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Pharmacotherapy 1 > EN and PEN > Flashcards

EN and PEN Flashcards

1
Q

List types of short-term EN

A

NG, nasoenteric (ND, NG), OG, OD, OJ

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2
Q

List types of long-term EN

A

PEG, gastostomy, jejunostomy

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3
Q

What is a PEG tube?

A

PEG=percutaneous endoscopic gastrostomy tube
These are direct access from outside source to GI tract. Can handle well as long as keep site on skin clean.
More invasive. Allow for larger bolus feeds for food and medication compared to short-term.

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4
Q

What are the adv/disadv of a jejunostomy?

A

Jejunostomy adv: decreases risk of aspiration. don’t have to worry about reflux from stomach into esophagus. More difficult to place.
Also need infusion pump for feeds.

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5
Q

List types of peripheral PN

A

peripheral vein

midline catheter access

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6
Q

List types of central parenteral nutrition

A

central venous catheter (subclavian=SC, internal jugular=IJ, femoral)

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7
Q

List yptes of central PEN

A

central venous catheter (SC, IJ, femoral)

peripherally inserted center cathter=PICC.

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8
Q

More concentrated PN must be administered through

A

central veins

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9
Q

PICC is a ___ line

A

central

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10
Q

What is combination feeding?

A

administration of both EN and PN

bridge therapy for pts who are unable to meet caloric/protein req with EN

preserves enterohepatic circ and barrier function of the GI tract

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11
Q

risk factors for malnutrition

A
  1. unintentional weight change (>10% w/in 6 mo or >5% w/in 1 mo)
  2. body weight 20% under IBW
  3. NPO >7-10 d
  4. incr metabolic needs
  5. inadequate nutrient intake (alcoholic/substance abuse, chronic disease states, deficiencies)
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12
Q

describe acute malnutrition

A

status of protein-depleted pt w adequate fat reserve

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13
Q

desribe chronic malnutrition

A

depletion of pro and fat stores, w class emaciated-appearence

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14
Q

SGA for normal noursihment

A

no wt loss (<0.5-1 kg)

no abnormal dietary ntake

no hx of <2d of anorexia, N/V, diarrhea

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15
Q

SGA for moderate malnourishment

A

wt loss of 5-10% of usual wt in 6 mo

abnormal dietary intake for 1 mo

hx of anorexia, N/V or diarrhea for short time

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16
Q

SGA for severe malnourishment

A

wt loss of >10% in <6 mo

inadequate intake for >1 mo

hx of anorexia, n/V, or diarrhea for >1 mo

**=====> visual somatic protein wasting; BMI<18.5 `

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17
Q

Define Kwashiokor

A

protein malnutrition:

caused by dietary deficiency of protein for several wks/mos

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18
Q

Features of Kwashiokor

A 
hypoalbuminemia
anemia
edema
muscle atrophy
delayed wound healing
imp'd immunocompetence
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19
Q

Define Marasmus

A

protein-calorie malnutrition

devos over mo-yrs

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20
Q

Features of Marasmus

A 
wt loss
reduced BMR
depletion of SQ fat
decr tissue turgor
bradycardia
hypothermia
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21
Q

What is an appropriate visceral protein to monitor for acute nutritional status?

A

pre-albumin

t1/2=2-3 d

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22
Q

What visceral proteins are used to assess nutritional status?

A

albumin
pre-albumin
transferring
retinol-binding

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23
Q

Measuring ___ can be used to individual daily protein reqs

A

24 hr urine collection (UUN)

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24
Q

Define nitrogen balance

A

measurement of urinary excretion of nitrogen as urea

=N(in) minus N(out)

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25
Q

During times of stress urinary nitrogen excreteion incr or decr?

A

increases as stress causes proteins to be broken down.

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26
Q

List non-urinary sources of nitrogen loss.

A 
sweat
feces
respiration
GI fistula
wound drainage
burns
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27
Q

How to calculate daily nitrogen intake.

A

24 hr protein intake (g)/6.25

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28
Q

How to calculate nitrogen output

A

24 hour UUN (g) + 4

UUN=urinary urea nitrogen
4 is a correction factor that accounts for non-urinary nitrogen losses

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29
Q

What is the goal nitrogen balance?

A

zero for maintenance

*** +4 g for repletion

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30
Q

How many kcal/g of protein?

A

4 kcal/g

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31
Q

How many kcal/g of carbs?

A

3.4 kcal/g

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32
Q

How many kcal/g of IV lipids?

A

10 kcal/g

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33
Q

What to monitor for refeeding syndrome?

A

Mg, Phos, K levels

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34
Q

What is the metabolic response to stress such as illness or injury?

A

hypermetabolism and hypercatabolism

increased sympathetic NS stimulation

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35
Q

What occurs during incr’d SNS stimulation as a metabolic response to stress?

A

incr counterregulatory hormones (catecholamines, cortisol, glucagon, GH)

incr cytokines (TNF-alpha, interleukins 1&6)

incr immunomodulators–thromboxanes and prostaglandins

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36
Q

What is the end results of metabolic responses to stress?

A

accelerated proteolysis, glcogenolysis, lipolysis, gluconeogenesis, & insulin resistance

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37
Q

What does proteolysis during acute stress result in?

A

negative nitrogen balance and weight loss

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38
Q

What does a reduced tolerance to carbs during acute stress result in?

A

hyperglycemia

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39
Q

What does reduced fat utilization during acute stress result in?

A

hypertriglyceridemia

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40
Q

What is BEE?

A

Basal energy expenditure = BMR

metabolic activity req’d to maintain life

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41
Q

What is RRE?

A

resting energy expenditure or resting metabolic rate

of calories eq’d during 24 hrs in a non-active states

~10% higher than BEE (accounts for thermal effect of food, awake state)

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42
Q

What is TEE?

A

total energy expenditure

calories req’d to maintain current body wt

TEE=BEE x activity or stress factor

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43
Q

activity factor for bed rest/sedentary

A

1.2

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44
Q

activity factor for ambulatory

A

1.3

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45
Q

activity factor for anabolic

A

1.5

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46
Q

stress factor for non-malnourished adult s/p minor surgery

A

1.2

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47
Q

stress factor for adult w/ongoing sepsis, severe thermal injury, or hx severe malnutrition

A

1.4-1.5

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48
Q

If actual BW <130% IBW use

A

actual BW

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49
Q

if actual body >130% IBW use

A

nutritional BW

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50
Q

obese pts (>150% IBW) use

A

IBW

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51
Q

**goal daily calories fi non-stressed, non-depleted

A

20-25 kcal/kg/d

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52
Q

**goal calories if trauma/stress/surgery/critically ill

A

25-30 kcal/kg/d

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53
Q

**goal calories if major burn

A

35-40 kcal/kg/day

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54
Q

**goal calories for obesity

A

22-5 kcal/kg/day

use IBW

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55
Q

**goal protein for maintenance

A

0.8-1 g/kg/d

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56
Q

**goal protein for mild-moderate condition (repletion/med floor)

A

1-1.5 g/kg/d

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57
Q

**goal protein for mod-severe condition (trauma, surgery, ICU)

A

1.5-2 g/kg/d

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58
Q

**goal protein for burn

A

2-2.5 g/kg/d

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59
Q

**goal protein for obesity (>150% IBW)

A

2 g/kg/d

use IBW

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60
Q

standard distribution of non-protein calories

A

70% dextrose

30% fat

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61
Q

concurrent disease states for adjusting distribution of non-protein calories

A

DM, renal, hepatic dx
blood sguar
TG
concurrent infx of sepsis (consider omitting fat)

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62
Q

How to measure energy expenditure

A

indirection calorimetry
R!=VCO2/VO2
Goal R1=0.85-0.95
If RQ>1 = overfeeding and lipogenesis

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63
Q

RQ values for oxidized substrates

A

0.7 for fat
0.8 for proteins
1 for carbs

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64
Q

Phsyiologic adv of EN over PN

A

maintain gut integrity, prevent villi atrophy

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65
Q

immunologic adv of EN over PN

A

fewer infectious complication than PN, prevent bacterial translocation

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66
Q

safety adv of EN over PN

A

avoid catheter sepsis, embolus, arterial laceration, pneumothorax

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67
Q

cost adv of EN over PN

A

less expensive than PN, less equipment/personnel

less waste

68
Q

indications for NE

A

inability to consume o abs adequate nutrients due to inability to consume orally (burn/trauma) or where oral consumption is contraindicated

69
Q

contraindications for oral consumption

A 
CVA; dysphagia
dementia
head and neck surgery
esophageal obstruction
trauma/burn
70
Q

contraindications for EN

A 
expected need <5-10d
severe acute pancreatitis
high-output proximal fistuals
inability to gain access
intractable vomiting and diarrhea
GI ischemia
ileus
71
Q

describe continuous EN admin

A

pump, lower risk for abdominal distention d/t smaller volume, better tolerated

72
Q

describe intermittent EN admin

A

several feeds, gravity admin; >200 ml over 20-30 min

73
Q

describe bolus EN admin

A

> 200 mL over 5-10 min in gastostomy; higher aspiration risk

but adv is fewer feedings

74
Q

describe cyclic EN admin

A

over 8-20 h/d, depending on volume tolerance

also uses a pump, spread out over more time

75
Q

What is the usual calorie density of EN formulation?

A

1-2 kcal/mL

76
Q

What is the usual calorie density of EN formulations for fluid restriction?

A

2 kcal/mL

77
Q

What is the carb content of EN formulations?

A

glucose polymers for TFs, simple glucose for PO supplements

78
Q

what is the protein content for EN formulations?

A

intact or partially digested peptides (malabs or diarrhea)

79
Q

what is the fat content of EN formulations?

A

long, medium-chained FAs

80
Q

What are non-macronutrients included in EN formulations?

A 
fiber
water
electrolytes
MVI
trace elements
81
Q

What are immune-modulating ingredients in EN formulation?

A

omega-3 FAs
gluatmine
arginine

82
Q

What are appropriate EN formulations for pts w kidney disease?

A

calorically dense
var. protein
low elytes

83
Q

What are appropriate EN formulation for pts w liver disease

A

higher BCAA/AAA ratio, high calories

84
Q

What are appropriate EN formulations for pts w lung disease?

A

high fat

low carb

85
Q

What are appropriate EN formulation mods for pts w DM?

A

high fat

low carb

86
Q

What are appropriate EN formulation mods for pts that need immune modulation?

A

glutamine
arginine
omega-3 FAs

87
Q

EN supplements for protein

A

1 gel tube Prostat = 15 g protein

1 packet Beneprotein = 6 g protein

88
Q

En supplements for carbs

A

polycose, cuocal, benecalorie

89
Q

EN supplements for fiber

A

benefiber

90
Q

Mechanical EN complications

A

feeding tube misplacement, clogging, aspiration

airway/GI injury leading to resp compromise or abdominal abscess/infx

91
Q

GI complications of EN

A

gastroparesis
GERD
diarrhea
constipation

92
Q

metabolic complications of EN

A

hyperglycemia
elyte, vit, mineral def
refeeding syndrome
dehydration

93
Q

Initial monitoring parameters for EN

A

I/O
wt
feeding tube position and site
gastric residual volume

94
Q

daily monitoring parameters for EN

A

I/O
wt
number and consistency of stools
abdominal distention

95
Q

prn monitoring parameters for EN

A

chemsticks
feeding tube position and site
gstric residual volume

96
Q

Oral med admin w/EN

A

common
many meds can be crushed, admin’d in feding tube, then flushed w sterile water

do NOT crush meds w special delivery systems

avoid mixing liquid meds w EN formulation d/t phys incompatabilities

97
Q

How to unclog feeding tubes

A

pancreatic enzyme tablet
NaHCO3 tab
10 mL warm water

98
Q

How to prevent drug-nutrient interactions w continuous feed EN

A

interrupt to give meds

99
Q

how to prevent drug-nutrient interactions w bolus feed EN

A

space meds btw TFs

100
Q

Example of drug-nutrient interactions in EN

A 
phenytoin
fluoroquinolones
tetracyclines
warfarin
PPIs (omeprazole, lansoprazole)
101
Q

Describe TNA PN formulation

A

Total Nutrient Admixture or 3-in-1

carbs, fat, and AA in same IV admixture

milky appearance

102
Q

Describe 2-in-1 PN formulation

A

carbs, AA in same admixture

several commercially prepared pre-mixed formulations

fat infused separately

103
Q

Central PN

A

delivered by a large diameter vein

Central line (SC, IJ, femoral) or PICC

104
Q

PPN

A

periphal parenteral nutrition

by peripheral vein of hand or forearm

105
Q

limitations of PPN

A

dextrose 12.5%
Ca and Phos content
Osmolarity (max 900-1100 mOsm/L)

106
Q

PPN not recc’d for

A

severe stress
malnutrition
considerable caloric/elyte reqs
PN >5 d

107
Q

indications for PPN

A 
nonfunctioning/inaccessible GI tract:
bowel ischemia
intractable vomiting/diarrhea
hyperemesis gravidum
GI bowel obstruction/ileus
severe IBD
short bowel syndrome

prolonged NPO course >7d

108
Q

contraindications for PN

A 
functioning GI tract
treatment <7d in pts w/o severe malnutrition
inability to obtain venous access
prognosis does not warrant PN
when risks exceed benefits
109
Q

max carb utilization rate

A

4-5 mg/kg/min

110
Q

proprofol 10% provides

A

1.1 kcal/mL

111
Q

PN for egg allergy pts?

A

cannot use fat emulsion bc egg yolk phospholipid is used

112
Q

max intake of fat emulsion in PN

A

2.5 g/kg/d lipid

not to exceed 60^ of daily caloric intake

113
Q

EFAD

A

essential fatty acid deficiency

must include lineoleic and linolenic acid

can result from several day sof therapy w/o fat supplementation

114
Q

Na in PN

A

1-2 mEq/kg/d

added as Cl, acetate, or phosphate; largely dep on fluid balance of pt

115
Q

K in PN

A

1-2 mEq/kg/d

added as Cl, acetate, or phosphate

116
Q

Phosphorus in PN

A

20-40 mM/d

1 mM phosphate supplies 1.33 mEq Na or 1.47 mEq K *****

117
Q

Ca in PN

A

10-15 mEq/d

added as gluconate; watch Ca-Phos to avoid precip

118
Q

Mg in PN

A

8-20 mEq/d

high demands in catabolic/malnourished pts

119
Q

vitamins in PN

A

RDA

include ADEK, ascorbic acid, B complex

120
Q

trace elements in PN

A

RDA

include Zn, Cu, Mn, Chromium, selenium

121
Q

increased Cl ratio (vs acetate) for micronutrient PN rec’d in:

A

metabolic alkalosis d/t K def
loss of gastric contents from vomiting
gastric decompression

122
Q

When is an increased acetate ratio (vs Cl) rec’d for micronutrients in PN?

A 
RF
metabolic acidosis due to excessive bicarb loss in RTA
massive diarrhea
small bowel
pancreatic fistulas
123
Q

Acetate is converted in the body to ___ in a ___ ratio

A

bicarbonate

1:1

124
Q

PN solutions are intially formulated to provide ___ of cation salts as __ and __ as ___

A

2/3 as chloride

1/3 as acetate

125
Q

Possible additives in PN

A

H2-antagonists
Regular Insulin

Heparis is mostly EXCLUDED
Albumin should NOT be added to PN

126
Q

Regular insulin in PN

A

hyperglycemia cases:
0.1 U/2.4 kcal dextrose

high insulin req should be maintains via separate drip

[don’t include <10 U b/c binds to plastic; really only for long term insulin needs]

127
Q

What are examples of mechanical complications in PN?

A

infusion pump failure
catheter-related: pneumothorax, migration to wrong vein, improper position w/in cardiac chambers, arterial puncture, bleeding

128
Q

What are examples of infectious complications in PN?

A

central venous catheter (CVC) infx

infx 2/2 soln contamination (rare)

129
Q

What are examples of metabolic complications of PN?

A 
liver disease
hypertriglyceridemia
hyperglycemia
refeeding syndrome
essential FA def
metabolic bone disease
130
Q

When to monitor Chem 6 for PN?

A

initially, daily (unstable), 1-2 x /wk (stable)

same for BUN, SCr, and glucose!

131
Q

When to monitor albumin for PN?

A

initially

1-2 x/wk 9stable)

132
Q

when to monitor prealbumin in PN?

A

prn

133
Q

Monitoring PT/INR prn n PN is useful bc

A

bleeding risk

assess certain micronutrients: vit K, Calcium

134
Q

Describe Refeeding Syndrome

A

fluid and elyte abnorm ass’d w metabolic complications that devo during nutrition repletion in malnourished pts

for example, new glc load –> insulin –> ATP –> need phos –> hypohpos (symp)

insulin –> decr K –> hypokal –> hypomag

135
Q

Important clinical manifestations of hypophosphatemia

A

Sz
coma
death

136
Q

Important clinical manifestations of hypokalemia

A

cardiac arrhythmia
atrial tachycardia
sudden death

137
Q

Important clinical manifestations of hypomagnesemia

A

Sz
coma
death

138
Q

Important clinical manifestations of vitamin/thiamine deficiency

A

lactic acidosis

death

139
Q

Important clinical manifestations of sodium retention

A

fluid overload
pulmonary edema
cardiac decompensation

140
Q

How to prevent refeeding syndrome

A

identify pt at risk

correct elyte abnormal before nutrition

start low and go slow: ~25% of goal on day 1, incr over 3-5 d

141
Q

___ affects the stability of IV lipids

A

pH: coagulates in acidic environment

this leads to problems when try to acidify bags to avoid CaPhos precip

142
Q

TPN Destabilization to look out for

A

aggregation and cracking of lipid

Precipitation of CaPhos

143
Q

how to reduce destabilization of lipds

A

keep AA conc at 2.5% or more

pH >5.0

dextorse conc >3.3%

avoid trivalent cations (iron dextran)

avoid mixing dextrose and lipid directly

add lipid last

144
Q

how to calculate protein calories

A

g protein x 4 kcal/g

145
Q

how to calculate non-protein claories

A

total kcal - protein kcal

146
Q

How much space in the TPN should be used for electolytes/additives?

A

~150 mL

147
Q

Always start a TPN at no more than ___ of goal.

A

50%

25% if at risk for refeeding is good start

148
Q

Some appropriate monitoring factors for TPN

A 
Accucheck
BUN
Cr
elytes (chem-6, Mg, Phos, Ca)
LFTs
alb/pre-alb
CRP
PT/INR
TG
149
Q

what is the appopriate filter size for 2-in-1 TPN?

A

0.22 micron

150
Q

What is the appropriate filter size for 3-in-1 TPNs?

A

1.2 micron

151
Q

How to d/c TPN?

A

taper progressively and be sure to d/c insulin

152
Q

Max admin of TPN in cycling TPN

A

200 mL/hr

153
Q

Nutrition in short bowel syndrome

A

recs based on presence/absence of a colon:

w/ colon: high car-low fat (80/20)

consider vit B12 supp

154
Q

Nutrition in DM pts

A

maintain glc btw 110-220 mg/dL
**140-180 mg/dL in critically ill pts
Give 30% of total kcal as fat

Gastric atony and delayed emptying is typical in type 1 DM

155
Q

nutrition in cardiac disease pts

A

avoid overfeeding

fluid restriction

156
Q

Nutrition in renal disease

A

fluid restriction : 2kcal/mL EN formula

pre-dialysis: low protein
w/ renal insuff (<30 mL/min): 0.5-0.8 g/kg
w/o renal insuff: 0.5-01 g/kg

dialysis: standard protein
Intermittent HD: 1-1.3 g/kg
continuous renal replacement therapy (CRT): 1.5-2 g/kg

157
Q

Nutrition in pulmonary failure

A

Calories: 20-30 kcal/kg
give 30-50% of total kcal as far;
protein: 1-2 kg/kg

limit carbs: avoid overfeeding

158
Q

Nutrition in hepatic disease

A

high caloric intake: 35 kcal/kg/day

no encephalopathy, standard protein: 1-1.2 g/kg/d

encephalopathy: protein restriciton 0.6 g/kg/d

Na restriction if ascites or edema

159
Q

Other special pops in Nutrition

A 
acute pancreatitis
surgical subsets: trauma, TBI, open abdomen, burns
sepsis
SICU
chronically critically ill
obese critically ill
160
Q

*Nutrition in GERD

A

make sure H2 antag or PPI is ordered, place in TPN if able (famotidine)

161
Q

*Nutrition in NG suctioning

A

may cause hypnatremia, hypokalemia, and/or hypochloremia

162
Q

*Nutrition in N/V

A

may lead to hypovolemia, Na+ imbalance, hypokalemia

163
Q

*Nutrition in dialysis

A

removes 10-20% AAs

164
Q

*Nutrition in wound healing

A

consider adding zinc, vitamin C

165
Q

*Nutrition w loop diuretics

A

May cause hypokalemia Na+ balances

166
Q

*Nutrition w steroids

A

may incr blood sugars, may need to add insulin

167
Q

Use NBW if BMI

A

> 30

Pharmacotherapy 1 (26 decks)

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