, away from light exposure
when transitioning from PN to EN , the most common complication is
hyperglycemia (limit GIR to <4 mg/kg/min)
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
PN
critically ill patients with normal nutrition/no risk of malnutrition should avoid PN for
7 days
is PN recommended as the first line of nutrition therapy in acute Chron’s or Ulcerative Colitis flare
no
peri operative PN can be used in ____ with a risk assessment
severe malnutrition
most errors when ordering PN happened during these steps in the process
transcription, prescription and administration
a patient’s clinical condition should lead decision of whether to start or withhold therapy in these settings
hyperglycemia, azotemia, encephalopathy, hyperosmolality, severe fluid/electrolyte abnormalities
once PN is infusing at goal rate in the hospital, what should be monitored
fluid ,electrolyte/renal status, daily BG, TCG/LFT periodically , visceral protein weekly, urine output
this type of amino acid PN formulation is used for hepatic encephalopathy
branched chain amino acids and decreased aromatic amino acids
patients under metabolic stress, trauma, thermal energy have increased needs for these types of amino acids
branched chain, essential
patients with severe fluid restriction may need this special amino acid formula with ___ to ___ % acids
15-20%
this type of lipid formulation for PN may be able to reduce risk of PNALD
SMOF
ILE provide ___mmol/L of phosphorous
15
this type of ILE has 100% fish oil
Omegaven
single IV vitamin products are not available in these micronutrients
biotin, pantothenic acid, riboflavin, vitamin A,D or E
a typical 10mL dose of MVI contains this much vitamin K
150 mcg
single entity or multi trace elements provide ____ mg of zinc
3-6.5 mg
single entity or multi trace elements provides ___ mg of copper
1-1.3
single entity or multi trace elements provides ____ mcg of selenium
0-60 mcg
per ASPEN recommendations when multiple ____ products are inappropriate for PN use ____ products should be used to meet a patient’s needs
element
single entity
when using single entity copper reduce the amount to
0.3-0.5 mg/day
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
0.1 mg, 40mcg
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
dextran
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
glutamine
there is currently no form of IV glutamine because
not FDA approved, poor solubility/stability
carnitine only comes in the form of _____ in parenteral nutrition for those with carnitine deficiency such as neonates and infants
L-carnitine
in the setting of ILE shortage who should be prioritized
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
in the setting of IV MVI shortage who should be prioritized
patients only on IV nutrition, medical need
if there is a shortage of MVI, what alternatives are there
- consider oral/enteral MVI when EN or PO intake is started
- avoid liquid MVI as can cause GI upset
- Ration IV MVI to 50% 3x/week
- If MVI-13 not available, use MVI 12 (no vit K) and give separate IV vitamin K 150mcg/d or 5-10 mg/ week
how much vitamin K IV is needed a day/week
150mcg/day
5-10 mg/week
_____MVI’s should never be substituted for adults MVI
Pediatrics
Adult IV MVI should be given to neonates because
they have propylene glycol, polysorbate and aluminum which can be toxic to neonates
During an IV MVI shortage reserve electrolytes for _____ PN patients or patients with ______ need
sole
medical
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
malabsorption or non functioning GI tract
if a multi mineral/trace element formula for IV is not available, use ____ formulations
single IV
withhold IV adult multi trace elements for the first month to _____ adult PN patients who are not critically ill or have pre existing deficits
newly initiated
if calcium chloride is given in substitute for calcium gluconate in PN during a shortage, what must be taken into consideration
calcium chloride is much more INSOLUBLE that calcium gluconate and should be given in a separate IV line to avoid PN compatibility issues.
the desired dextrose concentration for a TNA TPN solution is > ____ and >___% for amino acids to prevent ______destabilization
10% dextrose,
4% amino acids
lipid
who’s responsibility is it to ensure that PN is prepared safely
Pharmacy
an essential part of the PN compounding process is to create
a compound with an accurate formulation, free of microbes and particulate matter
Review Current USP guidelines for PN safety/purity
- enforced for compounding sterile preparations
- assigns low, med, high risk
- 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
trace elements can lead to contamination from these 6 substances
aluminum arsenic chromium zinc manganese copper
the amount of contamination in PN depends on these 3 factors
manufacturer
vial size
concentrations
The 2004 federal regulation state that _______ content must be labeled in large volume PN formulations, pharmacy bulk packaging and small volume PN formulas
aluminum
the max amount of aluminum per liter allowed in Large Volume PN is
25mcg/L
Storage of PN products in _____ which a high affinity for aluminum should instead by stored in ______ to decrease aluminum contamination
Don’t store in glass
STORE in plastic
less than ___% of aluminum is absorbed by the GI tract
<1 %
this organ is an effective barrier for aluminum
the lungs
Extra aluminum during toxicity will deposit in these 4 areas
Lungs
Bones
Liver
Brain
Which patients are at the highest risk for aluminum toxicity in PN
Renal Dysfunction (cannot excrete) High intake of PN products Iron deficiency (transferrin assist with excretion) Infants/Pedi patients
what are the signs/symptoms of an aluminum toxicity
encephalopathy, osteomalacia, reduced PTH secretion, erythropoietin resistant microcytic anemia
the FDA defines the upper limit of aluminum to be ___ and requires a ____ in the manufactures product
4-5mcg/kg/day; requires a warning statement
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
7-10 (perioperatively)
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
lower
name 2 absolute indications for the use of PN
high output fistula especially if over 500mL/day and GI obstruction limiting po intake >1 week
routine use of perioperative PN is indicated for severely malnourished patients to prevent preoperative complications when used for
> 7 days
in a home PN patient TNA TPN, what should added immediately before infusion
multivitamin
what are the recommended maximum PN components for fluid, g/kg carb, g/kg fat and g/kg protein
30-40mL/kg fluid
7g/kg carb
2.5 g/kg/day fat
2 g/kg protein (depending on the disease)
the best way to express the dextrose content in PN to avoid misinterpretation
grams per 24 hour infusion
max lipid infusion rate to avoid infusion complications
- 11 g/kg/hour lipid
1. 1 g/kg/day
provide at least ___ to __% of linoleic acid to avoid EFAD
2-4%
provide at least 0.25 to 0.5 % _____ to avoid EFAD
alpha linolenic acid
avoid providing IVFE if serum triglycerides exceed
400mg/dL
avoid infusion of >_____g/kg/hour of fat to a void hypertriglyceridemia
0.125 g/kg/hour
when 2 oils are mixed together into an emulsion this is known as a ___ mixture
physical
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
structured lipids
what is the primary advantage of using structured lipids in TPNA
lowers serum triglyceride levels because they are utilized at a slower rate
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
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
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
glutamine and arginine
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
arginine
the most appropriate PN amino acid solution for the non-dialysis patient with acute renal failure contains
a balance of essential and non essential amino acids
metabolic alkalosis is PN is mostly likely contributed by
amino acids; they have large amounts of endogenous acetate which metabolizes into excess bicarbonate
the addition of______ to PN has the benefit of unaltered GI permeability
glutamine diphosphate
the disadvantage of adding glutamine to PN is it can cause
hyperammonemia
renal parenteral formulas have higher amounts of ____ compared to the standard
essential amino acids
the addition of glutamine may be contraindicated in
hepatic failure
Glutamine diphosphate can be added into PN as long as it is added within ___ hours compounding
48 hours
this is a non-essential amino acid that is the primary fuel for the small bowel
glutamine
A patient with an ileostomy getting TPN is likely to need supplemental
sodium, potassium and acetate (loss of bicarb through stool)
what PN additive may cause throbocytopenia
heparin
_____ 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
INR
_____ 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
vitamin K
____ 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.
Iron dextran
the higher the ___ of an element, the higher the destabilizing power
valence
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
fat soluble vitamins
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
water soluble vitamins
increased endogenous insulin levels that don’t adjust to the decrease in dextrose infusion following the discontinuation of PN is called
rebound hypoglycemia
after stopping PN, blood glucose should be monitored for how long to prevent rebound hypoglycemia
30 minutes-1 hour
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
rebound hypoglycemia
Are parenteral feeding formulations hypotonic, isotonic, or hypertonic to body fluids?
Hypertonic
The osmolarity of a parenteral feeding formulation is primarily dependent on:
The dextrose, amino acid, and electrolyte content
List the approximate mOsm contributed by dextrose, amino acids, and electrolytes
Dextrose = 5 mOsm/g
Amino acids = 10 mOsm/g
Electrolytes = 1 mOsm per mEq of individual electrolyte additive
What is the maximum osmolarity tolerated by a peripheral vein?
900 mOsm/L
How must a hyperosmolar formula be delivered into the body and why?
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
CPN is preferred in patients who will require PN support for longer than what time frame?
7-14 days. CPN can ultimately be maintained for weeks to years
What is the dextrose dose in peripheral parenteral nutrition (PPN)?
150-300 gm/day (5-10% of the final concentration
What is the amino acid content of PPN?
50-100 gm/day (3% of final concentration)
Why is PPN an undesirable option for patients with a fluid restriction?
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
What 2 criteria must patients meet to be considered for PPN?
- They must have good peripheral venous access
- They should be able to tolerate large volumes of fluid (2.5-3 L/day)
What time frame is PPN appropriate?
Patients should require at least 5 days but no more than 2 weeks of partial or total PN
List the contraindications to PPN
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
What is the usual osmolarity of CPN?
1300-1800 mOsm/L
What is the usual osmolarity of PPN?
600-900 mOsm/L
Why is the use of midline catheters recommended in patients needing PPN for more than 6 days?
The catheter’s length and lower probability of dislodging compared with other peripheral cannulas. Midline catheters however do not eliminate the risk of thrombophlebitis
How often might a peripheral IV site need to be rotated when using PPN?
At least every 48-72 hours
Define permissive underfeeding and its intent when used with PN
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
Define hypocaloric feeding and its intent
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
Define supplemental PN
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
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?
Patients receiving perioperative support; acute exacerbations of Crohn’s, GI fistulas, or extreme short bowel syndrome; critical care and cancer patients
List the considerations for PN use
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
List situations during which CPN should be used
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
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
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.
Parameters under which PN indication is dependent
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.
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?
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
List clinical (biochemical) conditions that warrant cautious use of PN and the suggested criteria
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)
True or false: PN has been shown to improve patient outcomes as the primary management of acute exacerbations of Crohn’s or ulcerative colitis
False
What is the role of PN in pancreatitis?
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.
PN kcal and any special nutrient recommendations when used with pancreatitis?
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)
What are the effects of the stress of surgical procedures?
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
List the 2 main benefits of EN use in critical illness
- 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
- The low risk of mesenteric ischemia when introducing EN
List the criteria that critically ill patients usually meet to warrant the use of PN
- Malnourished at baseline
- Will not reliably ingest or absorb significant amounts of EN for a period of greater than 7-10 days
- Have been adequately resuscitated from any hemodynamic compromise
What is routine PN use in patients receiving chemo or radiation associated with?
Increased infectious complications and no improvement in clinical response, survival, or toxicity to chemotherapy
Conditions warranting caution when initiating PN in the home
Medical conditions: DM, CHF, pulmonary disease, severe malnutrition, hyperemesis gravidarum
Electrolyte disorders: Hypernatremia, hypokalemia, hyperchloremic metabolic acidosis, hypophosphatemia, hypochloremic metabolic alkalosis
Why is EN preferred over PN in cancer patients undergoing hematopoietic cell transplant?
Glycemic control is better during EN than PN
What are the requirements set forth by Medicare before home PN costs are reimbursed?
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)
Abnormalities in carbohydrate, protein, and fat metabolism are characterized in the stressed patient as:
Hyperglycemia, insulin resistance, uremia, encephalopathy, hyperosmolality, and hypertriglyceridemia
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)
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.
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
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.
Why might patients with limited cardiac function not tolerate a PN infusion?
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
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
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.
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?
On initiation check daily x3
Critical illness check daily
Stable patients check 1-2x per week
How often should serum triglycerides be checked on initiation of PN? During critical illness? In stable patients?
On initiation check on day 1
Critical illness check weekly
Stable patients check weekly
How often should capillary glucose be checked on initiation of PN? During critical illness? In stable patients?
On initiation check as needed
Critical illness check 3x or more each day until consistently <150
Stable patients check as needed
How often should LFTs (ALT, AST, ALP, total bilirubin) be checked on initiation of PN? During critical illness? In stable patients?
On initiation check on day 1
Critical illness check weekly
Stable patients check monthly
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.
PN may be discontinued when the patient can meet and tolerate an adequate percentage of their estimated energy and protein needs via enteral route.
How can rebound hypoglycemia be prevented when PN therapy is discontinued?
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
What has been demonstrated in the use of PN in malnourished patients?
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
for a pregnant patient with hyperemesis gravidarium presenting with fluid/electrolyte imbalances, ketonuria and dehydration, what would be the first line of therapy
IV fluid, additional B vitamins such as B12 and B6 as well as thiamine
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
Thiamine
Folic Acid
what is the second line of therapy for hyperemesis gravidarum
hold oral intake, start antiemetic
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
enteral feedings
when should PN be considered for hyperemesis gravidarum
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
Rapid IV infusion of potassium phosphate can cause
thrombophlebitis
infusion rates of IV phosphate should not exceed ___mmol/hr because it can cause ________ and metastatic ___ deposition/organ dysfunction
7 mmol/hr
thrombophlebitis
calcium phosphate deposition
the most common complication associated with PN
hyperglycemia
hyperglycemia is the most common complication associated with PN due to
stress associated hyperglycemia in sepsis/acutely ill causing insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion
what is the glycemic BG target for the majority of critically ill patients
140-180mg/dL (American Association of Clinical Endocrinologists and American Diabetes Association)
a target BG below ____ is not recommended in the ICU due to the adverse effects of hypoglycemia
<110mg/dL
What is the preferred approach for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus
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
what form of glutamine supplementation improves physical compatibility and stability for admix in PN solutions
glutamine dipeptide (L-alanyl, Lglutamine, Glycl L glutamine)
___glutamine supplementation is more beneficial than enteral supplementation
parenteral
IV glutamine supplements are _____ available in the U.S.
not
free ____ is unstable in PN solutions
glutamine
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
11-14 kg/ABW/day
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
65-70%
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
11-14 kcal/kg/ABW
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
22-25 IBW
protein should be provided in a range > or equal to ____ g/kg _____ a day for patients with a BMI of 30-40 kg/m2
2.0 g/kg IBW day
protein should be provided in a range up to ____g/kg ____ a day for patients with a BMI greater than or equal to 40
2.5 g/kg IBW /day
the majority of PN complications that increase PN Prescription errors happen when
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
According to ASPEN , what is the best way to express dextrose content on the PN label to avoid misinterpretation
total grams within 24 hours (ie 255 grams/day)
On the PN label, PN ingredients are ordered in ____ for adults and ______ for pediatrics and neonates
amounts per day for adults
amounts per kg for neonates/peds
On the PN label, macronutrients should be expressed in
grams per day
On the PN label, micronutrients should be measured in
mEq,mmol,mcg,mg per day (units)
Mandatory items on a PN ORDER FORM per ASPEN
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
electrolytes on the PN order form and label should be expressed in
complete salt form
Mandatory inpatient PN label should contain
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
if ILE is hung separately, the mandatory PN label should also contain
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#
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
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
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
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
A critically ill obese patient has a BMI >33.4 kg/m2, how much protein is recommended per SCCM and ASPEN
greater than or equal to 2.0 g/kg IBW
Which of the following is an indication to start PN
high output fistula, Chron’s disease, pancreatitis, hyperemesis gravidarum
high output fistula
When is PN indicated in severe burn patients
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
The routine use of preoperative PN is indicated for patients with a non functioning GI tract who are ____ to decrease perioperative complications
severely malnourished when used for >7 days pre op
An adult patient with an abdominal tumor resulting in an unresolved SBO for over 7 days is a candidate for PN true or false
true
Any adult with a GI obstruction that precludes oral intake for at least 1 week is a candidate for PN true or false
true
Palliative use of nutrition support in terminal ill patients is ______ indicated
rarely
patients who are scheduled for surgery and are _______ are recommended for PN if PN can continue for 7-10 days
severely malnourished
When should PN be used in Chron’s
only after failure to tolerate EN (studies have found no advantage of PN over the use of EN)
EN should only be used in patients with Chron’s requiring
nutrition support therapy
peri operative specialized nutrition support is indicated in patients with IBD who are ___ and surgery can be safely postponed
severely malnourished
In a TNA ILE is stable at room temperature for ______ and stable refrigerated for ________
24 hours (room temp) 9 days (refrigerated)
Prolonged exposure to light of an ILE can cause
degradation
ILE is most stable at a pH of ____ and adding _____ can cause instability
6-9 pH
acidic dextrose
ILE administration via Piggy Back separate from dextrose and protein has a max hang time of
12 hours
ILE administration via piggy back separate from dextrose and protein tubing/filters should be changed
with each new infusion
_____ micron filters should be used to stop fat emboli, air emboli, microorganisms, or particulate matter from the patient
1.2 micron
what is the most appropriate distal catheter tip placement at a peripherally inserted central catheter
superior vena cava
a catheter inserted via peripheral vein (cephalic or basilic) whose distal tip lies in the vena cava
PICC line
central or peripheral access is defined by
position of the distal tip
disadvantages of PICC lines
limited self care ability
limited mobility
high rate of malposition or coiling
long lines increase risk of occlusion
advantages of PICC lines
NO risk of pneumothorax of puncture of carotid/subclavian arteries
NO repeated skin punctures
comes in single, double or triple lumens
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
AFTER chest x-ray confirms correct cath tip placement
one of the most common complication(s) of central venous catheters inserted at the bedside
misplacement/pneumothorax
fluoroscopy for central line insertion allows
immediate repositioning of catheter tip
The CDC recommends to ______ routinely replace CVC’s, PICCs, HD catheters or pulmonary artery catheters to prevent catheter related infections
NOT
DON’T Recommend to routinely replace
The CDC recommends ______ remove the CVC/PICC based on fever alone
DON’T remove the line based on fever alone
______ should be used to determine appropriateness of catheter removal if infection is evidenced from another site or non infectious cause
clinical judgement
Catheter insertion over a guidewire during bacteremia should ______ due to a source of infection/colonization of the skin to the insertion site
SHOULD NOT BE DONE
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)
iron dextran
Phase separation and liberation from free oil from the destabilization of TNAs can result over time with an excess of ____ added to a formula
cations
The ____ the cation valence, the greater the destabilizing power of a TNA with oil (ILE)
greater the valence, the more disruptive
A PICC line should only be removed if
it is suspected or known to be the source of infection
the LEAST favorable place for a PN catheter is
femoral
Evidenced based interventions for patients with IV catheters that should be implemented together for the best outcomes is known as
the institute for health care improvement central line bundle
what are the two principles of the central line bundle
- optimal cath selection
2. avoid of CV access in places at high risk for infection (femoral catheters, when alternative access is available
what are the max percentages of dextrose and amino acids appropriate for peripheral PN
10% dextrose
3% amino acids
osmolarity up to _______ mOsm/L can be safely infused peripherally
900 mOsm/L
high concentrations of ____ increases calcium phosphorous precipitation in PN
amino acids
the increase of temperature of PN bags increases the dissociation of ____ salts
calcium
storage of PN in the refrigerator decreases the risk of _____ precipitation
calcium phosphate
when compounding PN, always add _____ first then ______
PHOS FIRST
then calcium
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
standard
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
non essential amino acids
Branched Chain Amino Acid PN formulations are the most appropriate for
a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources, despite optimal pharmacotherapy
APSEN recommends the use of _______ amino acid formulas for critically ill patients with acute and chronic liver disease
standard amino acid formulations
Failure to provide linoleic and alpha linolenic acids with PN will most likely result in
essential fatty acid deficiency
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
2-4% total calories linoleic acid
- 25-0.5% total calories alpha linoleic acid
- 5 to 1 gram/kg/day
what is a lipid injectable emulsion produced by the transesterification of fatty acids to form a composite triglyceride molecule?
a structured lipid
what is the purpose of using a structured lipid for an injectable lipid emulsion
to slow the rate or release and utilization of medium chain fatty acids
in a patient with hepatobiliary disease, which trace elements should be withheld or require a dose reduction when prescribing PN
manganese and copper due to impaired excretion in liver disease
what parts of PN are a major source of aluminum exposure 2/2 contamination of raw materials and byproducts
calcium salts, phosphate salts, calcium gluconate and potassium phosphate
The FDA mandates all manufacturers to measure and report the maximum content of ______ in their products
aluminum
per the FDA, large volume PN products should contain less than _____ mcg/L of aluminum
25 mcg/L
per the FDA, small volume PN products should label the amount of aluminum________
at the time of product expiration
a long term PN patient begins to experience Parkinson’s like symptoms; which trace element toxicity is most likely to present these symptoms
manganese
excess manganese accumulates in the _____ when not excreted through bile appropriately
the brain
What are the Parkinson’s like symptoms from hypermagnesemia
rigidity
involuntary movement
tremors
what patients are at risk for manganese toxicity
patients who are on TPN and have liver failure and elevated LFT’s because bile excretion is limited
patients with chronic liver disease should get ____ free TPN
manganese free
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
equal
when compared to the DRIs for water soluble vitamins given orally, the DRI’s for parenterally administered water soluble vitamins are
higher
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)
greater than
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
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)
according to the United States Pharmacopeia (USP) chapter 797, PN solutions are categorized as low, medium and high risk corresponding with the probability of
microbial contamination, chemical or physical contamination
according to the United States Pharmacopeia (USP) chapter 797, PN high risk solutions involve
NONSTERILEE ingredients and devices
Automated Computed Devices for compound TPN are _____ error free
NOT ERROR FREE, errors can still occur
Error rates of ACD devices compared to manual compounding are ____% and ___% respectively
22% ACD
39% Manual
There should be established ____ limit warnings and _____ based limits in the pharmacy and ACD systems
dose limit warnings
weight based limits
_____ should develop monitoring and surveillance plans for PN compounding
pharmacies
when is manual compounding appropriate to use over ACD’s when preparing PN
- when the volume of PN are less than the ACD can accurately provide
- when chemical interactions between PN components cannot be mitigated by sequencing
- conservation during drug shortages
_______ all healthcare providers should have the ability to override soft and hard limit alerts from ACDs
NOT ALL
the preparation of compounded sterile preparations (CSPs) for all patient populations should be _____ for each population, with ________ strategies
separate, separate
a translucent band at the surface of the emulsion separate from the remaining TNA dispersion is called
creaming
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
Initial phase
common occurrences
Doesn’t (little clinical risk)
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
Cracking (terminal state of emulsion destabilization)
Cracking of a TNA solution is the _____ phase of emulsion destabilization and can cause a ____ risk of clinical danger
terminal phase of emulsion destabilization
high risk of clinical danger
what complication is most likely to occur when transitioning a critically ill patient from PN to EN and why. how can this be limited?
hyperglycemia because there may be an overlap in excess nutrients given when transitioning. This can be limited by keeping GIR < 4 mg/kg/min
rapid infusion of IV Na or KPhos may result in ____ from an abrupt decrease in ________
tetany from abrupt decrease in serum calcium
potassium phosphate in PN is _____ in nature, acid base wise
acidic/acidifying
while getting PN, your patient develops metabolic acidosis. What serum electrolyte level needs to be monitored most closely
potassium
during metabolic acidosis and tissue catabolism, there is an extracellular shift in ____ to maintain electroneutrality. Correcting metabolic acidosis will treat this.
potassium
what is considered the most serious complication of significant hyperphosphatemia?
soft tissue and vascular complications 2/2 calcification when serum calcium multiplied by serum phos exceeds >55mg/DL
