Chapter 17: Complications of PN

Question 1

**To provide hyperglycemia with initiation of PN, what does ASPEN/SCCM recommend?

Answer 1

**PN should be initiated at half of the estimated energy needs, or approximately 150 to 200 g dextrose, for the first 24 hours. Delivery of less dextrose (~100 g) would be appropriate if the patient has a low BMI or poor glucose control.

Question 2

Carbohydrate administration should not exceed a rate of X to X mg/kg/min or X to X kcal/kg/day in acutely ill patients.

Answer 2

4 to 5 mg/kg/min OR 20 to 25 kcal/kg/day

Question 3

How often should capillary [blood glucose] be monitored?

Answer 3

Q 6 to 8 hours in patients receiving subQ, short-acting insulin AND more frequently in critically ill patients receiving insulin gtt.

Question 4

(T/F) The dextrose dose in the PN formulation should not be advanced until the patient’s blood glucose are controlled.

Answer 4

TRUE.

Question 5

What is a common initial insulin regimen? What about with patients who are already hyperglycemic?

Answer 5

Common = 0.05 to 0.1 units per gram of dextrose in PN solution Hyperglycemic = 0.15 to 0.2 units per gram of dextrose

Question 6

XX of the total amount of SSI required over 24 hours may then be added to the next day’s PN formulation.

Answer 6

2/3

Question 7

What is the only type of insulin that should be added to the PN formulation?

Answer 7

Regular insulin

Question 8

What are 3 treatment types for PN-associated hypoglycemia?

Answer 8

1. Initiation of 10% dextrose infusion
2. Administration of an ampule of 50% dextrose
3. AND/OR Stopping any source of insulin administration.

Question 9

(TRUE/FALSE)

Abrupt discontinuation of PN solutions has been associated with rebound hypoglycemia.

Answer 9

TRUE.

If a PN solution must be discontinued quickly, a dextrose-containing fluid should be infused for 1 to 2 hours following PN discontinuation to avoid a possible rebound hypoglycemia. Obtaining a capillary [BG] 30 minutes to 1 hour after the PN solution is discontinued will help identify rebound hypoglycemia.

Question 10

What are the recommendations related to PN, in preventing EFAD?

Answer 10

1% to 2% of daily energy requirements should be derived from linoleic acid and about 0.5% of energy from linolenic acid.

This goal translates to approx. 250 mL of 20% or 500 mL of 10% soy-based ILE administered over 8 to 10 hours, twice a week.

Alternatively, 500 mL of a 20% soy-based ILE can be given once a week.

Question 11

(TRUE/FALSE)**

Withholding or limiting soy-based ILE in critically ill patients for the first week of PN has been suggested as a strategy to reduce immunosuppression complications.

Answer 11

TRUE.

However, ASPEN/SCCM gave the quality of the evidence a very low rating.

Question 12

**What are the ASPEN recommendations related to hypertriglyceridemia?

Answer 12

** ASPEN recommends that serum triglyceride concentrations greater than 400 mg/dL be avoided when infusing ILE, and clinicians should reduce the ILE dose or discontinue ILE if this level of hypertriglyceremidemia occurs.

The dose of ILE should also be reduced or discontinued in mechnically ventilated patients receiving propofol for sedation because it is supplied as a 10% ILE.

Question 13

(TRUE/FALSE)

Adult patients receiving PN should receive a standard daily dose of parenternal MVI.

Answer 13

TRUE.

Question 14

**What is the advice from ASPEN to help clinicians cope with parenteral MVI product shortages?

Answer 14

**ASPEND recommends:

• Reserve a supply of IV MVIs for those patient solely receiving PN
• Use oral or enterally administered MVI whenever possible
• To ensure fair allocation of products nationwide, do not stockpile parenteral MVI
• Do not use pediatric IV MVIs for adult patients
• When all options to obtain IV MVIs have been exhausted, ration use by reducing the dose by 50% or giving 1 dose 3 times a week.
• If IV MVIs are no longer available, administer individual thiamine, ascorbic acid, pyridoxine, and folic acid daily.

Question 15

(TRUE/FALSE)

Iron is a component of PN formulation.

Answer 15

FALSE.

It is not a component because of compatibility limitations.

Question 16

What are the 2 terms that are used to refer to hepatic dysfunction secondary to intestinal failure that occurs in the setting of PN.

Answer 16

• PNALD (PN-associated liver disease)
• Intestinal failure-associated liver disease

These terms are used interchangeably, and replace ‘PN-induced liver disease’

Question 17

What are the 3 types of hepatobiliary disorders associated with PN therapy?

Answer 17

• Steatosis
• PNAC (PN-associated cholestasis)
• Gallbladder stasis

Question 18

Define steatosis.

Answer 18

Hepatic fat accumulation; seems to be a complication of overfeeding; may progress to fibrosis or cirrhosis in patients receiving long-term PN.

Question 19

Define PN-associated cholestasis (PNAC).

Answer 19

• A condition of impaired secretion of bile or frank biliary obstruction that occurs predominantly in childre, but it may also occur in adult patients receiving long-term PN
• Presents as: elevated alkaline phosphatase, y-glutamyl transpeptidase and conjugated (direct) [bilirubin] w/ or w/o jaundice (but all of these lack specificity because levels may be elevated in other diseases as well).
• An elevated serum conjugated bilirubin (greater than 2 mg/dL) is considered the prime indicator for cholestatis.
• Serious complication bc it may progress to cirrhosis or liver failure

Question 20

Define gallbladder stasis.

Answer 20

Development of gallstones or GB sludge with subsequent cholecystitis.

This complication is related to more to the lack of enteral stimulation than the PN infusion itself.

Question 21

A balanced PN formulation should provide X to X% of nonprotein energy, such as CHO and X to X% as fat.

Answer 21

70 to 85% CHO

15 to 30% Fat

Question 22

What is Ursodial?

Answer 22

A form of bile acid widely used to treat various chronic cholestatic liver diseases, and it has been shown to improve biochemical markers of cholestasis.

Note: No IV form is available.

Question 23

What is the clinical definition of osteoporosis?

Answer 23

Based on a bone mineral density measurement that is more than 2.5 standard deviations below the mean score for young-adult, ethnicity, and sex-matched controls.

Question 24

Define osteomalacia.

Answer 24

Characterized by softening and bending of the bones that occur because the bones contain osteoid tissude that has failed to calcify; generally caused by vitamin D deficiency

Dx requires a bone biopsy for histologic examination of bone tissue; very difficult to identify

Question 25

**What is the ASPEN recommendation for phosphorus added to PN formulations?

Answer 25

** 20 to 40 mmol/day.

Question 26

(TRUE/FALSE)

Teriparatide is the only FDA-approved medication that stimulates bone formation.

Answer 26

TRUE.