Complications of Parenteral Nutrition Flashcards
1
Q
Excess ___ administration has been associated with hepatic steatosis as excess ___ deposit in the liver as fat
A
-Carbohydrate
-Carbohydrates
2
Q
Providing balanced dextrose and fat calories seems to decrease the incidence of ___, possibly by decreasing hepatic triglyceride uptake and promoting fatty acid oxidation
A
Steatosis
3
Q
Is metabolic bone disease related to carbohydrate administration?
A
No
4
Q
Is hypercalcemia related to carbohydrate administration?
A
No
5
Q
Excess ___ administration has been shown to cause increased carbon dioxide production.
A
Carbohydrate
6
Q
Name 3 complications of short-term PN
A
- Electrolyte abnormalities
- Dehydration
- Catheter malposition
7
Q
Is metabolic bone disease a concern in long-term parenteral nutrition patients?
A
Yes
8
Q
How to the PN formulation contribute to metabolic bone disease?
A
The contribution of the PN formulation to the development of bone disease is unclear
9
Q
___ ___ upon discontinuation of PN may occur, especially in individuals with underlying conditions that affect glucose regulation or those patients requiring large doses of insulin.
A
Rebound hypoglycemia
10
Q
To reduce the risk of hypoglycemia with cessation of PN, a ___-___ hour taper (e.g. 50% rate reduction) prior to discontinuation is recommended, especially when the patient is unable to take adequate oral or EN feeding
A
1-2 hour
11
Q
Ordering a point-of-care glucose ___-___ minutes after cessation of PN is recommended to identify and treat rebound hypoglycemia.
A
30-60 minutes
12
Q
Name 4 electrolyte abnormalities that may occur with refeeding syndrome
A
- Sodium retention
- Hypophosphatemia
- Hypokalemia
- Hypomagnesemia
13
Q
Sodium retention usually occurs in the early phase of the refeeding syndrome and is exacerbated by excessive ___ and ___ intake.
A
Sodium and fluid
14
Q
Sodium retention in refeeding syndrome may lead to ___ overload, ___ edema, and ___ decompensation
A
-Fluid overload
-Pulmonary edema
-Cardiac decompensation
15
Q
Name the complications associated with severe hypophosphatemia
A
Dyspnea (along with other signs of respiratory failure) and seizures
16
Q
What are some physical manifestations that might arise with severe hypokalemia and hypomagnesemia?
A
Predisposes patients to cardiac arrhythmias and neuromuscular adverse effects such as weakness and muscle cramps
17
Q
True or false: Use of maximal-barrier precautions during catheter insertion (mask, cap, sterile gloves, long-sleeve gowns, and sheet drapes) reduces the incidence of catheter-related infections more than the use of only sterile gloves and drapes alone
A
True
18
Q
With central line placement: skin preparation with chlorhexidine results in ___ (higher or lower) ___ incidence of microbial colonization than povidone-iodine
A
Lower
19
Q
True or false: Prophylactic use of antibiotic ointment at the catheter exit site encourages the development of resistant flora and should be avoided.
A
True
20
Q
Antibiotic prophylaxis during catheter insertion has not been demonstrated to reduce the incidence of catheter-associated ___.
A
Sepsis
21
Q
What is fibrin sheath?
A
A fibrin sheath, or fibrin sleeve, is a thrombotic catheter occlusion and develops when fibrin adheres to the external surfaces of the catheter
22
Q
___ catheter occlusions can result from mechanical obstructions, drug or mineral precipitates, or lipid deposits. Mechanical obstruction may reflect catheter migration or malposition that occurs during insertion or use
A
Non-thrombotic
23
Q
How do precipitates that produce catheter occlusions form?
A
-Drug crystallization
-Drug-drug incompatibilities
-Drug-solution incompatibilities
24
Q
True or false: Hepatic dysfunction can result from long-term administration of PN
A
True
25
Conversion to cyclic TPN administration allows the body to ___ fat and results in lower ___ levels as well as improved liver enzymes.
-Fat
-Insulin
26
True or false: underfeeding calories administration will result in steatosis
False. It is important to avoid excess calories as excess calorie administration will result in steatosis.
27
The initiation of ___ feeding stimulates bile flow and may protect against gut bacterial translocation
Enteral
28
If hepatic dysfunction occurs, serum concentrations of trace elements such as ___ and ___ should be monitored on a regular basis
Manganese and copper
29
PPN formulations are ___ solutions that can possibly cause pheblitis or extravasation.
Hyperosmolar
30
Define extravasation
Extravasation is the leakage of fluid or medication from a blood vessel into the surrounding tissues.
31
PPN solutions are usually limited to an osmolarity of ___-___ mOsm/L.
600-900
32
Fat can be used to increase caloric density of the formulation without increasing the ___.
Osmolarity
33
Minimum final concentrations of amino acid ___%, dextrose ___%, and fat ___% are recommended for stability purposes of TPN
-4%
-10%
-2%
34
Know how to estimate the osmolarity of PPN when given the grams of protein and dextrose:
The following formula can be used to estimate the osmolarity of a PPN:
Amino acid 1g = 10 mOsm
Dextrose 1g = 5 mOsm
Add these together and divide by total volume.
Ex:
Amino acid 75g = 750 mOsm
Dextrose 210g = 1050 mOsm
750 mOsm + 1050 mOsm = 1800 mOsm/3000mL = 600 mOsm/L
35
1g of amino acids = ___ mOsm
10
36
1g dextrose = ___ mOsm
5
37
Name 3 examples of metabolic bone disease reported in PN-dependent patients
1. Osteomalacia
2. Osteoporosis
3. Osteopenia
38
Aluminum contaminants can be mainly found in what components of parenteral solutions?
Calcium and phosphate salts, trace minerals and vitamins
39
True or false: Patients with renal insufficiency are at higher risk for aluminum toxicity due to impaired kidney aluminum excretion.
True
40
Aluminum toxicity causes ___ by impairing calcium bone fixation, inhibiting the conversion of 25-hydroxyvitamin D to the active 1, 25-dihydroxyvitamin D or reducing ___ hormone secretion.
-Osteomalacia
-Parathyroid
41
In 2000, the FDA issued a rule specifying acceptable aluminum concentrations in large volume parenterals and defined a possible safe upper limit for parenteral aluminum intake at less than ___-___ mcg/kg/day.
4-5
42
Name the 4 characteristics of early phase of manganese toxicity
1. Weakness
2. Anorexia
3. Headache
4. Apathy
43
After the early phase of manganese toxicity, the following symptoms present:
Parkinson-like features including muscle rigidity, mask-like face, staggered gait, and fine tremor
44
What component of PN may put a patient at risk for manganese toxicity?
Manganese toxicity may occur in patients on long-term therapy supplemented with a combination multiple trace element preparation.
45
Cholestasis and biliary obstruction may also increase the risk of toxicity as greater than ___% of manganese excretion is via the bile into the feces.
90%
46
Selenium deficiency is associated with ___ disease (a type of cardiomyopathy) and increased ___ injury
-Keshan
-Oxidative
47
What symptoms could be observed in selenium toxicity?
Loss of hair and nails, skin lesions, tooth decay, and peripheral neuropathy.
48
An elevated serum bicarbonate level is one of the markers of metabolic ___
Alkalosis
49
What might cause metabolic alkalosis?
Nasogastric suctioning, volume depletion and diuretic use.
50
In a PN patient, excess use of ___, which is metabolized to bicarbonate, may precipitate a metabolic alkalosis
Acetate
51
Name some common causes of metabolic acidosis
Excess chloride, diarrhea and acute renal failure
52
Name the primary intervention for reducing risks of central venous access device-related infections (as determined by the CDC)
Education and training of health care personnel.
53
True or false: Administering antibiotics prior to inserting central venous catheters has been shown to be effective in reducing the rates of central venous access device-related infections.
FALSE: Administering antibiotics prior to inserting central venous catheters has NOT been shown to be effective in reducing the rates of central venous access device-related infections.
54
The most important contributor to metabolic bone disease is a negative ___ balance
Calcium
55
Hypocalcemia occurs as a result of decreased calcium intake and/or increased calcium ___ excretion
Urinary
56
Name factors that cause hypercalciuria
1. Excessive calcium and inadequate phosphorus supplementation
2. Excessive protein in PN solutions
3. Cyclic PN infusions
4. Chronic metabolic acidosis.
57
Ideally, protein doses for long-term PN provision should not exceed ___g/kg/day.
1.5
58
The exact mechanism of protein-induced hypercalciuria is unknown, however name 4 things it could be related to.
1. Increased GFR
2. Increased excretion of sulfates
3. Ammonia
4. Urinary titratable acidity (metabolic acidosis) that decreases renal calcium reabsorption
59
If hypertriglyceridemia is unnoticed and untreated, it may lead to the development of ___ and altered ___ function.
-Pancreatitis
-Altered pulmonary function
60
Avoid serum triglyceride levels greater than ___ mg/dL in adults and greater than ___ mg/dL in neonates
-400
-200
61
The most appropriate nutrition intervention for a patient experiencing metabolic alkalosis is to ___ the chloride:acetate ratio in the PN solution.
Increase
62
The most appropriate nutrition intervention for patient experiencing metabolic acidosis is to ___ the chloride:acetate ratio in the PN solution
Decrease
63
Acetate is converted to ___ by the liver which could help correct metabolic acidosis
Bicarbonate
64
Define a clinical exit site infection
Erythema, tenderness or purulence within 2 cm of the catheter exit site.
65
Management of catheter exit site infection includes culture of any ___ from the catheter exit site in addition to blood cultures
Drainage
66
Topical antimicrobial agent on the basis of the exit site culture can be used if there is no ___ from the catheter exit site and no clinical signs of ___
-Purulence
-Sepsis
67
When is exchange of a catheter over guide wire recommended?
1. If a catheter is infected and catheter removal is indicated and other IV access is unavailable
2. If the patient is at increased risk for bleeding due to hypocoagulability in the setting of CVAD infection
68
Systemic ___ treatment is used in the presence of purulent drainage from the catheter exit site or if topical treatment is unsuccessful
Antimicrobial
69
The catheter should be ___ if systemic antimicrobial treatment fails or if the patient has clinical signs of sepsis
Removed
70
Patients with ileostomy or small bowel fistula output are at risk for loss of ___ and ___.
Water and electrolytes
71
Sodium content of ileostomy output can be as high as ___ mEq/L.
100
72
A high BUN/Cr ratio of ___:___ indicates volume depletion.
20:1
73
___ can result when fluid replacement does not contain adequate sodium to account for ileostomy losses
Hyponatremia
74
Patients with Crohn's disease are at risk for MBD if they have malabsorption of ___ and vitamin ___ or use ___ to control their disease.
-Calcium
-Vitamin D
-Corticosteroids
75
Patients with cancer are increased risk for MDB as they may have decreased food intake and altered ___ and vitamin ___ metabolism associated with surgery or chemoradiation.
Calcium and vitamin D
76
MBD may develop in cancer patients as a result of therapy-induced amenorrhea or the elevation of cytokines or ___-like peptides.
Parathyroid
77
There is evidence that renal wasting of calcium may occur in individuals with ___ syndrome, which would increase risk of MBD
Short bowel
78
Hyper___ism is a secondary cause of osteoporosis
Hyperthyroidism
79
What is a sentinel event?
A sentinel event is a patient safety event of an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
80
When should sentinel events be investigated and responded to?
Sentinel events signal the need for immediate investigation and response.
81
The ___ ___ sentinel event policy is designed to help organizations identify sentinel events and take action to prevent their recurrence
Joint Commission's
82
Name examples of sentinel events
1. Medication errors
2. Wrong site surgery
3. Restraint-related deaths
4. Blood transfusion errors
5. Operative or postoperative complications
83
Define Process Measure
A process measure has a scientific basis which focuses on a process that leads to a certain outcome.
84
Define clinical measure events
Clinical measure events evaluate the processes or outcomes of care associated with the delivery of clinical services.
85
Define accountability measures
Accountability measures are quality measures that emphasize research, proximity, accuracy, and adverse effects in order to result in positive patient outcomes.
86
___ ___ occurs when elevated endogenous insulin levels do not adjust to the reduced dextrose infusion following abrupt cessation of PN.
Rebound hypoglycemia
87
Does rebound hypoglycemia happen to all patients?
Although rebound hypoglycemia is not a universal occurrence, some patients may be at higher risk because of underlying conditions that affect glucose regulation.
88
What patients would be at a higher risk for rebound hyperglycemia?
These patients include those with malnutrition and renal or liver disease however hypertension alone should not predispose one to hypoglycemia.
89
A ___ to ___ hour taper at the end of PN infusion can reduce the risk of rebound hypoglycemia
1-2
90
What is a TPN/PN "taper"
Cutting the rate in half
91
Parenterally fed patients require a significantly ___ dose of insulin in order to achieve normoglycemia
Higher
92
Hyperglycemia risk is ___ with acute pancreatitis
Elevated
93
How does stress-associated hyperglycemia develop in patients with sepsis?
It is a result of insulin resistance, increased gluconeogenesis and glycogenolysis and suppressed insulin secretion
94
Insulin resistance may be exacerbated in ___ patients during times of stress.
Obese
95
Patients with renal failure demonstrate a prolonged insulin half-life as the kidney accounts for ~___-___% of its clearance from systemic circulation.
40-50%
96
True or false: renal failure is associated with a higher incidence of severe hypoglycemia
True
97
Pinch-off syndrome occurs when the catheter is being compressed between the ___ and the ___.
-First rib
-Clavicle
98
Pinch off syndrome can lead to intermittent ___ of infusion and aspiration and an increased risk of catheter ___.
-Occlusion
-Fracture
The external portion of the catheter may frequently tear as a result of the increased pressure required to overcome the compressed catheter, thus requiring repair.
99
What is the hallmark sign of pinch-off syndrome?
Changes in the patient's position can widen or narrow the angle between the rib and clavicle, usually by raising or lowering the arm, which can relieve occlusion of the catheter.
100
What is the treatment for pinch-off syndrome?
The treatment is removal of the catheter and reinsertion in a more lateral position in the subclavian vein or placement in the internal jugular vein.
101
The most appropriate nutritional intervention for respiratory acidosis is to ___ the total calorie content of the PN regimen.
Decrease
102
Overfeeding should be avoided as excessive calorie supplementation can lead to hyper-___ due to excessive carbon dioxide production relative to oxygen consumption.
Hypercapnia
103
What are some clinical manifestations of a catheter-related bloodstream infection?
-At least one positive blood culture
-Fever, and no apparent source except the catheter
104
Bactermia and fungemia are examples of what?
A catheter-related bloodstream infection
105
Do catheter-related blood stream infections often present with redness and purulence at the catheter site?
NO!
106
Tenderness, erythema, or induration from the catheter site along the subcutaneous tract of a tunneled catheter might be a ____ infection
Tunnel line infection
107
Erythema or induration within 2 cm of the catheter exit site, in the absence of concomitant blood stream infection and without purulence might be an ___ infection
Exit site infection
108
Inflammation of the vessel wall as well as erythema and pain near the catheter insertion site or along the affected vein might be catheter-related ____
Catheter-related phlebitis
109
Is thiamine water soluble?
Yes
110
What factors can deplete body stores of Thiamine?
Malnutrition, weight loss, chronic alcoholism
111
How does carbohydrate intake affect Thiamine demand?
Increases the demand for Thiamin
112
What is Thiamine's role in the body?
Essential coenzyme in carbohydrate metabolism
113
When is Thiamine supplementation indicated?
In patients at risk for refeeding syndrome
114
What is the recommended dosage of Thiamin before feeding or dextrose-containing IV fluids?
100 mg
115
For how many days should Thiamin be supplemented in patients with severe starvation or chronic alcoholism?
5 - 7 days or longer
116
What are the signs that indicate a risk for Thiamin deficiency?
Severe starvation, chronic alcoholism, other high risk for deficiency
117
What is the recommended limit for dextrose in PN components?
4-5 mg/kg/minute
## Footnote
This limit is set to prevent complications such as hyperglycemia.
118
What is the recommended limit for soybean lipid in PN components?
1 gram fat/kg/day
## Footnote
This guideline helps manage fat intake in patients receiving parenteral nutrition.
119
What are the estimated protein requirements for medically stable adults?
0.8 – 1.5 g-protein/kg/day
## Footnote
This range helps ensure adequate nutrition for adults not experiencing acute illness.
120
What are the estimated fluid requirements for medically stable adults?
30-40 mL fluid/kg/day
## Footnote
Proper hydration is critical for maintaining physiological functions.
121
Is the density of skin flora at the catheter site a major contributing factor for catheter-related blood stream infections (CRBSI)?
Yes
## Footnote
Higher skin flora density increases the risk of infections.
122
Which site on the body is recommended for placing central venous access devices (CVADs) to reduce the risk of infection?
Subclavian site
## Footnote
This site is preferred over jugular or femoral sites.
123
True or False: The external jugular is a preferred location for a CVAD for parenteral nutrition.
False
## Footnote
The external jugular is not preferred for CVAD placement.
124
What is the treatment for catheter occlusion due to lipid sludge?
70% ethyl alcohol assists with lipid deposits.
## Footnote
Lipids are soluble in alcohol, making it effective for clearing lipid sludge.
125
What type of medications can cause precipitation leading to catheter occlusion?
Acidic medications and basic medications.
## Footnote
Examples include vancomycin (acidic) and phenytoin (basic).
126
What solution is used to clear precipitation from acidic medications and Calcium-phosphorous precipitation?
0.1-N hydrochloric acid (HCl).
## Footnote
This can help clear precipitates from medications like vancomycin.
127
What can cause catheter occlusion in patients receiving TPN?
Poor flushing habits leading to lipid sludge and deposits.
## Footnote
Total Parenteral Nutrition (TPN) patients may experience occlusions if not properly flushed.
128
Occlusion from basic medications can be cleared with _______.
8.4% sodium bicarbonate or 0.1-N NaOH.
## Footnote
These solutions are effective for basic medications like phenytoin and oxacillin.
129
True or False: Calcium-phosphorous precipitation can be cleared with 0.1-N hydrochloric acid.
True.
## Footnote
This acid can help clear specific types of precipitates related to catheter occlusion.
130
Malassezia furfur is classically associated with superficial infections of the ___ and associated structures
Skin
## Footnote
This organism is a lipophilic yeast.
131
___ is a lipophilic yeast that has been reported as a cause of catheter-related blood stream infections.
Malassezia furfur
## Footnote
This is particularly noted in premature infants and patients receiving PN containing ILE.
132
In which patient population is Malassezia furfur most commonly associated with catheter-related blood stream infections?
Premature infants and patients receiving PN containing ILE
## Footnote
PN refers to parenteral nutrition.
133
What is a crucial step in the treatment of patients infected with Malassezia furfur?
Administration of antifungal therapy, discontinuation of ILE, and removal of the intravascular catheter, especially with non-tunneled catheter infections.
## Footnote
This is part of the appropriate treatment along with discontinuation of ILE and removal of the intravascular catheter.
134
What are the 3 basic types of hepatobiliary disorders associated with PN?
Steatosis, cholestasis, gallbladder sludging (stones)
## Footnote
PN stands for parenteral nutrition.
135
What lab values is hepatic steatosis characterized by?
Mild elevations in aminotransferases, serum alkaline phosphatase, and bilirubin concentrations
## Footnote
Hepatic steatosis is most often a complication of overfeeding.
136
In which population does cholestasis primarily occur?
Children
## Footnote
Cholestasis is characterized by impaired biliary secretion.
137
What is the most common laboratory manifestation of cholestasis?
Elevated conjugated bilirubin levels
138
What causes gallbladder sludging or stones in patients on long-term PN?
Lack of enteral stimulation in the GI tract
139
Is hepatic steatosis related to overfeeding?
Yes
## Footnote
The lab values consistent with hepatic steatosis are present in this scenario.
140
What is the standard frequency for glucose checks in a patient with diabetes on PN?
Every 2-6 hours, depending on facility protocol, insulin requirements, and general clinical condition.
141
What is the maximum infusion rate of dextrose for patients with diabetes receiving PN?
5 mg/kg/min.
142
What is the starting amount of dextrose per day for diabetic patients on PN?
100-150 grams.
143
What is the estimated initial amount of insulin to add to PN for a diabetic patient?
0.05-0.1 unit insulin/gm dextrose.
144
How should the insulin dosage be adjusted daily for diabetic patients on PN?
Increased daily to achieve glycemic goals by adding 2/3 of previous day's sliding scale insulin.
145
What is the association between increased blood glucose levels and infection in diabetic and critically ill patients?
Higher frequency of infection.
146
What factors contribute to hyperglycemia in critically ill patients receiving PN?
Intense counter-regulatory hormone and cytokine responses to severe disease and excessive administration of glucose.
147
What 7 conditions predispose patients to refeeding syndrome?
1. Chronic starvation
2. Prolonged fasting or minimal oral intake (>7 days)
3. Chronic alcoholism
4. Anorexia nervosa
5. Malabsorption syndromes
6. Morbid obesity followed by significant weight loss
7. Wasting diseases such as cancer and AIDS
## Footnote
These conditions can lead to electrolyte imbalances when feeding is resumed.
148
What is the best approach to preventing cholelithiasis?
Early initiation of oral or enteral feeding, even in small amounts
149
What does early feeding stimulate to help prevent cholelithiasis?
Cholecystokinin secretion, bowel motility, and gallbladder emptying
150
What are the results of injections of CCK-OP?
CCK-OP is used to induce gall bladder contractions and reduce biliary sludge. It has yielded mixed results and caused gastrointestinal intolerance in some patients
151
What is ursodiol used for?
Although ursodiol has been shown to improve bile flow, doses of 6-15 mg/kg/day have yielded mixed and limited results.
152
In what form is ursodiol available?
Oral dosage form (so absorption may be affected in patients with intestinal resection)
153
What are the main characteristics of refeeding syndrome?
Alterations in electrolytes and vitamins.
154
Which electrolyte imbalances are commonly associated with refeeding syndrome?
-Hypokalemia
-Hypophosphatemia
-Hypomagnesemia
155
What are the potential consequences of refeeding syndrome?
Significant morbidity and mortality.
156
What are hallmark symptoms of catheter related central venous thrombosis?
Arm, shoulder, or neck swelling, limb, jaw, or ear pain, and dilated collateral veins over the arm, neck or chest
## Footnote
These symptoms indicate potential issues related to central venous catheters.
157
What causes central venous thrombosis?
Endothelial trauma and inflammation caused by central venous catheters
## Footnote
This trauma can lead to venous thrombosis.
158
What may obstruction of blood flow within a CVC cause?
Collateral vein congestion and edema on the affected side
## Footnote
This is a result of impaired venous return due to thrombosis.
159
True or False: Dilated collateral veins are a symptom of catheter related central venous thrombosis.
True
## Footnote
This symptom is part of the clinical presentation.
160
What type of fatty acids are soybean-based ILE primarily composed of?
Omega-6 polyunsaturated fatty acids
## Footnote
Omega-6 fatty acids are known to be proinflammatory.
161
What potential negative effect do soybean-based ILE contain that may impair bile flow?
Toxic phytosterols
## Footnote
Phytosterols are plant-derived compounds that can interfere with bile flow.
162
Name 4 ways to reduce parenteral nutrition associated liver disease risk
1. Cycling PN
2. Supplementing with enteral feeding
3. Adding ursodiol
4. Increasing the omega 3:omega 6 ratio
## Footnote
Ursodiol is a medication used to improve bile flow.
163
Why is 0.1N hydrochloric acid effective for clearing catheters with crystalline occlusions?
Due to its acidic pH favoring calcium and phosphate solubility.
## Footnote
The acidic environment helps dissolve crystalline deposits that obstruct catheter flow.
164
What complications can arise from direct infusion of hydrochloric acid into the venous system?
Fever, phlebitis, and sepsis.
## Footnote
These complications highlight the risks associated with improper use of hydrochloric acid in clinical settings.
165
What is the recommended treatment for catheter occlusions due to high pH medication precipitates?
Sodium bicarbonate 1 mEq/mL.
## Footnote
This treatment has been anecdotally reported to be effective for certain medication-related occlusions.
166
What causes hypertonic hyponatremia (also called Pseudohyponatremia)?
Presence of osmotically active substances other than sodium in the extracellular cellular fluid (ECF)
Causes water to move from the intracellular fluid (ICF) to the ECF to equilibrate osmolality.
This movement will cause sodium dilution in the ECF, leading to hyponatremia.
167
What are common causes of hypertonic hyponatremia?
1. Hyperglycemia
2. Infusion of hypertonic fluids (with little or no sodium)
3. Medications (e.g. mannitol)
168
For each 100 mg/dL increase in blood glucose above 100 mg/dL, how much is serum sodium expected to fall?
1.6 mEq/L
169
What is the conventional therapy for an occluded central venous access device (CVAD) due to an intraluminal clot?
Local thrombolytic therapy with a low dose agent in a single or repeated bolus.
170
Which thrombolytic agent is FDA-approved for CVAD occlusions?
Cathflow (Alteplase).
171
What is the recommended dose of alteplase for treating CVAD occlusions?
2 mL, or 110% of the volume of the catheter lumen if less than 2 mL (maximum dose 2 mg).
172
How does alteplase function in treating occluded CVADs?
It catalyzes the conversion of clot-bound plasminogen to plasmin and initiates fibrinolysis.
173
How does the effectiveness of alteplase compare to urokinase 500 IU for CVAD occlusions?
Alteplase was found to be more effective than urokinase 500 IU.
174
Is heparin 100 units/mL appropriate for treating CVAD occlusions?
No, it is appropriate for catheter flushing but not for treatment of CVAD occlusions.
175
What do elevations of alkaline phosphatase, gamma glutamyltransferase, and conjugated bilirubin suggest?
Cholestasis or biliary obstruction
## Footnote
These elevations indicate issues with bile flow in the liver.
176
What is the typical serum conjugated bilirubin level that indicates cholestasis?
>2 mg/dL
## Footnote
Elevated levels of conjugated bilirubin are a key indicator of cholestasis.
177
What do abnormalities in aminotransferases indicate?
Hepatocellular steatosis
## Footnote
These abnormalities reflect damage to liver cells.
178
List the steps to prevent unnecessary catheter removals and/or unnecessary instillations of compounds to relieve the catheter occlusion.
1. Obtain thorough history of signs/symptoms of catheter malfunction from the patient
2. Double-check catheter function for patency and blood aspiration
3. Check for mechanical causes of occlusions (clamps, kinked tubing, tight sutures, replace needle if implanted vascular access port) and assess if occlusion is related to postural changes (rolling of shoulder or raising or lowering of arm on the side of the catheter)
4. Obtain thorough history of recent flushing techniques, medication infusions, and blood aspiration
5. Assess for physical signs of edema, redness, pain, or dilated vessels.
## Footnote
This helps to identify specific issues related to the catheter's function.
179
Magnesium is important in the regulation of ___cellular potassium
Intracellular
180
What refractory condition may result from hypomagnesemia?
Refractory hypokalemia
181
What are the likely causes of refractory hypokalemia in hypomagnesemia?
Accelerated renal potassium loss or impairment of sodium-potassium pump activity
182
When hypokalemia and hypomagnesemia coexist, what should be corrected first?
Magnesium deficiency
183
The normal absorption rate of manganese from the gastrointestinal tract is ___-___% of dietary intake
6-16%
## Footnote
This absorption rate indicates how efficiently manganese is taken up from food sources.
184
What is the bioavailability of manganese when provided by the parenteral route?
100%
## Footnote
This occurs because the gastrointestinal tract is bypassed.
185
How is manganese primarily excreted from the body?
In the feces via bile
## Footnote
This excretion pathway is significant for understanding manganese levels in patients.
186
What risks may arise in patients with impaired biliary excretion - concerning manganese?
Risk for brain tissue accumulation and effects on the central nervous system
## Footnote
Accumulation can lead to toxicity and neurological issues.
187
How can manganese toxicity be monitored?
By MRI brain imaging or erythrocyte or whole-blood assessment
## Footnote
These methods help determine manganese levels in the body.
188
What percentage of manganese is contained in red blood cells?
60-80%
## Footnote
This high concentration in red blood cells is important for assessing manganese status.
189
Most adults can meet their fluid needs with ___-___ mL/kg/day
25-35 mL/kg/day
190
What is the maximum osmolarity of a PPN solution?
900 mOsm/L
191
What complications can arise from exceeding the osmolarity limit in PPN?
Phlebitis, thrombophlebitis
192
Aside from impaired bowel function - what would make a patient a good candidate for PPN?
Good peripheral access, ability to tolerate large volumes of fluid (2.5 - 3 L/day), contraindication to central venous access
193
How long should PPN be administered?
At least five days with no more than two weeks of total therapy
194
What are 6 contraindications for PPN?
1. Significant malnutrition
2. Severe metabolic stress
3. Large nutrient or electrolyte needs
4. Fluid restriction
5. Greater than two week need for PN support
6. Renal and liver compromise
195
What is a Groshong CVC?
A Groshong CVC has a three-position, pressure-sensitive valve that restricts blood backflow and air embolism by remaining closed when not in use.
196
What is the benefit to a Groshong CVC?
It reduces the need for catheter clamping. When the valve is closed it prevents blood from entering the CVC and clotting.
197
How should a Groshong CVC be flushed?
There is NO need for heparin flushes to maintain catheter patency, but the CVC should be flushed with normal saline after medication administration or blood aspiration to ensure the valve is in the closed position
198
What is the most common non-infectious catheter-related complication?
Catheter occlusion
## Footnote
Catheter occlusion can lead to significant complications in patient care.
199
What are the 3 types of catheter occlusion?
1. Intraluminal occlusion
2. Vessel thrombosis
3. Mechanical occlusion
## Footnote
Each type presents with specific challenges in management.
200
What symptoms are typically associated with catheter occlusion?
Resistance to both infusion and aspiration
## Footnote
This resistance indicates that there may be an obstruction in the catheter.
201
Where do fibrin sheaths typically occur in relation to catheters?
On the distal catheter tip
## Footnote
Fibrin sheaths can significantly affect the function of the catheter.
202
True or False: Fibrin sheaths make both infusion and aspiration difficult.
False
Fibrin sheaths work as a one-way valve allowing medications and nutrition to be infused but making aspiration of blood difficult
## Footnote
Fibrin sheaths allow infusion but hinder aspiration.
203
Is PN-associated metabolic bone disease often symptomatic or asymptomatic?
It is often asymptomatic.
204
Can PN-associated metabolic bone disease occur with normal biochemical parameters?
Yes, it can occur in the face of normal biochemical parameters.
205
What is the greatest risk factor for metabolic bone disease in patients?
Long-term PN and corticosteroid therapy.
206
What is the calorie range that, if exceeded, can lead to hepatic steatosis in mechanically ventilated patients?
25-30 kcals/kg
207
Under what condition can calories above 25-30 kcals/kg be justified in mechanically ventilated patients?
If indirect calorimetry results show an REE above this range
208
What adverse effects are associated with excessive calorie provision in ventilated patients?
1. Hepatic steatosis
2. Failure to wean from the ventilator with hypercapnia
3. Hyperglycemia
209
What are the symptoms of tunnel infection?
Pain, swelling, erythema, or induration along the subcutaneous tract of a tunneled catheter
## Footnote
Tunnel infection is associated with the site of the tunneled catheter.
210
What is pinch-off syndrome?
A complication of subclavian tunneled central catheters with intermittent or permanent occlusion related to postural changes
## Footnote
Pinch-off syndrome can lead to significant complications if not managed properly.
211
What symptoms are indicative of thrombosis?
Chest pain, earache, jaw pain, swelling of the arm, shoulder, neck, or face on ipsilateral catheter side, or leaking at the exit or insertion site
## Footnote
Thrombosis can occur due to various factors including catheter placement.
212
What characterizes superior vena cava syndrome?
Shortness of breath, dyspnea, cough, cyanosis of face, neck, shoulder and arms, and distended chest or neck veins
## Footnote
This syndrome can arise from obstruction of blood flow in the superior vena cava.
213
Compare and contrast the pathogenesis of contamination of tunneled vs. non-tunneled catheters
Tunneled: contamination of the catheter hub with intraluminal colonization is the most common route of infection
In contrast, non-tunneled CVAD infection is often related to extraluminal colonization of the catheter or intraluminal colonization of the hub and lumen of the CVAD.
## Footnote
This indicates that the hub of the catheter is primarily where the infection begins.
214
Name 2 of the lesser common pathologies for catheter infection
Occasionally, catheters might become hematogenously seeded from another focus of infection.
Rarely, infusate contamination leads to catheter-related bloodstream infection.
## Footnote
Understanding these types is crucial for preventing infections.
