Parenteral Nutrition Flashcards
Male IBW Calculation
IBW = 50 + 2.3 (in > 60)
Female IBW Calculation
IBW = 45.5 + 2.3 (in > 60)
NBW Calculation
NBW = IBW + 0.25(wt - IBW)
When do you use NBW?
if actual weight is > 130% of IBW
What classifies someone as under body weight (UBW)?
actual weight 20% below IBW
When does involuntary weight loss become concerning?
Weight loss > 10% within 6 months
After how many days of NPO does a person become at risk for malnutrition?
7 days
What types of patients are hypermetabolic at baseline?
trauma and burn patients
What medication leads to increased metabolic needs?
high dose steroids
Why does chronic alcohol/substance abuse put you at risk for malnutrition? (2)
decreases functional protein levels; intake of empty calories
All hospitalization patients should have their nutrition risk assessed within __ hours of admission.
48
What 3 aspects of a patient history are important for assessing nutrition risk?
dietary; medical; medication
Normal Transthyrenin (prealbumin) level
15-40 mg/dL
Why is it important to get baseline a baseline prealbumin value?
prealbumin is a negative acute phase reactant and can be lowered during inflammatory response
Which type of malnutrition is characterized by wasting of skeletal muscle and SQ fat as well as cachectic appearance?
protein-calorie malnutrition
What is another name for protein-calorie malnutrition?
marasmus
What type of malnutrition is characterized by adequate caloric intake?
protein malnutrition
What is another name for protein malnutrition?
kwashiorkor
Which type of nutrition is associated with trauma and burn patients?
protein malnutrition (kwashiorkor)
Which type of malnutrition is associated with muscle wasting?
protein-calorie malnutrition (marasmus)
List common symptoms of marasmus. (3)
hair loss; edema; skin folds
List common symptoms of kwashiorkor. (3)
failure to gain weight; large belly; change in skin pigment
Why must you provide carbs before protein in a patient with protein malnutrition?
if you just give protein, the body will use up all the protein for energy and stores will never be repleted
Increased protein catabolism leads to ______ UUN.
Increased
How is UUN measured?
24 hr urine collection
UUN represents ___% of total nitrogen excretion.
85-90
Goal nitrogen balance
+3 to +5 grams
Nitrogen balance calculation
(N in) - (N out)
(N in) equation
N in = [24-hr protein intake (g)] / 6.25
(N out) equation
N out = [24-hr UUN (g)] + 4
How often should you check a nitrogen balance?
once a week
Caloric requirement for all patients
25-30 kcal/kg/day
What is the goal RQ?
0.85-0.95
A high RQ is associated with _____.
overfeeding
A low RQ is associated with _____.
underfeeding
Underfeeding leads to depletion of ____ stores.
protein
Protein requirement for mild/moderate stress (floor patients)
1-1.5 gm/kg/day
Protein requirement for moderate/severe stress (ICU, trauma, burn)
1.5-2 gm/kg/day
What is the standard distribution of non-protein calories?
70% dextrose / 30% fat
How would you change the NPC distribution if a patient had high blood sugar?
decrease dextrose, increase fat
How would you change the NPC distribution if a patient had high triglycerides?
increase dextrose, decrease fat
When might 100/0 NPC be used?
sepsis; bloodstream infections
List the indications for parenteral nutrition. (6)
- anticipated NPO > 7 days
- inability to absorb nutrients via the gut
- enterocutaneous fistulas
- inflammatory bowel disease
- hyperemesis gravidum (pregnant patients)
- bone marrow transplant
What are some problems that lead to the inability to absorb nutrients through the gut? (4)
- bowel or colonic ileus
- small bowel resection
- malapsorptive states
- vomitting/diarrhea
Why might bone marrow transplant patients require PN?
mucositis caused by treatments may cause pain that prevents the patient from eating
What are the 3 sites available for central venous catheter insertion?
- subclavian
- internal jugular
- femoral
Short term CVCs are _______.
percutaneously inserted
Long term CVCs include: (3)
- PICC
- tunneled
- implanted port
What type of catheter is most commonly used?
triple lumen
TEE calculation
TEE = REE x 1.2
1 gram protein = ___ kcal
4 kcal
1 gram dextrose = ___ kcal
3.4 kcal
What is the maximum carbohydrate utilization?
4-5 mg/kg/min
1 gram lipid = ___ kcal
10 kcal
What are anthroprometrics?
measures of the body’s muscle protein
What are the 4 ways you can measure a person’s muscle protein?
weight; triceps skin fold; arm muscle circumference; physical appearance
What is the goal final dextrose concentration for a TPN?
10%
What are the ingredients in Intralipid? (4)
Soybean oil; glycerin; egg yolk phospholipid; water
What type of essential fatty acid is available in Intralipid? (Hint: comes from soybean oil)
omega-6-fatty acid
Which two parts of Intralipid might people be allergic to?
glycerin & egg yolk
What are the ingredients of SMOFlipid?
soybean oil; medium-chain TG; olive oil; fish oil
What type of EFA is in fish oil?
omega-3-fatty acid
Which EFA is better?
omega-3-fatty acid
What part of SMOFlipid might people be allergic to?
fish oil
What are the benefits of SMOFlipid over Intralipid? (2)
improved liver function; lower increase in TG
General lipid dosing in adult patients
1-1.5 g/kg/day
Max lipid dose for adults
2.5 g/kg/day
What sedative medication contains lipids?
propofol
How much lipid is in propofol?
1.1 kcal/mL
Which two types of fat emulsions are isotonic?
10% and 20%
What does a total nutrient admixture consist of?
dextrose, AA, and lipids all in one bag
What does a convential administration TPN consist of?
dextrose and AA in one bag with lipids given intermittently as IVPB
What is not included in a premix solution TPN?
lipids
Are electrolytes included in a premixed solution TPN?
they can be made with or without electrolytes
Patients with a CrCl of ___ should not receive electrolytes in their TPN.
< 50
You should start a TPN at __% of the goal rate and reach the final rate in ___ hours.
25%; 24 hours
How often should you check BG after initiating the first TPN bag?
every 4-6 hours
What do you do if after checking the patient’s BG it is > 200 mg/dL?
continue TPN at the same rate and re-check in 4-6 hours
When would you initiate insulin in a TPN patient?
after 2 consecutive BG checks > 200 mg/dL
How do you stop a TPN?
decrease rate by 1/2 every 2 hours
How much vitamin product goes in a TPN?
10 ml/day
How often should you monitor a patient’s prealbumin?
twice a week
How often should you monitor RQ and UUN?
once a week
What labs should you get at baseline for a patient being started on a TPN? (7)
CMP; Mg; Phos; Ca; prealbumin; hepatic function; PT/INR
What electrolyte is most at risk for depletion in refeeding syndrome?
phos
What are 3 consequences of refeeding syndrome? (Hint: all hypo-)
hypophosphatemia; mypomagnesemia; hypokalemia
What is the first thing you should do to prevent refeeding syndrome in at-risk patients?
replete electrolytes before initiating feeds
To prevent refeeding syndrome you should limit dextrose to _____ on the first day of feeds.
100-150 g/day
To prevent refeeding syndrome you should limit fluids to _____ on the first day of feeds.
800 ml/day
To prevent refeeding syndrome you should provide __% of total caloric needs on the first day of feeds.
50%
Essential fatty acids make up __% of daily calories.
4-10%
What is the mechanism behind EFA deficiency?
inhibits lipolysis and fatty acid mobilization
When does EFA onset usually occur?
10-14 days after starting fat-free regimen
What are the two options for prevention of EFA deficiency?
- 500 ml of 10% fat emulsion twice weekly
2. 250 ml of 20% fat emulsion twice weekly
