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Lecture 5: Parenteral Nutrition Flashcards

1
Q

ASPEN

A

American society for parenteral and enteral nutrition

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2
Q

What is ASPEN

A

Organization made up of all different health care professionals
Mission: improve patient care by advancing science/practice

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3
Q

Parenteral nutrition (PN)

A

Provision of nutritional requirements via IV route
Given as TPN or partial PN

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4
Q

TPN formulations

A

3-in-1 TNA
2-in-1

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5
Q

TNA is stable if

A

Dextrose >10%
Amino acid >4%
Lipid >2%

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6
Q

Creamed emulsion

A

Can use after shaking to make homogenous

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7
Q

Cracked emulsion

A

Can’t be made homogenous, do not use

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8
Q

TNA should not be used in

A

Infants and neonates due to stability and Ca/Phos solubility concerns

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9
Q

Multichamber bags

A

require activation to mix prior to infusion due to stability reasons

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10
Q

Commercial TPN

A

Suitable for adults
maybe some adolescent/pediatric patients
Ideal for home use

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11
Q

Compounded TPN

A

797 applies
made by hand (rare) or automated compounder

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12
Q

TPN process

A
  1. TPN ordered by provider team
  2. TPN order processed by pharmacist
  3. TPN compounding
  4. Pharmacist check/dispense
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13
Q

TPN components

A
  1. macronutrients (protein, carbohydrates, fats)
  2. Additional components (electrolytes, vitamins, trace elements, medications)
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14
Q

Standard AA solutions contain

A

essential and nonessential AA

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15
Q

Protein provides how many kcal?

A

4 kcal/gram

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16
Q

Protein formulations

A

Travasol
Aminosyn
FreAmine

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17
Q

Specialized pediatric formulations

A

Trophamine
Premasol
- composition closely approximate to breastmilk

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18
Q

Specialized protein formulation

A

For renal/hepatic dysfunctions
Expensive

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19
Q

Carbohydrates

A

supplied as anhydrous dextrose
usually use concentrated solution (D70W)
use more concentrated dextrose

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20
Q

When compounding pediatric/small TPNs, you should use (more/less) concentrated dextrose solutions?

A

More concentrated dextrose solution

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21
Q

Carbohydrate kcal

A

3.4 kcal/g

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22
Q

How to administer dextrose in TPN

A

Stepwise titration to goal
(want appropriate insulin response)

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23
Q

Fats are supplied as

A

ILE, contains fat, glycerin, phospholipid
Give through 1.2 micron filter

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24
Q

Hang time for TNA

A

24 hr

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25
ILE (alone) hangtime (alongside 2-in-1)
12 hours if repackaged 12-24hrs if original container
26
Rationale for ILE alone hang time < TNA
higher potential for microbial growth in isotonic lipid emulsion with pH near physiologic range
27
Fat generally thought to provide how many kcal?
9 kcal/g
28
Why is caloric density of IV lipid emulsion (ILE) different from just fat?
slightly different because calories from glycerin/phospholipids
29
10% lipid emulsion
1.1 kcal/ml
30
20% emulsion
2 kcal/ml most widely used
31
30% emulsion
2.9 kcal/mL
32
Can you administer 30% emulsion directly to a patient?
NO must use as a TNA
33
Plant based lipid
soybean source provides omega 6 fatty acid
34
Why is omega 6 fatty acids not good
very damaging to liver over time -- could cause liver disease and failure in chronic use
35
Fish oil based
Omegaven 10% provides omega 3 fatty acid Less pro-inflammatory and actually anti-inflammatory for the liver
36
Fish oil based could lead to _____
essential fatty acid deficiency (EFALD)
37
Fish/Oil based
SMOF Newer product, nice balance of different fatty acids less pro-inflammatory overall & avoid essential fatty acid deficiency
38
SMOF contains
Soybean oil (omega 6) Medium chain triglycerides Olive oil (omega 9) Fish oil (omega 3)
39
Contraindications for lipid
hypersensitivity to soybean Fish egg
40
Fat overload syndrome
ILE administration rates >> rate of hydrolysis, FFA uptake, and CL Your body can't clear lipids fast enough Usually occurs in accidental overdose (accidentally swap rates of 2-in-1 with the ILE)
41
You should always give ILE infusion over how long?
Give infusion over 12-24 hrs Promotes CL of IVLE and minimizes risk
42
Max rate ILE infusion infants/childrens
0.15 g/kg/hr
43
Max rate ILE infusion adults
0.125g/kg/hr
44
Parenteral nutrition associated liver disease (PNALD)
hepatic effects of long term parenteral nutrition, can progress to hepatic failure (mostly due to pro-inflammatory lipid emulsion)
45
Lipid minimization strategies (PNALD)
Dose reduction modify lipid schedule alternate lipid formulation
46
Vitamins are supplied as
commercially available age appropriate systems
47
Vitamins are two vial system because
of stability, must be combined for use
48
How are vitamins ordered for TPN
Ordered per institutional protocols Can be modified as clinical situation warrants
49
Trace elements
Copper, zinc, chromium, magnesium, selenium No product available that traces needs - can use commercial trace prod, individual element, etc
50
Other additives/medications
H2RA (famotidine only) Levocarnitine low dose heparin regular insulin (adsorbs) Iron dextran
51
Role of clinical Rph
fluid/caloric requirements Electrolyte needs/acid base status manage complications growth (neonates/children)
52
Dispensing Rph
check Ca/phos ppt ion balancing ingredient volumes Osmolarity limitations
53
Ca/Phos ppt less likely if
Decreased dose Ca gluconate Low pH (acidic) Phos first, everything else, then Ca last Low temperature Short storage time
54
Continuous TPN
given over 24 hrs
55
Cycled TPN
12,16,or 20 hrs a day
56
Benefits of cycled TPN
convenient for home use more closely mimics enteral feed Allows post-absorptive state may avoid liver damage w/ chronic Attempted only after pt metabolically stable (TPN>7days)
57
What limits the cycle of administration and determines how short of a window TPN can be cycled?
Dextrose (avoid hyperglycemia/hypoglycemia)
58
Peripheral TPN administration
MAX osmolarity 900 mOsm/L Max dextrose concentration 10-12.5% Limit to calcium concentration (vesicant)
59
Central TPN administration
ideal for long term allows for higher dextrose content (can give higher calorie)
60
Metabolic complications TPN
hyperglycemia Electrolyte abnormalities acid base imbalance Hypertriglyceridemia Liver dysfunction
61
Mechanical TPN complications
Central line - catheter complications -
62
Infectious complications
Central line associated blood stream infection (CLABSI)

compounding (12 decks)

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