Parenteral Nutrition Flashcards
1
Q
mOsm/g of Dex
mOsm/g of AA
mOsm/g of electrolytes
A
Dex: 5
AA: 10
Electrolytes: 1 per mEq
2
Q
PPN Dex and AA g amounts
A
Dex: 150-300
AA: 50-100
3
Q
PPN Requirements (4)
A
At least 5 days
Up to 2 weeks
Good peripheral access
Able to tolerate large volume (2.5-3L)
4
Q
3 downsides PPN
A
May cause phlebitis
Hyperosmolar
May require frequent IV rotation sites
5
Q
Midline is recommended if PPN needed >6 days d/t
A
Length
Decreased probably of dislodging
6
Q
Contradictions to PPN (5)
A
Significant malnutrition Severe metabolic stress Large fluid/electrolyte needs Fluid restriction Renal/liver compromise
7
Q
Hypocaloric PN may improve ______
A
N balance
But little data >30 days
8
Q
Permissive underfeeding
A
80% of needs
9
Q
Recommendations for PN in post-op wound healing
A
Start within 5-10 days if unable PO/EN
10
Q
PN with caution when BUN > Glc > Osomalrity > Na > K < Hcl > or < Phos
A
BUN > 100 Glc > 300 Osmolarity > 350 Na > 150 K < 3 Hcl > 115 or < 85 Phos < 2
Need to be hemodynamically stable
11
Q
When to start TPN
A
Well-nourished not at risk (even critically ill) - after 7 days
Critically ill at high risk - consider earlier
12
Q
Critically Ill labs monitor daily vs weekly
A
Daily: Electrolytes + Cl, BUN, Cr, CO2 Glucose Weight I/O
Weekly:
CBC
Clotting labs
TAGs, Liver labs
13
Q
Stable monitor labs weekly vs 1-2x/week vs 2-3x/week
A
Weekly:
CBC, Clotting labs, TAG
1-2x/week:
Electrolytes
2-3x/week
Weight
14
Q
Why no bowel rest in pancreatitis?
A
Important to maintain GI integrity to prevent further complications
Add glutamine if NPO?
15
Q
Critical Illness: PN if all 3 factors
A
- Malnourished at baseline
- Unable to do EN for >7-10 days
- Hemodynamically stable
Also indicated for paralytic ileus, acute GI bleeding, or complete bowel obstruction
16
Q
Home PN use caution with (6)
A
DM CHF Pulmonary disorder Severe malnutrition Hyperemesis gravidarum Electrolyte disorders
17
Q
Dextrose concentration >10% reserved for central administration d/t propensity to cause
A
Thrombophlebitis in peripheral veins
18
Q
Glycerol/Glycerin kcal/kg and use
A
4.3 kcal/kg, Peripheral
19
Q
Protein generally assumed to be __% Nitrogen
A
16%
20
Q
Modified AA formula
A
High in BCAA, low in aromatic AA
Limited indication for use
Maybe hepatic encephalopathy (high aromatic may alter mental status)
Theory BCAA may also benefit stress/trauma
21
Q
SMOF lipids composition, good for, associated with
A
Soy Mct Olive Fish
Oleic acid and decreased omega 6
Good for: Can’t tolerate soy, carnitine deficiency
Associated with decreased liver changes and antioxidant preservation
22
Q
ILE contains ___ phospholipid emulsifier
A
Egg
23
Q
ILE infusion goal
A
< or equal to 0.11 g/kg/h
24
Q
Fat overload syndrome
A
Headache, seizure, fever, jaundice, hepatosplenomegaly, abd pain, shock
25
Goal EER for lipids and g/kg/d
Less than or equal to 60%
2.5 g/kg/d
Can limit to 1 g/kg/d d/t high omega 6
26
Preferred form of magnesium and calcium in PN
Mag sulfate and Ca gluconate
| Less likely to provide chemical incompatibility
27
Avoid Calcium _____ in PN
Ca Chloride
28
PN electrolyte requirements
```
Na: 1-2 mEq/kg
K: 1-2 mEq/kg
Ca: 10-15 mEq/kg
Mag: 8-20 mEq/kg
Phos: 20-40 mmmol
```
29
TNA advantages (6)
More efficient, cost effective, convenient
Less manipulation and risk contamination
Slower bacterial growth
30
TNA Disadvantages (8)
Need pore size filter 1.2 um
Less stable, less compatible for Ca Glu and Na/K Phos, less daily catheter lifespan
More prone to separation , increased risk of catheter occlusion
Low pH of AA may destabilize lipid
Opacity (difficult to see)
31
If using true peripheral vein, _____ and ___ should be low
Cal and K concentration
32
In TNA, desired concentration of dex and AA to prevent destabilization
Dex >10%
AA >4%
ILE >2%
33
ILE hang time for 2-in-1
12 hours
34
Benefits of ACDs vs Disadvantages
Easily tailored to meet needs
More efficient
Decreased risk touch contamination
Shelf stable
Not appropriate for all pts
Electrolytes, AA and Dex standardized
35
Stability and examples
Degradation of nutrient that changes characteristics; Ability to maintain integrity/activity
Ex: Milliard reaction between IV dex and lysine -> brown discoloration
Ex: Light degradation
36
Factors effect ILE emulsion stability (2)
Alters electrical charge between fat droplets:
pH <5
Addition of electrolyte salts
Low pH also degrades egg emulsifiers
37
Physical sign of emulsion destabilization
Yellow oil streaks or amber layer on top
38
What increase CaPhos solubility? Downside?
Cysteine HCl
| Lowers pH
39
Factors increase Ca/Phos precipitation (4)
High Ca amount
High Phos amount (including Phos in AA)
CaCl
High temperature
40
Factors increase Ca/Phos solubility (3)
High amount AA
High amount dextrose
Low pH
41
Increased risk aluminum toxicity (4)
Renal dysfunction
Iron deficiency
Pediatric
Long term PN
42
Size filter removes precipitates
5 um
43
Use ____ size filter for AA/dex 2-in-1
0.22 um
| Retain microorganisms, but they are also effective in trapping precipitates found in dextrose–amino acid PN
44
Use ___ for TNA and ILE added to 2-in-1 via Y connector
1.2 um
45
Time for new in line filter change
24 hours for TNA and 2-in-1
| 10-12 hours for ILE only
46
ILE in TNA can hang 24 hours because
Lower pH of TNA inhibits bacterial growth
47
If micron filter occludes...
Don't remove
48
Usual dextrose administration rate and maximum rate
3 mg/kg/min
| Max liver can oxidize: 5 mg/kg/min
49
Fluid restriction PN, calculate in order:
1. AA 2. Fat 3. Dex
| Fat first to maximize kcal with available fluid
50
Preferred access for PN/Central access
SVC - main venous return to heart
| Rate of blood flow rapidly dilutes
51
CVC Cuff
Attaches to CVC and acts as anchor and mechanical barrier
52
Dacron cuff
Subcutaneous tissue
| Tunneled cath
53
Collagen cuff
Attach to cath at insertion, ions exert antimicrobial activity
54
Groshong cath
VAD with pressure sensitive 3 way valve - eliminate the need for daily heparin flush and cath clamping before disconnecting
55
PVC catheter increases risk for ___ and ____
Thrombus and phlebitis
56
Peripheral vs CVC tip placement
Peripheral: Just outside SVS or IVC (inferior vena cava)
CVC: distal SVS, IVC or R atrium
57
Peripheral access
Peripheral : Hand/lower arm
| Midline : Above elbow/antecubital fossa in cephalic or basilic vein
58
Must immediately remove peripheral catheter if
Infiltrate or complication is suspected
59
Midline and peripheral lines not for ___ or ___
osmolarity >900 or dex >10%
60
Midline only for ___ weeks and not for ___
2-4 weeks, not for central access
61
Nontunneled PICC: time, complication risk, downside
Weeks to months
Low risk
Limited ability for self care/ADL
Most common acute care short term
62
Percutaneous central catheter (CVC or PICC) nontunneled: location, time, infection risk, downside
Jug, subclavian, femoral
7-14 days
High risk infection
Not for home care
63
Jugular (cuff or non/tunneled or not): Benefit, Downside
Can preserve subclavian for HD pts
| Can easily dislodge
64
Tunneled, Cuffed catheter: Site, time, benefits
Jugular or subclavian
Long term
Easy self care, coverable, Limited risk bacteria
65
TIVAD: Site, Benefits, Downside
Peripheral, jugular, subclavian
Long term
More cosmetic, only need care when accessed
Expensive
66
Translumbar/hepatic/collateral
Only when all others cant
67
Phlebitis symptoms
Pain, ethythema/redness, tender, palpable cord
68
Dwell time temporary cath
5-7 days
69
Guidewire exchange can replace malfunctioning catheter if ___
No infection
| However higher rate of infection if do exchange over guidewire
70
Midline can ____ risk infection and risk for phlebitis d/t ____
Decrease
| Less changing
71
What to do with dislodged PICC
Do not advance
| Can exchange over guidewire if no infection
72
Contraindications to new CVAD
Sudden deterioration
New unexplained fever
WBC <1000/mL
If platelet count <50000, give platelets within 2 hours
73
Immediate complications of CVAD placement; What reduces risk?
Pneumothorax, air embolus, arterial puncture, arrythmia (if too far into atrium)
Cutdown approach
74
Clean access sites with (3)
CHG
70% alcohol
10% povidone iodine
Dry before dressing with sterile gauze or transparent dressing
75
Routine use of antibiotic ointment not recommended because
Changes normal bacteria, increase risk resistant bacteria
76
Hub
End of VAD connects to med tube/cap
77
Access VAD for ____ prior to each infusion and ____ after
| Why
Blood return; flush with NS after
Ensures patency
Decrease risk precipitation/occlusion
78
Access VAD for ____ prior to each infusion and ____ after
| Why
Blood return; flush with NS after
Ensures patency
Decrease risk precipitation/occlusion
79
How to flush VAD
Use single use of locking solution
Use 10 mL syringe
Never forcibly flush
80
What is locking
Instilling antiseptic solution following routine flush
Usually dwell
Helps prevent infection an clot formation
81
Ethanol lock solution: Properties, Treats, what catheter
Bacterial/fungicidal properties
Treat CRBSI
Only use silicone catheters
82
Signs and sources CRBSI
WBC >10500, fever, chills, tachycardia, N/V, hypotension
Tender, swelling, redness, exudate
Skin, hands/devices, seeding, infusate
83
Remove catheter for which infections
S aureus and fungus
84
Noninfectious complications (6)
```
PE
Air embolus
Cardiac tamponade
Cath migration
Nerve injury
Occlusion
```
85
Primary type of catheter dysfunction
Thrombotic occlusion
86
Catheter patency
Ability infuse via resistance and ability aspirate blood
87
Volume of flush solution should be
Twice volume of catheter
88
Intraluminal occlusion: Sign, Type
Resistance both infuse and aspirate
| Drug/lipid precipitate
89
How to clear lipid occlusion
70% ethyl alcohol
90
How to clear Ca/Phos precipitate
0.1 HCl
91
How to clear med occlusion
Na bicarb
92
Fibrin Sheath - distal cath tip: what is, Sign, how to clear
Reaction to injury
Inability to aspirate
Thrombolytic
Endovascular cath stripping
93
Vessel/pericath thrombosis: Sign, how to clear
Resistance both infuse and aspirate
Thrombolytic agent
Endovascular stenting
94
Mechanical occlusion: Sign, Cause, How to fix
Resistance both infuse and aspirate
External clamp, cath kink, occluded port needle, constricting suture
Rectify closed clamp, tight suture, or cath malposition
95
Symptoms venous thrombus/vascular obstruction
```
Neck vein distention
Edema
Tingling/pain
Tight throat
Venous chest pattern
```
96
Thrombolytic clear CVAD occlusion
Alteplase
97
What to do for exit site infection
Only remove is systemic treatment fails or pt is septic
98
Disease states at increased risk for metabolic bone disease (4)
Crohns, cancer (altered Ca and Vit D, chemo), SBS (ca wasting), hyperthryroidism
99
Cholestasis indicated by
Bilirubin >2 mg/dL
100
How is Manganese excreted
Bile
101
Reduce risk of catheter-related infection? (3)
Max barrier technique
Adequate training
Clean insertion site with 2% chlorohexidine prep
102
If suspect occlusion, (5)
1. Obtain s/s of cath malfunction
2. Check function and patency
3. Check for mech obstruction (clamp/kink/sutures tight/needle if there) and postural changes
4. Assess pt flushing/infusing/aspirating techniques
5. Assess site
103
Max PN macro components recommended
30-40 mL/kg/d fluid
7 g/kg/d CHO
2.5 g/kg/d fat
2 g/kg/d protein
104
Malassezia furfur and at risk (2)
Yeast, superficial infection of skin
| Most often premies and those with ILE
105
Thrombosis symptoms
Inflammation, edema, pain, dilated vein
106
Long term PN monitoring (week, month, 3-6 mo, 6 mo)
Weekly then decrease when stable: BMP/Mag/Phos
Monthly then decrease when stable: CBC, Liver fxn INR
3-6 months: Iron, Vitamin D
6 month: Zn, Cu, Selenium, Mn
107
Excess CHO complications
Hepatic steatosis
| Increased CO2 production
108
Initiate PN at
1/2 needs
150-200 g dextrose
1st 24 hours
109
Add insulin to PN initial
0.05-0.1 units/g dex
110
Insulin is ___ effective in chromium deficiency
Less
111
Prevent EFAD
1-2% linoleic
0.5% alpha linolenic
or 250 mL 20% (or 500 mL 10%) 2x week
112
How fast can EFAD occur in fat-free PN for adults
1-3 weeks
113
OK to hold ILE in critically for 1st week d/t
Soy based ILE may be immunosuppressive
114
Hyperlipidemia may cause ()
Decreased immune response, altered hemodynamics, increased risk pancreatitis
ILE - <30% or over 8-10 hours
115
Use ILE in pancreatitis
Safe if TAGS <400
116
Causes azotemia
Dehydration, excess protein, inadequate nonprotein energy
| Hepatic/renal insuffiency increased risk d/t decreased ability to eliminate urea
117
Causes azotemia
Dehydration, excess protein, inadequate nonprotein energy
| Hepatic/renal insuffiency increased risk d/t decreased ability to eliminate urea
118
Thiamine/Folic acid supplementation in PN
50-100 mg thiamin and 1 mg folic acid for 5-7 days
119
Be careful of vitamin A in
Liver and renal failure
120
HD patients may need more ____ d/t losses from HD
Water soluble vitamins
121
Ration MVI in shortage
50% or give 3x/week
| If not available, give vitamin C, thiamin, folic acid, pyridoxine
122
Trace elements concern for toxicity in hepatobiliary disease
Manganese and Copper
123
When is refeeding most concern
2-5 days
| Increased demand for Phos for ATP and uptake with insulin
124
Steatosis in PN
Fat accumulation d/t excess energy stimulating insulin which promotes lipogenesis and inhibits FA oxidation
Mostly adults
Can happen within 2 weeks
125
Cholestasis in PN (PNAC) cause
Impaired bile secretion or obstruction
AA play a role
Mostly children
Bili > 2 mg/dL
126
Gallbladder stasis in PN
Impaired bile flow/contractility d/t lack of Gi stimulation leading to gallstones/sludge
127
Little to no fat can also cause ____ d/t excess CHO and EFAD
Steatosis
128
Carnitine deficiency is associated with developing and concern in which population
steatosis, encephalopathy
Infants, renal failure
Supplementing may help mobilize fat stores and prevent it in neonates
129
Ursodiol is and treats
Form of bile acid that treats cholestasis
130
Osteomalacia
Softening of bones d/t vitamin D deficiency
131
Risks for bone loss (12)
```
Cushing disease, hyperthyroid, amenorrhea
Crohns, SBS, Malabsorption, Roux en Y
Cancer
Bed rest, Spinal cord injury
Alcohol abuse
Anorexia
```
132
Meds increase risk for bone loss (7)
Corticosteroids, Heparin, Coumadin, Levothyroxine, Phenytoin, Phenobarbital, Methotrexate
133
Increase Ca loss in long term PN d/t (4)
Inadequate Phos
High protein
Chronic metabolic acidosis
Cyclic PN
134
___ (2) can suppress PTH
Mag deficiency and excess vitamin D
135
Copper deficiency can cause
Osteoporosis
136
Prevent/treat osteoporosis in PN (8)
```
Avoid high protein/sodium
Supp Ca and Phos
Treat acidosis
Adequate Mag and Copper
Minimize almuinum
Avoid heparin
Avoid smoking
Limit alcohol/caffeine
```
137
Which medication is incompatible with PN
Octreotide
138
What cause a high risk for PN and medication precipitate?
pH of each differ significantly
| PN pH 5.0-6.5
139
What to do for pinch off syndrome
Remove it
140
Amount of divalent cations that compromise TNA stability
> 20 mEq
141
Tunneled Cath examples and purpose
Hickman, Groshong, Powerline, Broviac
Reduced risk infection and removal
142
Creaming TPN
Translucent band surface emulsion
| Lipid particles destabilized but not safety concern usually
143
Specific TPN Medicare coverage (3)
Calories outside 20-35 range
Protein outside 0.8-1.5 range
Lipid >1500 g month
144
Mural thrombus
Clot or buildup on vessel
145
The most common route of infection for a tunneled central venous catheter (CVC) is
contamination of the catheter hub
146
Chronic metabolic acidosis increases risk for
Ca loss
147
Tx CRBSI
catheter salvage with 70% ethanol lock + systemic antibiotic therapy
148
High nutrition risk NRS and NUTRIC score
NRS 2002 ≥5 or
| NUTRIC score ≥5
149
Free Water Deficit =
TBW × [1 – (140/Serum Sodium)]
