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compounding > Lecture 5: Parenteral Nutrition > Flashcards

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
Q

ILE (alone) hangtime (alongside 2-in-1)

A

12 hours if repackaged
12-24hrs if original container

26
Q

Rationale for ILE alone hang time < TNA

A

higher potential for microbial growth in isotonic lipid emulsion with pH near physiologic range

27
Q

Fat generally thought to provide how many kcal?

A

9 kcal/g

28
Q

Why is caloric density of IV lipid emulsion (ILE) different from just fat?

A

slightly different because calories from glycerin/phospholipids

29
Q

10% lipid emulsion

A

1.1 kcal/ml

30
Q

20% emulsion

A

2 kcal/ml
most widely used

31
Q

30% emulsion

A

2.9 kcal/mL

32
Q

Can you administer 30% emulsion directly to a patient?

A

NO must use as a TNA

33
Q

Plant based lipid

A

soybean source
provides omega 6 fatty acid

34
Q

Why is omega 6 fatty acids not good

A

very damaging to liver over time – could cause liver disease and failure in chronic use

35
Q

Fish oil based

A

Omegaven 10%
provides omega 3 fatty acid
Less pro-inflammatory and actually anti-inflammatory for the liver

36
Q

Fish oil based could lead to _____

A

essential fatty acid deficiency (EFALD)

37
Q

Fish/Oil based

A

SMOF
Newer product, nice balance of different fatty acids
less pro-inflammatory overall & avoid essential fatty acid deficiency

38
Q

SMOF contains

A

Soybean oil (omega 6)
Medium chain triglycerides
Olive oil (omega 9)
Fish oil (omega 3)

39
Q

Contraindications for lipid

A

hypersensitivity to soybean
Fish
egg

40
Q

Fat overload syndrome

A

ILE administration rates&raquo_space; 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
Q

You should always give ILE infusion over how long?

A

Give infusion over 12-24 hrs
Promotes CL of IVLE and minimizes risk

42
Q

Max rate ILE infusion infants/childrens

A

0.15 g/kg/hr

43
Q

Max rate ILE infusion adults

A

0.125g/kg/hr

44
Q

Parenteral nutrition associated liver disease (PNALD)

A

hepatic effects of long term parenteral nutrition, can progress to hepatic failure (mostly due to pro-inflammatory lipid emulsion)

45
Q

Lipid minimization strategies (PNALD)

A

Dose reduction
modify lipid schedule
alternate lipid formulation

46
Q

Vitamins are supplied as

A

commercially available
age appropriate systems

47
Q

Vitamins are two vial system because

A

of stability, must be combined for use

48
Q

How are vitamins ordered for TPN

A

Ordered per institutional protocols
Can be modified as clinical situation warrants

49
Q

Trace elements

A

Copper, zinc, chromium, magnesium, selenium
No product available that traces needs
- can use commercial trace prod, individual element, etc

50
Q

Other additives/medications

A

H2RA (famotidine only)
Levocarnitine
low dose heparin
regular insulin (adsorbs)
Iron dextran

51
Q

Role of clinical Rph

A

fluid/caloric requirements
Electrolyte needs/acid base status
manage complications
growth (neonates/children)

52
Q

Dispensing Rph

A

check Ca/phos ppt
ion balancing
ingredient volumes
Osmolarity limitations

53
Q

Ca/Phos ppt less likely if

A

Decreased dose
Ca gluconate
Low pH (acidic)
Phos first, everything else, then Ca last
Low temperature
Short storage time

54
Q

Continuous TPN

A

given over 24 hrs

55
Q

Cycled TPN

A

12,16,or 20 hrs a day

56
Q

Benefits of cycled TPN

A

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
Q

What limits the cycle of administration and determines how short of a window TPN can be cycled?

A

Dextrose (avoid hyperglycemia/hypoglycemia)

58
Q

Peripheral TPN administration

A

MAX osmolarity 900 mOsm/L
Max dextrose concentration 10-12.5%
Limit to calcium concentration (vesicant)

59
Q

Central TPN administration

A

ideal for long term
allows for higher dextrose content (can give higher calorie)

60
Q

Metabolic complications TPN

A

hyperglycemia
Electrolyte abnormalities
acid base imbalance
Hypertriglyceridemia
Liver dysfunction

61
Q

Mechanical TPN complications

A

Central line
- catheter complications
-

62
Q

Infectious complications

A

Central line associated blood stream infection (CLABSI)

compounding (12 decks)

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