Exam 3 lecture 2 Flashcards
General protein intake guidelines based on type of pt
Maintenance of normal person- 0.8-1
Mild-moderate stress (floor hospial)- 1-1.5
Moderate to severe stress (ICU, trauma, surgery, burn- 1.5-2
obesity (BMI>30)- 2 gm/kg/day (ideal body weight)
Severe obesity (BMI>40)- 2.5 gm/kg/day (ideal body weight)
What is NPC? WHat is a good distribution of NPC that we should know for exam? What would 100/0 split mean?
Non protein calories. Adequate calories must be present for protein utilization.
NPC distribution should be 70/30
-70-85% dextrose
-15-30% fat
100% of calories come from dextrose and none are from fat
Which is more complicated, PN or EN? Define PN. WHat are other names for PN
PN is more complicated
PN is the process of supplying nutrients via an IV delivery system (protein, fats, carbs, electrolytes, vitamins, minerals) also known as TPN, PN, TNA, 3- in- 1
What are PN indications? (EXAM)
If patient is
-anticipated prolonged NPO course (>7 days)
-inability to absorb nutrients via gut secondary to
a) small bowel or colon ileus
b) Extensive small bowel resection
c) Malabsorptive states
d) Intractable vomiting/diarrhea
-enterocutaneous fistulas
-inflammatory bowel disease
- hyperemesis gravidum
-bone marrow transplant (mucositis)
what are the ROA of PN
- Peripheral
- Central
How well tolerated in peripheral PN? What is the number for total osmolarity to remember when doing peripheral PN? Concentration of dextrose in PN when giving peripherally?
- not well tolerated via peripheral vein
- restrict final dextrose concentration to 5-10% or total osmolarity to <900 mOsm/L
What are some limitations of peripheral PN?
requires large volumes of fluid (may not be the best choice for HF or AKI/CKD patients)
Limited in calories (secondary to osmolarity and fluid limitations)
Short term access (<7-10 days)
ALWAYS double check to confirm peripheral route was intentional
What are some advantageas and disadvantages of central PN
Advantage
- allows administration of hypertonic solutions
- more calories can be delivered
disadvantages
- risk of infection (appropriate central line care is key)
- central line is not a benign procedure
-pneumothorax
-air embolus
- thrombus
What are the three main central venous access points
- subclavian (under clavicle)
-internal jugular (neck)
-femoral (groin)
sub clavian or IJ used for TPN, not femoral
What are some long term venous access for central venous access
-PICC (peripherally inserted central catherer)
- Tunneled
Implanted port
WHat are the types of catheters? WHat is used in TPN
- single lumen
-double lumen
-triple lumen
Triple lumen used in TPN
How many calories in one gram of protein
4 kcal
One gram of dextrose is how many kcals? What is the maximum carbohydrate utilization?
3.4
4-5 mg/kg/min is max
How many kcal for 1 gram of lipid? WHat is the use of giving fat in TPN
10 kcal
prevents essential fatty acid deficiency
What are some IV fat emulsions
Intralipid 10%- older product, has egg yolk (no egg allergy patients
SMOF lipid (soybean, medium chain triglycerides, olive oil, fish oil) People with fish allergy can not take this
compare SMOF lipid to pure soybean oil product (intralipid)
- improved LFT, lower TG levels from baseline
less pro inflammatory
less negative side effects
Maximum intake of fat?
60% of caloric intake maximum for fat
max of 2.5 gm/kg/day of lipids
Propofol also has fat in it so remember to subtract this from the fat requirements
What are the different rules for IV fat emulsion administration
If IV fat emulsion is given alone- it should be 10 or 20% solution
30% if given in a 3 in 1
May be infused via peripheral vein, piggy backed or put into a dextrose amino acid solution to create a 3 in 1
What are some considerations to take to avoid infetious complications when giving IV fat
IV lipids provide a suitable environment for pathogen growth
hang time of IV fat emulsion should be limited to 12 hours after opening package
If added as TNA (3 in 1), safety is increased to 24 hrs
Administration of PN summary
- Total nutrient admixture ( custom TPN)
- dextrose, AA and lipids in one bag
- 3 in 1 TPN - Conventional administration (custom tpn
- dextrose and AA in one bag
- lipids 2-3 times a week as a separate IVPB - premix solutiojn for injection (standard tpn)
has no lipids
What is the use of an In-line filters? What sizes should we use?
Reduces infusion of particulates and microorganisms
filter size- 1.2 micron filter can be used for all TNAs or 3 in 1 (w/lipids)
0.22 micron size only used in 2 in 1 formulations (no lipids)
What is the name of premix PN solutions for standard TPN
clinimix/clinimix-E (e is for electrolyte)
How do we decide whether we are gonna use Clinimix or clinimix E (whether we use electrolytes or not)
if Crcl<50- no electrolytes0 only use clinimix
If Crcl > 50- use clinimix E
PN initiation and discontinuation guidelines? How often to check BS? What to do for high BS?
Start at 25% of goal and achieve final rate within 24 hours (watch blood sugar)
check BS every 4-6 hours and before each increase in rate
If BG> 200, continue at same rate x 4 hours and recheck
If repeat BG > 200, consider insulin therapy
cessation- Decrease rate by half q 2 hrs until rate < 50 ml/hr, then dx
What is the max rate for cycling PN
200 ml/hr
What are some elctrolyte considerations when adding electrolytes
In patients with renal disease- caution should be used with Potassium, phosphate and magnesium
Acid-base balance obtained through balance of acetate and chloride
Avoid calcium + Phosphorous precipitation
(axoid ca x phos)> 150
What are considerations to take when giving vitamins parenterally
1) Adult & Pediatric (>40kg)
-10 ml/day of injectable adult multivitamin-12
contains small amount of vitamin K (be careful with warfarin)
2) Pediatric
- 2 ml/day of injectable multivitamin
40 kg is cut off (rememebr for exam)
When should we adjust trace elements
In liver dysfunction- (chronic liver disease or LFTs >2x ULN)- discountinue trace elements.
Supplement Zinc and selenium individually
In renal disease (CKD, ESRD)- consider checking serum levels if use expected beyond 14 days
Use selenium and chromium with caution
Is Iron added to PN
NOOO, Fat will not get absorbed.
Also has infectious complications. Always use a separate line
Can we add medications to PN
For the most part, addition of medications to PN is not advised. Famotidine may be utilized for GERD or stress ulcer prophylaxis
Never use pantoprazole (no PPI) with PN
Regular insulin only can be added to the bag (not for acute patients)
When is a time we give IV insulin
Hyperkalemia
When should we use NBW
if wt>130% IBW
How many fluid to use in an adult patient
30-40 ml/kg/day
How many grams of protein for ICU/surgery patients
1.5-2 gm/kg/day
How to calculate the number of mEQ of sodium in parenteral nutrition
Aim for 1/s NS to start. WHich is equal to 1 L = 77 mEq/L
example 2.4 L
1 L= 77 MEQ
2.4=?
criss cross
How to give potassium to PN patient
0.5-1 mEq/kg to start
- upto 2 mEq/kg
may need to reduce in renal failure
How to give calcium with PN
10-20 mEq/day on average
start at 10 mEq/day if calcium is normal
How to give magnesium in PN patients
start at 8 mEq/day if normal level
How to add Phosphorous into PN
0.3 MMol/kg
caution in renal failure
1Mmol Kphos = 1.4 mEq Kphos
(REMEBER THIS)
Things to take into consideration when supplementing Cl in PN
50-100 mEQ/day
Acid in PN (must balance against base) (acetate is the base)
2/3 chloride (acid and 1/3 base (acetate) (remember this for exm)
What are the positive cations and negatives? Which two are already balanced that we do not include?
Positive- sodium, potassium
Negatives- Chloride, acetate, phos
Magnesium and calcium are already balanced
KNOW HOW TO BALANCE FOR EXAM
example- If we give sodium and potassium, we add them up, which gives us our Positives. For this example lets say it is 225
We also calculate the amount of phos given (remember to convert to mEq by multiplying by 1.4. for this example lets say it is 31 mEq
225-31=194
That means we have 194 left to balance. 2/3 should be chloride, 1/3 should be acetate
128 cl
66 mEq
Amount of MV to give patients above 40 kg? Amount of multi trace elements to give patients with no renal/liver failure
MVI- 10 ml
MTW- 1 ml
complications of PN
1)mechanical complications-
clotting of the line
Displacement
2)Infectious
- catheter related sepsis
- solution contamination
- bacterial translocation
What is bacterial translocation? Complications that this could cause?)
Time dependent passage of bacteria or endotoxins from GI tract to extra-intestinal sites
Enteric organsims cause systemic infections (pneumonia, central line infection, Abscess, Multi-organ dysfunction syndrome)
What are some metabolic complications of PN
Hyper or Hypo glycemia (important)
electrolyte and fluid imbalance
liver fumction abnormalities
Baseline monitoring for PN
- CMP, Mg, Phos, Ca
- hepetic function
- pre albumin/ CRP
- PT/INR
Q 4-6 H
- finger sticks for glucose
What are things to monitor daily for PN? Twice weekly? Weekly?
Daily- Vital signs, I/O, CMP (electrolytes, glucose, BUN/SCr), feeding tube placement,
Twice weekly- Weight, CBC, Mg, phos, Ca (prealbumin/CRP)
in ICU setting increase to daily
Weekly- Triglycerides, Respiratory quocient (RQ)/indirect calorimetry
additional complications of PN
Refeeding syndrome and essential fatty acid deficiency
What is refeediing syndrome
Potentially life threatening condition that occurs within first few days of feeding starved patient.
constellation of fluid, electrolyte vitamin deficiency
What are the three most common electrolyte disturbances we see with refeeding syndorme
Hypophosphatemia, hypomagnesemia, hypokalemia
risk factors for refeeding
Rapid feeding,
low BMI
excessive weight loss
Insufficient calorie intake
low levels of K, Phos or mag prior to feeding
loww of SQ fat or muscle mass
High risk comorbidities- alcoholism, anorexia, nervosa, marasmus
Prevention of refeeding syndrome
Replete electrolytes before initiating feeds
Limit carbs to 100-150 gm
limit fluids to 800 ml/day
Provide 50% of caloric needs on first day
advance caloric needs by 20-33% of goal every 1-2 days
Give Thiamine 100 mg daily x 5-7 days
What percent of daily calories are essential fatty acids
4-10%
Mechanism of how EFAD happens? clinical onset? symptoms?
EFAD- essential fatty acid deficiency
Mechanism- continous infusion of hypertonic dextrose will increase circulating insulin levels
Inhibits lipolysis and fatty acid mobilization
onset- 10-14 days on fat free PN regimen
sx- dry scaly skin, brittle hair
How to prevent EFAD
recommended minimum to avoid EFAD is 4% caloric intake be lipids
Provide atleast 500 ml of 10% fat emulsion over 3-5 hours twice weekly
OR
Provide atleast 350 ml of 20% fat emulsion over 5-9 hrs twice weekly
Are most patients gonna be on EN or PN
EN (if the gut works, use it)
When do we use EN
If the gut works, use it
Oral consumption inadequate
Oral consumption contraindicated
- esophageal obstruction
-Head and neck injury
-dysphagia
- Trauma
- Cerebrovascular accident
0 dementia
advantages to EN
Provides GI stimulation
- decreased chance for bacterial translocation (EXAM)
Avoids risk associated with IVs (line infections, pneumothorax)
more physiological than PN
less expensive
Contraindications to EN (indications for PN)
certain types of fistulas
intractable vomiting
non mechanical onstruction- ileus
mechanical obstruction (hernia, tumor)
severe malabsorption
severe GI hemorrhage
ROA of EN
G= (ends in stomach=gastric)
J= ends in jejunum (past stomach)
o= oral
N == sasal
NG- nasogastric
OG- orogastric
NJ- Nasojejunal
OJ- orojejunal
Gastrostomy (PEG tube), placed surgically
jejunostomy- PEJ
How to determine ROA of EN
Risk of aspiration
if low risk- May utilize gastric
If high risk- jejunal preferred
Tolerance
Vomiting- Use jejunal
Gastric residuals- use jejunal
Duration of therapy
Long term- COnsider PEG or PEJ
