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PHRM 864 Module 3 > Parenteral and Enternal Nutrition - Lecture 2 > Flashcards

Parenteral and Enternal Nutrition - Lecture 2 Flashcards

1
Q

Parenteral nutrition

A

the process of supplying nutrients via an intravenous delivery system (i.e. protein, carbohydrates, fat, electrolytes, vitamins, minerals)
synonyms: TPN, PN, TNA, 3-in-1

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2
Q

PN indications

A

anticipated prolonged NPO course (>7 days)
inability to absorb nutrients via the gut, such as secondary to: small bowel or colonic ileus, extensive small bowel resection, malabsorptive states, intractabl vomiting/diarrhea
enterocutaneous fistulas
inflammatory bowel disease
hyperemesis gravidum
bone marrow transplantation (mucositis)

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3
Q

Routes of administration

A

peripheral
central

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4
Q

Peripheral PN

A

dextrose and amino acid solutions are hypertonic: not well tolerated via a peripheral vein
restrict final dextrose concentration to 5-10% or total osmolarity to < 900 mOsm/L
addition of other substances to solution may enhance vein tolerance

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5
Q

Peripheral PN requires

A

large volumes of fluid: may not be the best choice for HF or AKI/CKD pts
limited in calories: secondary to the osmolality AND fluid
short term access (<7-10 days): does this pt need PN at all?
pharmacy/MD error? (always double-check to confirm peripheral route was intentional)

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6
Q

Central PN advantages

A

allows administration of hypertonic solutions
more calories can be delivered

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7
Q

Central PN disadvantages

A

risk of infection: appropriate central line care is key to prevention
central line is not a benign procedure: pneumothorax, air embolus, thrombus

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8
Q

Central venous access

A

central venous catheter (CVC) insertion sites: subclavian (SC) - under clavicle, internal jugular (IJ) - in neck, femoral - in groin
short term: percutaneously inserted
long term: PICC (peripherally inserted central catheter), tunneled, implanted port

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9
Q

Meeting energy requirements

A

protein calories
non-protein calories (NPC): carbohydrates, fats

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10
Q

Meeting protein requirements

A

one gram protein = 4 kcal - many hospitals actually order protein in gm/day
standard amino acid products: travasol, freamine III, aminosyn II

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11
Q

Carbohydrates (dextrose)

A

max concentration available: D70% (D70W)
one gram dextrose = 3.4 kcal
limitations: a final dextrose concentration > 10% (adults) and >12.5% (peds) should not be infused into a peripheral vein due to vein irritation
max carb utilization: 4-5 mg/kg/min (double check)

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12
Q

IV fat (lipid) emulsion - intralipid

A

provides a concentrated source of calories:
1 gram lipids = ~ 10 kcal
prevents essential fatty acid deficiency
intralipid 10% consists of: soybean oil, glycerin (check for allergies), egg yolk phospholipid (check for allergies), water for injection

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13
Q

IV fat (lipid) emulsion - SMOFlipid

A

SMOFlipid consists of:
soybean oil - omega-6 essential fatty acid
medium-chain triglycerides - rapidly available energy source
olive oil - omega-9 monounsaturated fatty acid
fish oil (check for allergies) - omega-3

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14
Q

SMOFlipid compared to pure soybean oil products

A

improved liver function (lower ALT/AST concentrations)
lower increase in TG levels from baseline

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15
Q

SMOFlipid compared to non-omega-3 PN

A

less pro-inflammatory
less negative impact on liver function
reduced risk of infection
decreased length of hospital stay

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16
Q

Additional lipid considerations

A

max intake - do not exceed: 60% of caloric intake as lipid; generally 1-1.5 gm/kg/day of lipids in adults - max of 2.5 gm/kg/day of lipids in adults if tolerating; 4 gm/mg/day of lipids in infants/peds
propofol is a 10% lipid solution; provides 1.1 kcal/mL

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17
Q

IV fat emulsion - administration

A

IV fat emulsion 10% and 20% are isomolar (isotonic) with serum: may infuse via peripheral vein; piggyback into PN; admix into dextrose/amino acid solution to decrease osmolarity
IV fat emulsion 30%: must be incorporated into total nutrient admixture (3-in-1)

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18
Q

IV fat emulsion - infectious complications

A

IV lipids provide an environment suitable for pathogen growth:
hang-time of IV fat emulsion by itself should be limited to 12 hrs after opening of manufacturer packaging; if added as TNA (3-in-1) safety is increased to 24 hrs

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19
Q

Administration of PN - total nutrient admixture (custom TPN)

A

dextrose, AA, and lipids in one bag
3-in-1 = TPN (total parenteral nutrition)

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20
Q

Administration of PN - conventional administration (custom TPN)

A

dextrose and AA in one bag
lipid 2-3 times a week as a separate IVPB

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21
Q

Administration of PN - premix solution for injection (standard TPN)

A

available with or w/o electrolytes
no lipids

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22
Q

In line filters

A

reduces infusion of particulates, microprecipitates, microorganisms, pyrogens, and air
1.2 micron filter can be used for all total nutrietn admixtures (TNAs) or 3-in-1 (w/ lipids)
0.22 micron filter only used for 2-in-1 formulations (no lipids)

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23
Q

Premix PN solutions (clinimix/clinimix E)

A

standard TPN - not able to customize these products
amino acid in dextrose - with or w/o electrolytes
lipid compatible
peripheral and central line preparations
contains: amino acids + dextrose (+/- Na, K, Mag, Ca, acetate, Cl, Phos)

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24
Q

Clinimix/Clinimix E dosing

A

standard PN order, must assess renal function: CrCl < 50 - standard PN formula, NO electrolytes; CrCl>/= 50 - standard PN formula WITH electrolytes

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25
Q

PN initiation and discontinuation guidelines

A

start at ~25% of goal and achieve the final rate within 24 hrs
initiation: check blood glucose Q4-6 hrs, before each increase in rate; if BG < 200, continue at same rate x 4 hrs and recheck, if repeat BG > 200, consider insulin therapy
cessation: decrease rate by half q2hrs until rate < 50mL/hr, then discontinue

26
Q

Cycling PN (for pts going home on PN)

A

infusion over ~12-18hrs/day
transitioning to EN or PO intake
pts who desire time free from the infusion pump (home PN pts)
rate of infusion generally cut back (tapered) during the first/last hour of infusion to prevent dysglycemias
no specific guidelines for cycling PN (max ~200mL/hr)

27
Q

Additives

A

electrolytes
vitamins
trace elements

28
Q

Electrolytes

A

calcium, magnesium, phosphorous, sodium, potassium, chloride, acetate

29
Q

Calcium standard daily range

A

10-20 mEq

30
Q

Magnesium standard daily range

A

8-24 mEq

31
Q

Phosphorous standard daily range

A

15-45 mMol

32
Q

Sodium standard daily range

A

1-2 mEq/kg

33
Q

Potassium standard daily range

A

0.5-1 mEq/kg to start

34
Q

Chloride and acetate standard daily range

A

as needed to maintain acid-base balance
chloride ~2/3
acetate ~1/3

35
Q

Electrolyte considerations

A

in pts with renal disease: caution should be used with potassium, phosphate, and magnesium (b/c these are renally cleared)
acid-base balance obtained through balance of acetate and chloride
avoid calcium + phosphorous precipitation: avoid Ca (mg/L) x phos (mMol/L) > 150

36
Q

Vitamins

A

thiamin, riboflavin, niacin, folic acid, panthotenic acid, pyridoxine, cyanocobalamin, biotin, ascorbic acid, A, D, E, K
adult and pediatric (>40 kg): 10 mL/day of injectable adult multivitamin-12
pediatric (3 kg-40 kg): 2 mL/day of injectable pediatric multivitamin

37
Q

Trace element adjustments

A

liver dysfunction (chronic liver disease or LFTs > 2x ULN): discontinue trace elements, supplement individually: zinc 5 mg (1mL), selenium 60 mcg (1mL)
renal disease (CKD/ESRD on hemodialysis): consider checking serum levels if use expected beyond 14 days, use selenium and chromium with caution, different rules for CRRT

38
Q

Iron

A

give IV iron separately
addition of iron to PN is not recommended: can destabilize IV fat emulsion in 3-in-1 formulations, may contribute to infectious complications

39
Q

Medications in PN

A

for the most part, the addition of meds to PN formulations is not advised; may use famotidine (H2 blocker) may be utilized for GERD or stress ulcer prophylaxis
PPIs NOT compatible with PN

40
Q

Insulin in PN

A

regular insulin only!
common regimen: 0.1 units/gram of dextrose
if BG > 150 mg/dL: 0.15 units/gram dextrose
if BG > 300 mg/dL: do not initiate PN until < 200 mg/dL
max amount: 0.3 units/gram dextrose
5-10 units stick to the bag

41
Q

Converting phos mMol to mEq

A

average = 1 mMol phos = 1.4 mEq phos

42
Q

Positive ions

A

sodium and potassium

43
Q

Negative ions

A

chloride, acetate, and phos

44
Q

Chloride:acetate balance

A

total positive and negative ion balance must equal zero
consider acid/base status and CMP
additional losses can contribute
titrate based on response

45
Q

PN complications

A

mechanical
infectious
metabolic

46
Q

Mechanical complications

A

catheter related: clotting of line, displacement

47
Q

Infectious complications

A

catheter-related sepsis, solution contamination, bacterial translocation

48
Q

Bacterial translocation

A

time-dependent passage of bacteria or endotoxins from GI tract to extra-intestinal sites
enteric organisms cause systemic infections: pneumonia, central line infections, abcesses, multi-organ dysfunction syndrome
infectious morbidity and mortality

49
Q

Metabolic complications

A

electrolyte imbalances, fluid imbalance, hyper- and hypoglycemia, liver function abnormalities: steatosis (fatty liver), intrahepatic chloestasis, cholelithiasis

50
Q

PN baseline monitoring

A

baseline: CMP, Mg, phos ionized Ca; hepativ function panel; prealbumin/CRP; PT/INR
Q6-4H: finger sticks for glucose, residuals, distention, vomiting, aspiration

51
Q

Ongoing PN monitoring - daily

A

vital signs, intake/output, CMP, feeding tube placement and patency, may decrease frequency when stable

52
Q

Ongoing PN monitoring - twice weekly

A

weight, CBC, Mg, phos, Ca, prealbumin/CRP, ICU setting –> increase to daily

53
Q

Ongoing PN monitoring - weekly

A

albumin, transferrin, nitrogen balance, liver function tests, triglycerides, PT/INR, respiratory quotient/indirect calorimetry

54
Q

Additional complications

A

refeeding syndrome
essential fatty acid deficiency

55
Q

Refeeding syndrome

A

constellation of fluid, micronutrient, electrolyte, and vitamin imbalances
occurs within first few days of feeding a starved pt
potentially life threatening

56
Q

Clinical finding of refeeding syndrome

A

hypophosphatemia (most likely to experience! controls muscle contractions, stop breathing), hypomagnesemia, hypokalemia (3 you’re most likely to see)
respiratory distress
paresthesias
tetany
cardiac arrhytmias
hemolytic anemia

57
Q

Risk factors for refeeding

A

rapid feeding, excessive dextrose infusion
low BMI
excessive weight loss
insufficient caloric intake
low levels of K, phos, or Mag prior to feeding
high risk comorbidities: alcoholism, anorexia nervosa, marasmus

58
Q

Prevention of refeeding syndrome

A

replete electrolytes before initiating feeds
initiation recommendations (day #1): limit carbs (dextrose) to 100-150 gm, limit fluids to 800mL/day, provide adequate amounts of electrolytes, provide approx 50% of total caloric needs
advance calories/dextrose by 20-33% of goal every 1-2 days as tolerated
give thiamine 100 mg daily x5-7days

59
Q

Essential fatty acid requirements

A

estimated to be 4-10% of daily caloreis
EFAs include linoleic and linolenic acids

60
Q

Essential fatty acid deficiency MOA

A

continuous infusion of hypertonic dextrose will increase circulating insulin levels
inhibits lipolysis and fatty acid mobilization

61
Q

EFAD clinical onset and symptoms

A

clinical onset: several weeks on fat-free PN regimen (10-14 days)
sx: dry scaly skin, brittle hair, lack of luster

62
Q

Prevention of EFAD

A

recommended minimum requirement is to provide approx. 4% of caloric intake as lipids
prevention: provide at least 500 mL of 10% fat emulsion over at least 3-5hrs twice weekly OR provide at least 250 mL of 20% fat emulsion over at least 5-9hrs twice weekly

PHRM 864 Module 3 (9 decks)

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