Parenteral Nutrition Flashcards
EN Contraindications
EN is contraindicated
- Bowel obstruction
- Bowel surgery
- Persistient gut dysmotility
- Intractable diarrhea/vomiting
PN Indications
- Can not use EN
- Can be supplemental with EN
- Can not enter into GI tract (Facial injuries, upper GI tract block, severe esophageal varices)
PN may indications
IBD not responding to medical therapy
- Intense chemo with severe mucositis
- Major stress or trauma
PN Contraindications
- GI tract is functional
- Previously well nourished adult, minimal stress, expected to recover < 7 days
- Prognosis does not warrent aggressive therapy
- Risks > benefit
- No venous access
Central Access Devices
- PICC
Peripherally Inserted Central Catheter
- Inserted into peripheral vein –>
central venous system –> Superior vena cava
- Stay in place for 1 year
Central Access Devices
- Short Tern Non Tunneled
Multiple access needs for acute care
- Triple or Double lumen placed
- Jugular, Subclavian, Femoral vessel
- 4-6 weeks only
- High complication risk
Central Access Devices
- Long Term Tunneled
Broviac
- Can be single or millilumen
- Decreased risk of catheter infection
- Easier to care and repair
- Low risk of dislodgement
- Long term / recurring therapy (chemo)
Central Access Devices
- Implanted Catheter
- Attaches to a disk with a self sealing port
- Minimal changes to body image
- Does not require routine site care when not in use
- For infrequent but chronic IV therapy
Peripheral PN
Used more as a bridge
- Does not provide large amount of calories
- Macronutrients can not be adjusted
- Not used in fluid restricted
- Patient must have good peripheral access
- High risk of line thrombosis
Premixed PN
- What is it made up of
Made up of:
- Dextrose
- Amino acids
- Lipids
- Low in sodium potassium, magnesium
Premixed PN
- Pros/Cons
- Cost effective
- Improved patient safety
- Not appropriate for all patients (would not use in patient with low sodium)
Compounded PN
- What is it made up of
Made up of:
- Dextrose
- Amino Acids
- Electrolytes
- Vitamins
- Minerals
- With or without lipids (Ordered and mixed in separatley)
PN Composition
- Carbohydrate
2.5% - 70%
- High dextrose concentration for central PN
- Acidic solution
Provides 3.4 cals/gram
PN Composition
- Protein
Has a buffer (acetate) to counteract any
acids or bases
Also has a balance of essential, semi-essential, and non-essential amino acids
Provides 4 cals/gram
PN Composition
- Lipids
Non-carbohydrate energy source
- Provides essential fatty acids
- Egg yolk phospholipid as emulsifier
- Glycerin to provide isotonicity
Contains small amounts of Vitamin E and K
PN Composition
- Multivitamins
Vitamin K is added separately if indicated due to possible contraindications
PN considerations when adding medications
- Expected therapeutic action of medication
- Physiochemical compatibility and stability within PN mixture
- No other reasonable route of administration
Schedule 1 Medication Additions to PN
H2 Receptor Antagonists
Vitamin K
Regular Insulin
Be careful with adding drugs in PN
- If PN is stopped in then the patient would lose access to medication in PN
Schedule 1 Medication Additions to PN
- H2 Receptor Antagonist
For Stress Ulcer Prophylaxis
Schedule 1 Medication Additions to PN
- Vitamin K
- Contraindicated in history of DVT and warfarin
- Lipids have inherent vitamin K
- Allows easier Blood Glucose management
- Not to be sole glucose control, just meant to counteract dextrose in PN
PN
- Propofol
Usually hold lipids if giving propofol (especially in larger patients)
- Propofol = fat calories
PN
- Expiry Date
Once hung expiry is 24 hours
Lipids have a hang time of 12 hours
Compounded PN is shorter than premixed with no additional additives
Continuous PN
PN infused over 24 hours (lipids are run over 12 hours)
- If its a combination bag that contains lipids within it is good to run for 24 hours
Cycled PN
Must be hemodynamically stable
Must have well managed blood sugars
Must be able to handle higher fluid volume
Improved liver clearance
Helps patient to move around more
PN Complications
Mechnical
Metabolic
Infectious
Can reduce complications with proper care technique and close monitoring of physiologic and metabolic parameters
Mechanical Complications
- Placement related events
- Thrombosis
- Thrombophlebitis
Metabolic Complications
Electrolyte imbalance
Fluid imbalance
Hyper/hypoglycemia
Cholestatic liver disease
Metabolic bone disease
Lipid and dextrose are good home for microorganisms
