Nutrition: EN and PN Flashcards
Enteral Nutrition: Fat = __________kcal/g
Parenteral Nutrition:
Intravenous Lipid Emulsions (ILE):
1. ILE 10% = _______kcal/mL
- ILE 20% = ______kcal/mL
- ILE 30% = ______kcal/m
EN: 9 kcal/g
PN:
10%: 1.1 kcal/mL
20%: 2 kcal/mL
30%: 3 kcal/mL
Carbohydrates:
-Enteral: ___kcal/g
-Parenteral (dextrose): ____kcal/g
When is glycerol used?
EN: 4; PN: 3.4
Glycerol: alternative to dextrose in PN when pt has impaired insulin secretion (4.3kcal/g)
Protein = _____kcal/g (BOTH enteral and parenteral)
What is the purpose of supplementing protein? General protein requirements?
4 kcal/g
Purpose of supplementing protein: USUALLY for repariing or building muscle, can also be source of energy
-If pt catabolic (protein breakdown occurs faster than synthesis) often in critically ill pts, might use “protein sparing” technique where dextrose and fat are used to provide adequate energy and protein can be “spared” to use by muscle
General Protein requirements (**May NOT need to know):
-Ambulatory, non-hospitalized (non-stressed): 0.8-1g/kg/day
-Hospitalized or malnourished: 1.2-2g/kg/day
Who is a candidate for parenteral nutrition (PN)?
-Certain medical conditions: bowel obstruction, ileus, severe diarrhea, radiation enteritis, untreatable malabsorption (ex. cancer)
-Inability to absorb via GI tract for >5 days
PN: 2-in-1 vs. 3-in-1 formulations
2-in-1 formulation: dextrose and amino acids
-Clear and easier to see any precipitation
3-in-1 formulation: dextrose, amino acids, and lipids
-Called “Total Nutrient Admixture” or TNA
-Emulsion: “milky” appearance
PN: Considerations of administration
-When compounding, STERILE (follow USP 797)
-REQUIRES filter due to risk of precipitate
-Peripheral administration is possible for short term (<7 days), but risk of phlebitis (vein inflammation) and vein damage
-Central line: allows for higher osmolarity and wider variation in pH (common: peripherally inserted central catheter “PICC” line)
Determine fluid needs of pts
When weight is >20kg:
-Fluid requirement = 1,500mL + [20mL x (weight in kg - 20)]
**Overall, this will always apply to adults (pediatrics beyond scope)
General guideline of 30-40mL/kg/day
Determine caloric needs of pt
Basal Energy Expenditure (BEE)
-Males: 66.47 + 13.75 (weight in kg) + 5 (ht in cm) - 6.76 (age in years)
-Females: 655.1 + 9.6 (weight in kg) + 1.85 (ht in cm) - 4.68 (age in year)
Total Energy Expenditure = BEE x activity factor x stress factor
**Don’t worry as much about BEE formula (should be given on NAPLEX), but know how to use along
**Activity and stress factor should be given
Nitrogen Balance:
-How to calculate nitrogen intake
-How to calculate non-protein calories to nitrogen ratio (what are ideal ratios?)
Nitrogen intake = g of protein / 6.25
NPC:N ratio = NPC (dextrose and lipids in kcal) / nitrogen intake (grams)
-Most severely stressed: 80:1
-Severely stressed pt: 100:1
-Unstressed pt: 150:1
Amino acids = ____kcal/g
What are brands of some solutions for PN?
4 kcal/g
Brands: Aminosyn, FreAmine, Travasol, TrophAmine, Clinisol
**ALL protein sources
Lipids:
1. Common brands for PN
- If pt is given lipids once weekly (since pts do NOT have to be given daily), how would you calculate daily dose?
- Intralipid (all concentrations: 10%, 20%, or 30%); Smoflipid (20% only)
- Total calories per week / 7
Lipids:
1. Injectable lipid emulsions (ILE) when infused alone, are infused for _____ hours. When given as total nutritional admixture (TNA), administered over ___ hours.
- What filter should be used?
- What medications are often formulated as lipid emulsions that may need to be considered as total intake?
- 12; 24
- 1.2 micron (bigger molecules)
- Propofol, clevidipine
Sodium:
1. Intracellular or extracellular cation?
- When might Na intake be reduced?
- Common formulations as IV
- Extracellular
- HTN, CVD, renal dysfunction
3.
-Normal Saline (NS): 0.9%
-1/2 NS: 0.45%
-Hypertonic: >0.9% (CAUTION)
Sodium:
-What salt forms can be added to PN?
-Which salt form should be used when acidosis present?
When added to PN: sodium chloride, acetate, phosphate, or combo
Acidosis: use acetate –> can be converted to Na bicarbonate which can help correct
Potassium:
1. Intracellular or extracellular cation?
- When might K need to be reduced?
- What are the different salt forms?
- Typical K range
- Intracellular
2, CVD or renal dysfunction
- Potassium chloride (KCl), Potassium phosphate (KPO4), potassium acetate, or combo
- 3.5-5mEq/L
**Since K is INTRACELLULAR, serum K is actually reflection of extracellular and may NOT fully tell us what is exactly in the cells
Phosphate:
1. Role of phosphate
- What are the different salt forms?
- Why should dosage of phosphate be written in mmol?
- When might phosphate needs be reduced?
- Acid-base buffer, present in DNA and cell membrane, ATP, bone metabolism
- Sodium phosphate (NaPO4) or potassium phosphate (KPO4)
- The two salt forms are NOT equivalent in how much phosphate is provided
- Renal disease
Corrected Calcium Calculation
Ca corrected = serum Ca reported + [(4.0-albumin) x 0.8]
What is the interaction between calcium and phosphate? What can be done to avoid this?
They can bind together and precipitate which can be FATAL
Actions to take:
-Choose calcium gluconate over calcium chloride (less precipitation with PO4 due to less association thus less free Ca)
-Add phosphate first (after dextrose and amino acids) followed by other PN components, agitation the solution, and then add Ca+ to near end to take advantage of maximum volume
-Maintain proper pH (lower pH = less risk of precipiation) and refrigerate bag once prepared (temperature increases will increase precipitation)
-When added together, do NOT EXCEED 45 mEq/L
Beyond macronutrients and electrolytes, what else can be added to PN?
- Multivitamins
-Fat soluble: A, D, E, and K
-Water soluble: thaimine, riboflavin, niacin, pantothenic acid, pyridoxine, ascorbic acid, folic acid, cyanocobalamin, biotin) - Trace Elements
-Standard mixture: zinc, copper, chromium, and manganese (possibly selenium)
-Manganese and copper: avoid in severe liver disease
-Chromium, molybenenum, and selenium: avoid in renal disease
-IRON IS NOT ROUTINELY GIVEN PN - Insulin
- H2RAs - added for stress ulcer prophylaxis, but typically easier to give seperately
Drug-nutrient interaction: warfarin
Many enteral products will bind due to potassium, lowering INR –> hold tube feedings 1 hour before and 1-2 hours after
Drug-nutrient interaction: tetracyclines, quinolones, and levothyroxine
Chelate with polyvalent cations including Ca, Mg, and iron which reduces biolavailability –> separate from tube feeds
Drug-nutrient interaction: ciprofloxacin
Oral suspension is NOT compatible due to oil-base that adheres to tube –> IR tablets are used instead (crush and mix w/ water and flush the line w/ water before and after)
Drug-nutrient interaction: phenytoin
Dilantin suspension - levels reduce when drug binds to feeding solution causing subtherapeutic levels –> separate by 2 hours
Why is enteral nutrition preferred over parenteral nutrition?
-Lower cost
-Utilization of gut (preventing atrophy and other problems)
-Less complications (infections, hyperglycemia, cholelithiasis/cholestasis)
What are the types of tubes that can be utilized in enteral nutrition? What are some tube feeding risks?
- Nasogastric (NG) - tube from nose to stomach
- Percutaneous endoscopic gastrostomy (PEG or “G tube”) - tube that goes through skin to stomach
- Percutaneous endoscopic jejunostomy (PEJ or “J Tube”): tube into small intestine
Tube feed risks: aspiration, dehydration if NOT enough fluids provided
What are some common EN formula names?
Ensure, Osmolite, Jevity, Glucerna, Novasource (particularly for DM pts due to less sugar), Nepro (renal formula)
