Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PHM 604 GI > Parenteral Nutrition > Flashcards

Parenteral Nutrition Flashcards

1
Q

What is TPN?

A
  • Nutritional support given IV when enteral not safe/effective (macro+micronutrients)
  • Not disease-specific, but provision of calories/energy used to prevent malnutrition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

TPN General Problems

A

Expensive with risk of serious ADEs (appropriate use is essential)
- Must recognize when and when not to use
- Tailor to patient
- Monitor and adjust as needed
- Transition to enteral ASAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

TPN Adult Indications

A

Healthy adult unable to receive significant EN: Initiate after 7 days

Nutritionally-at-risk patients unlikely to achieve goal: Initiate within 3-5 days

Baseline moderate-severe malnutrition (EN not feasible): Initiate ASAP

Delay in metabolically unstable patients until condition improves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

“Nutritionally-at-risk” criteria

A

One or more:
- Involuntary weight loss: 10% <6mo, 10lbs <6mo, 5% <1mo
- BMI < 18.5 kg/m^2
- Increased metabolic requirements
- Altered diet and/or diet schedule

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

TPN Pediatric Indications

A

Limited data (can delay up to 7 days in a self-resolving illness situation)

If unlikely to tolerate EN for extended time:
Infants (1mo-1y): Initiate within 1-3 days
Children/adolescents: Initiate within 4-5 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Why do we initiate TPN sooner in pediatrics?

A

They have
- Decreased metabolic stores/reserves available
- Higher energy requirements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

TPN Neonate Indications (0-1mo)

A

Very-low birth weight (<1.5kg): Initiate promptly after birth

Preterm and critically ill term neonates: Initiate when EN unable to meet energy requirements for growth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Concern when holding fat in neonate diet for 3 days?

A

Essential fatty acid deficiency
(impacts brain development)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

TPN Indications Any Age

A
  • Impaired absorption (short bowel, high output intestinal fistula, gastroschisis)
  • Mechanical/motility issues (obstruction, ileus, inflammatory disease)
  • “Bowel rest” required (pancreatitis, ischemic bowel, pre/post-operative)
  • Inability to utilize EN (VLBW infant, hemodynamic instability, severe GI bleeding)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

TPN Types of Complications

A

Metabolic

Mechanical

Infectious

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

TPN Metabolic Complications

A
  • Hypo/hyperglycemia (target 140-180 mg/dL)
  • Electrolyte imbalances, refeeding syndrome (hypoK, hypophos, hypoMg)
  • Hypertriglyceridemia
  • Liver function abnormalities acute (AST/ALT elevations) and chronic (Alkaline Phos/Bilirubin > weeks)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

TPN Mechanical Complications

A
  • Pneumothorax
  • Catheter occlusion
  • Thrombus
  • Phlebitis (extravasation of TPN)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

TPN Administration: Peripheral line

A
  • Bedside insertion into veins of forearm/hand
  • Use for short-term duration

BUT

  • Increased phlebitis risk
  • Upper osmolarity limit of 900 mOsm/L
  • Not suitable for home TPN or long term
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

TPN Infectious Complications

A
  • Central line associated infections, bacteremia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

TPN Administration: Central line (PICC)

A
  • Bedside insertion into basilic, cephalic, or brachial veins (tip in superior vena cava)
  • Suitable for short to medium duration of TPN

BUT

  • May require radiologist
  • Increased DVT risk
  • Site: limits pt activity, easily removed, easily infected
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

TPN Administration: Tunneled catheter (Broviac, Hickman)

A
  • Suitable for long term TPN, cuffed to minimize contamination/dislodgement
  • Minimal restrictions to activity
  • Easier for self-care/hidden

BUT

  • Surgical/radiology guided insertion
17
Q

TPN Monitoring

A
  • Electrolytes
  • Glucose
  • Liver functions

Long term: conjugated bilirubin, triglycerides

Individualized, others may require different levels of trace elements, nitrogen balance, etc…

18
Q

What is refeeding syndrome?

A

Occurrence of electrolyte abnormalities (rapid depletion) in severely malnourished patients during rapid initiation of nutrition
- Can lead to fluid overload (monitor fluid status carefully)
- Start slow and advance over 3 days, initiate TPN at 1/2 of goal rate

19
Q

Which electrolytes do we pay attention to specifically in refeeding syndrome?

A

Monitor and aggressively supplement: Potassium, phosphate, magnesium

20
Q

TPN approaches

A

Standard approach: Commercial premade TPN bags, NOT for pediatrics

Individualized approach: Compounded prescription TPN, used in NICU/pediatric patients

Cycled TPN: Provided over a rate that is not the usual 24h, used in long term to allow “off time” and minimize risk of IFALD, ramp up and down rate, avoid drastic glucose shifts.

21
Q

Calculating fluid goals

A

Neonates: Initial 60-80mL/kg/day, titrated to 120-150mL/kg/day

Pediatrics: 4-2-1 method
1. 0-10kg: 4mL/kg/hr
2. 10-20kg: 2mL/kg/hr
3. any kg>20: 1mL/kg/hr

Adults*: 30-40mL/kg/day
Critically ill adults: minimal mL/kg/day to achieve adequate nutrition

22
Q

Amino acids (protein)

A
  • 4kcal/gram
  • 10mOsm per g/L or 100mOsm/%
  • Various solutions available
23
Q

Nitrogen balance

A

We want positive (anabolic state, energy in > energy out)

Nitrogen IN: Grams of protein / 6.25 = grams of nitrogen
Nitrogen OUT: UUN (g) + 4
Formula = IN - OUT

UUN = urine urea nitrogen, collected over 12-24 hours
+4 for insensible losses

Increase protein if nitrogen balance is negative

24
Q

Dextrose (carbohydrates)

A
  • 3.4kcal/gram
  • 5mOsm per g/L or 50mOsm/%
  • Peripheral limit D10-12.5%
  • Product = D70W
25
Q

Lipid emulsions (fat)

A
  • 9kcal/gram
  • Various products with different fat concentration
  • Maximum rate of infusion** = 0.15g/kg/hr in pediatrics, 0.11g/kg/hr in adults
  • Must administer with a 1.2 micron filter (3-in-1s)
  • Maximum hang time of 12 hours
  • Certain emulsions may be contraindicated in egg/soybean/fish allergies
26
Q

Monitoring pearls for lipids

A

IFALD: liver function tests and bilirubin
Hypertriglyceridemia: TG > 200 mg/dL (neo./ped.), TG > 400 mg/dL (adults)
EFAD: essential fatty acid profiles in malnourished neo./ped. patients or any patient using lipid minimization strategies.

27
Q

Calcium-Phosphate Precipitation

A

Concentration dependent reaction leading to in-solution precipitates to form
Affected by:
- Dose of Ca/Phos
- pH
- Temperature
- Time
- Salt form (calcium gluconate preferred)

Separate addition to minimize risk - PHOS FIRST***

28
Q

Multivitamins

A
  • MUST be included for standard dosing TPN
  • Essential for various organ systems and physiological function
  • Some patients may need more (individualize) - long term TPN
  • Monitor patients on warfarin - contains vitamin K
29
Q

Trace elements

A
  • Zinc
  • Copper
  • Manganese
  • Chromium
  • Selenium
30
Q

Anion balance

A

Positive cations MUST be with negative anion
- Ordered based on mEq of cations in TPN
- Acetate or chloride, 1:1, 2:1, 1:2, maximum one or the other
Metabolic ACIDOSIS = increase acetate, decrease chloride
Metabolic ALKALOSIS = decrease acetate, increase chloride

31
Q

Lipid compatibility problems in TPN (3-in-1)

A

Creaming: safe to use, reversible
Cracking: UNSAFE to use, irreversible separation
Minimum concentrations for stability:
AA 4%, Dextrose 10%, ILE 2%

32
Q

Medications in TPN

A

(insulin, levocarnitine, heparin, famotidine)
- Check compatibility
- Determine risk or clinical utility provided over 24h

33
Q

Filter requirements

A

Dextrose-AA: 0.22 micron filter
Lipids/3-in-1: 1.2 micron filter

34
Q

TPN Use in Special Populations

A

Hepatic failure/disease: higher branch amino acid, lower aromatic

Diabetes: lower carbs, higher fat

COPD/lung disease: lower carbs, higher fat (less CO2)

Trauma/burns: increased metabolic needs, higher calories, more protein

35
Q

TPN order steps for adult

A
  1. Evaluate fluid and energy requirements
  2. Calculate kcal/day, g/day, and mL for each macronutrient
  3. Determine final concentrations of dextrose, AA, and lipids
  4. Calculate electrolyte doses (consider special circumstances)
  5. Select appropriate anion balance
  6. Perform “safety checks”
    - Max lipid rate 0.11 g/kg/hr
    - Glucose infusion rate close (less than) 4 mg/kg/min
    - Estimate osmolarity (AA + dextrose)
    - Check line/access (central vs. peripheral)
    - if TNA (3-in-1), ensure appropriate macronutrient % for lipid stability
36
Q

TPN order steps for pediatrics (2-in-1)

A
  1. Evaluate fluid and energy requirements
  2. Calculate kcal/day, g/day, and mL for each macronutrient
  3. Determine final concentrations of dextrose, AA
  4. Calculate infusion rates (mL/hr) for 2-in-1 and lipid infusion
  5. Calculate electrolyte doses (consider special circumstances)
  6. Select appropriate anion balance
  7. Perform “safety checks”
    - Max lipid rate 0.15 g/kg/hr
    - Glucose infusion rate (mg/kg/min)
    - Estimate osmolarity (AA + dextrose)
    - Check line/access (central vs. peripheral)

PHM 604 GI (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions