Exam # 3: Parental Nutrition Questions

Question 1

PPN vs TPN

Answer 1

1) Peripheral parenteral nutrition utilizes peripheral veins to administer nutrition, the maxmium osmolarity is 900 mOsm/L to avoid phlebitis, will not usually meet nutritional needs and is intended for short term usage (2-3) days. 2) Total peripheral nutrition or central parenteral nutrition utilizes a central vein ( the superior vena cava), provides total protein, calorie, and nutrient supplementation. The total osmolarity can exceed 1,000 mosm. intended for long term usage (7+ days).

Question 2

Example of PPN

Answer 2

Clinimix

Question 3

Criteria for the appropriate usage of PPN

Answer 3

1) you need peripheral vein access 2) be able to tolerate increased fluid volumes ( 2-3 L/day in a 60 kg adult) 3) require less than 2 weeks of PPN

Question 4

Conditions warranting the usage of TPN

Answer 4

1) inadequate calorie and or protein intake to meet needs 2) anticipated inability to eat for more than 10 days 3) chronic illness and the inability to use the GI tract

Question 5

Conditions that indicate TPN need

Answer 5

Overall intestinal failure ( severe malabsorption, short-bowel syndrome, obstruction, intractable diarrhea or vomiting, GI bleed, severe malnutrition) , bowel rest, severe malnutrition

Question 6

Potential complications with TPN

Answer 6

infection, air embolism, catheter tear, catheter clot, phlebitis, loss of central vein access ( adults have 6-8 sites and children have 4-6 sites)

Question 7

Why can TPN be tolerated with higher osmolarities?

Answer 7

the higher osmolarity load can be tolerated due to the high volume of blood returning to the heart

Question 8

PICC

Answer 8

used for TPN short term - peripherally inserted central catheter (placed into the front of the elbow and threaded into the subclavian vein into the superior vena cava.

Question 9

dextrose increments

Answer 9

concentrations of 2.5 - 70% with 5% incremental increases

Question 10

D%W (D25W)

Answer 10

translates to 25% dextrose concentration

Question 11

What is the minimal amount of dextrose used to spare protein?

Answer 11

1mg/kg/min

Question 12

excess dextrose infusion can cause

Answer 12

lipid synthesis and fatty liver, elevations in liver function tests, hyperglycemia, an increase in the production in CO2

Question 13

What is the most common malady associated with peripheral nutrition?

Answer 13

hyperglycemia; occurs when infusion rate exceeds that of the body’s ability to produce insulin

Question 14

At what level of blood triglycerides should fat not be infused?

Answer 14

when fasting triglycerides are greater than 400 mg/dl; monitor triglycerides by measuring serum triglycerides pre-infusion and 6 hours post infusion

Question 15

What are some possible additives to peripheral nutrition?

Answer 15

Minerals ( added last), histamine 2 antagonist, heparin, insulin

Question 16

what is the purpose of adding histamine 2 antagonist?

Answer 16

to decrease gastric acid secretion

Question 17

What is the purpose of adding heparin to PN?

Answer 17

to prevent clotting that might obstruct the flow of PN

Question 18

What is the purpose of adding insulin to PN?

Answer 18

to help regulate serum glucose levels

Question 19

What are some metrics evaluated while is a patient is on PN?

Answer 19

1) weight 2) fluid status 3) infection ( monitor WBC) and temperature

Question 20

What is the most common liver dysfunction found in adults taking PN? Children?

Answer 20

Adult - steatosis ; children - cholestasis

Question 21

What can cause liver dysfunction with PN?

Answer 21

excessive dextrose, lipid infusion, and/or calories.

Question 22

What metric is seen with a dysfunctional liver?

Answer 22

elevated liver enzymes

Question 23

How do we treat a dysfunctional liver associated with PN?

Answer 23

decrease dextrose intake, decrease IVFE intake, switch to cyclic infusion

Question 24

Effects of prolonged PN

Answer 24

mucosal atrophy, enterocyte hypoplasia, decreased intestinal activity, very little appetite

Question 25

How many days does it take for the gut to adjust to enteral intake?

Answer 25

about 5 days

Question 26

Refeeding syndrome

Answer 26

initial PN infusion should aim to meet 75% to 100% of BEE, monitor for hypophosphatemia, hypokalemia, hypomagnesemia, fluid overload, congestive heart failure, and hyperglycemia, add electrolytes and minerals administered as needed.

Question 27

Transitional feeding period

Answer 27

period during oral and or enteral nutrition is initiated and PN is discontinued, accomplished in a timed manner, it is necessary to avoid deterioration of nutritional status when PN is discontinued.

Question 28

Example of Transition from TPN to Tube Feeding

Answer 28

1) Select appropriate tube feeding formula 2) start tube feeding at low rate ( 30-40cc/hr) 3) Increase 25-30 ml/hr every 8-24 hours tolerated 4) When patient meets 75% of nutrients via TF, PN can be discontinued

Question 29

Oral facial hypersensitivity

Answer 29

neurological damage that is caused by a lack of oral stimulation especially when tube fed or using TPN ( manifests as overactive gag or cough reflex), touching the tongue can cause a gag reflex, touching the teeth or gums can use a strong bite reflex

Question 30

Treatment of oral facial sensitivity

Answer 30

1) speech language pathologist 2) oral desensitization exercises 3) gradual introduction or different stimuli

Question 31

Which approaches require consideration of osmolality?

Answer 31

Tube feeding and PPN

Question 32

Which type of nutrients supplementation is inappropriate to use when a patient is exhibiting malabsorption issues?

Answer 32

Standard Enteral Formula

Question 33

Which type of nutrition support can be administered at high rates/hour?

Answer 33

TPN

Question 34

Generally speaking, providing excessive carbohydrates, protein, and fat is potentially a greater problem with what type of nutrition support?

Answer 34

TPN