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Clinical Nutrition 2 > Parenteral Nutrition > Flashcards

Parenteral Nutrition Flashcards

1
Q

Synonyms for TPN?

A

Central Venous Nutrition

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2
Q

Indications for pN

A
  • Patient has failed EN with appropriate tube placement
  • Severe acute pancreatitis
  • Inaccessible Gi tract
  • Short Bowel Syndrome (<200 cm)
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3
Q

When may the GI tract become inaccessible?

A
  • Paralytic ileus
  • Mesenteric Ischemia
  • Small bowel obstruction
  • GI fistulas
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4
Q

When can paralytic ileus occur?

A
  • If EN is not provided when needed within the first 24 hours, causing tissue burns
  • This means no peristalsis, can cause distension and potential ischemia
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5
Q

When may EN be OK in GI fistula?

A

-When we can place to TF distal to the fistula

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6
Q

When may Short bowel syndrome manifest?

A
  • After multiple Gi surgeries, and may have to be on TPN

- Cannot absorb all the nutrients they need on only 200 cm

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7
Q

What are the indications for TPN?

A

-The contraindications for EN

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8
Q

What happens when we have high out-put EN drains?

A
  • There is a build-up of fluids in the Gi tract which is not desirable
  • PN may be indicated
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9
Q

What are the two types of PN?

A
  • Central Parenteral Nutrition

- Peripheral Parenteral Nutrition

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10
Q

When is peripheral venous access used?

A
  • Short term (72-96 hours)
  • Small tube, has less capacity to deliver large volumes of nutrition
  • Not indicated for severely malnourished
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11
Q

What is a PICC line?

A
  • Peripherally Inserted Central Catheter
  • Will end at the same place as a central venous catheter
  • No surgery required, and can be inserted at the bed-side
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12
Q

(T/F) We can only infuse central solutions into a PICC

A

False, can also support peripheral solutions

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13
Q

What is a CVC?

A
  • Central Venous Catheter, terminating in the superior vena cava
  • Long term
  • Requires surgical insertion
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14
Q

PPN osmolality restriction?

A

600-900 mOsm/L

  • Small veins cannot dilute hypertonic solution the same as larger veins
  • Risk of tissue burns and phlebitis
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15
Q

PPN dextrose concentration restriction?

A

150-300 g/day or 5-10% final concentration by weight

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16
Q

PPN AA concentration restriction?

A

-50-100 g/day or 3% final concentration by weight

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17
Q

PPN fluid requirement?

A

2.5-3L of fluid, as the PPN solution must be diluted to avoid tissue burns

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18
Q

When is PPNundesirable?

A

In patients with fluid restriction

  • Renal, heart failure, head trauma
  • PICC line may be indicated in these patients
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19
Q

Contraindications to PPN?

A
  • Significant malnutrition
  • Severe metabolic stress
  • Large nutrient or electrolyte needs
  • Fluid restriction
  • Prolonged PN (>2wks(
  • Renal or liver dysfunction
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20
Q

What is a strong vascular irritant? Why may this be an issue for someone with high electrolyte needs?

A
  • K+

- May be too irritating to deliver peripherally

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21
Q

(T/F) Reducing K+ should not preclude treatment to help prevent/manage re-feeding syndrome even though it is a vascular irritant

A

T

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22
Q

List complications of PPN

A
  • Phlebitis
  • Venous thrombosis
  • Thrombophlebitis
  • Extravasation and chemical burns
  • Occlusion
  • Pain
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23
Q

What does ASPEN recommend concerning removing and replacing PPN lines?

A

-Remove and replace no more than every 72-96 hours unless clinically indicated

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24
Q

Wherever possible, we should ____

A

use CPN

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25
Q

When is CPN indicated?

A

For long-term access - > 7 days to years

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26
Q

What is a key factor concerning CPN?

A

It is hyperosmolar (1300-1800) and therefore needs to be diluted in the veins of high pressure to avoid tissue burns

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27
Q

Glucose content in CPN?

A

150-600 g

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28
Q

Can CPN be used in the fluid restricted patient?

A

Yes

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29
Q

Which vein is catheterized in CPN?

A
  • Subclavian or jugular vein, for termination in the superior vena cava
  • 2-3 cm in diameter, 7 cm flow and 2L/min flow rate
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30
Q

Which medications may be used to reduce complications in PN?

A

-Hydrocortisone and heparin

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31
Q

How will heparin help?

A
  • Reduce phlebitis

- Will stimulate LPL which will help clear fat from vein, preserve the longevity of the catheter and prevent clotting

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32
Q

How will hydrocortisone help?

A

-Decrease irritation to the vein, alleviating phlebitis

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33
Q

What is a disadvantage of the high flow rate of CPN?

A
  • Anything diffused into the body through CPN will reach the body quickly
  • i.e. if there is a bacterial infection, it will be quickly dispersed into the body
  • Less of a risk is posed peripherally
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34
Q

What are possible complications to PN?

A
  • Sepsis
  • Embolism
  • Pneumothorax
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35
Q

What is a pneumothorax?

A
  • A collapsed lung
  • Occurs when air leaks into the space between the ling and chest wall
  • We could accidentally feed into the pleural space, causing an infection and a pleural effusion
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36
Q

Your patient presents to the ER with intractable vomiting and is not responding to anti-nausea meds. How do you feed this patient?

A

-PN, likely PPN if short term

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37
Q

What is the most common form of long-term parenteral access?

A

CVC

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38
Q

What is the compostions of PN formulations?

A
  • CHO (dextrose)
  • IFE
  • Proteins (Crystalline AA)
  • Additives (Vitamins, Minerals and Trace elements)
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39
Q

What is IFE?

A

Lipid emulsified in injectable water with egg phospholipid

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40
Q

Consideration about infusion of CHO in PN?

A

Carbohydrates are hydrophilic, and will attract water

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41
Q

Energy density of dextrose CHO?

A

3.4 kcal/g

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42
Q

Which stock concentrations are CHO solutions available in?

A

2.5-70%

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43
Q

Acidity of CHO solutions?

A

pH of 3.5-6.5

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44
Q

What % of dextrose will be administered the centra vein? Why not peripherally?

A
  • Solutions >10%

- Risk of thrombophlebitis, as there is a large amount of osmolality

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45
Q

Maximum tolerance for clearance CHO solution?

A
  • Less than 4-5 mg/kg/min
  • Healthy people can typically tolerate 15 g/kg/day
  • Use 3 mg/kg/min **
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46
Q

What is often included in the IVFE formulation?

A
  • Egg yolk, phospholipids, vitamin K and sodium hydroxide

- 100% soybean oils, or 50:50 soybean and safflower oils

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47
Q

10% IVFE?

A
  • 1.1 kcal/ml or 11 kcal/g
  • 10 g of lipid in 100 ml of solution
  • Vessel used to deliver the propofol sedative/anaesthetic
  • Caution on overfeeding
48
Q

20% IVFE?

A
  • 2 kcal/ml or 10 kcal.g
  • 20 g of lipid in 100 ml of solution
  • Most commonly used
49
Q

What is found in the Intralipid IVFE solution?

A
  • 20% soybean oil
  • 1.2% Egg Yolk Phospholipid
  • 2.25% Glycerine
  • Water for Injective
  • NaOH added to adjust the final pH
  • pH range from 6-8.9
50
Q

What is found in the SMOFlipid IVFE solution?

A
  • 30% Soybean oil
  • 30% MCT oil
  • 25% Olive Oil
  • 15% Fish Oil
51
Q

When may the pH of 6 of intralipid be sub-opitmal?

A

When mixing into the admixture (dextrose and AA), which may cause destabilization of the other macronutrients

52
Q

What is the rationale behind the compostion of the SMOFlipid?

A
  • Fish oil which contains anti-inflammatory omega-3 fatty acids, providing EPA and DHA
  • Soybean (omega-6) and olive oil (omega-9) to prevent EFAD and MUFA
  • MCT oil which will provide a readily available source of Energy
53
Q

_____ is how propofol is delivered in the ICU, in a ____ solution

A

Intralipid

10%

54
Q

What is propofol?

A

A lipid-based intravenous anesthetic sedative energy, where the lipid content is the same as the 10% fat emulsion

55
Q

How many kcal/ml of propofol?

A

1.1 kcal/ml

56
Q

Potential adverse effects if we overfeed and forget to calculate energy/fat from propofol??

A
  • Decreased lipid clearance
  • Hyper TG
  • Overfeeding
57
Q

What is the max IVFE infusion rate?

A

2.5 g/kg/day

58
Q

To prevent EFAD, what may be the lowest IVFE infusion rate?

A

0.4-1.0 g/kg/day

59
Q

Max IVFE infusion rate for the critically-ill or immuno-compromised?

A

1.- g/kg/day

60
Q

What does ASPEN suggest concerning EFAD deficiency between weeks 1-3 if there is no source in the PN?

A

-Deliver 250 ml of 20% or 500 ml of 10% soy-based IVFE over 8-10h twice/week to prevent deficiency

61
Q

When may we need to increase biweekly deliveries of IVFE to avoid EFAD?

A
  • If we are using SMOFlipid

- As there is less omega-3 and 6 fatty acids

62
Q

What is the minimum frequency of providing the lipid emulsion?

A

twice a week

63
Q

What is the recommended hand time for a prepared solution?TNA?

A
  • 12 hour, as the open container has mixed-in the sterile contents
  • 24 hour for TNA, as we can shake the bag, break the membrane right away
64
Q

What is the clinical presentation of EFA deficiency?

A
  • Xerosos (Eryhtema Craquele: Steatosisi)

- Can also be caused by deficiencies of retinol/RBP and zinc

65
Q

What is the AA PN solution composed of? Energy content? % concentrations?

A
  • Mixture of essential and non-essential amino acids
  • 4 kcal/g
  • 8.5%, 10% and 15%
66
Q

What % AA solutions available for PPN?

A

3.5-5.5%

67
Q

What % AA solutions available for CPN?

A

8.5-20%

68
Q

What is the common AA solution at the MUHC?

A
  • Travasol
  • 10% stock solution
  • No electrolytes
69
Q

What is Aminosyn?

A

-AA solution, available at 8.5 and 10% stock solutions

70
Q

Calcium intake in PN?

A

10-15 mmol

71
Q

Magnesium intake in PN?

A

8-20 mmol

72
Q

Phosphate intake in PN?

A

20-40 mmol/kg

73
Q

Sodium intake in PN?

A

1-2 mmol/kg

74
Q

Chloride intake in PN?

A

Enough to maintain acid-base balance

75
Q

Bicarbonate intake in PN?

A

To maintain acid base balance

76
Q

When we see 12 h and 24 h infusion rates, what can we infer?

A
  • That the admixture and the IVFE is administered separately

- “Piggy-back” method through a Y tube

77
Q

(T/F) Only TNA (or 3-in-1) can be used in central parenteral nutriton

A

F

Can be administered both in CPN and PPN

78
Q

Pros of 2-in-1 mixture?

A
  • More stable solution
  • Less risk of bacterial contamination
  • Longer hang times
79
Q

Cons of 2-in-1 mixture?

A
  • Faster infusion ate of IVFE can lead to hypertriglyceridemia
  • More nursing time is needed
  • Additional IV tubing for lipids is needed
80
Q

What is TNA?

A

The combination fo dextrose, amino acids, and IVFE with electrolytes, vitamins, minerals, trace elements and sterile water for injection in 1 IV bag

81
Q

Pros of TNA?

A
  • Decreased cost
  • Decreased nursing time
  • Less manipulation, thus less infections
  • Fat clears better when administered >12 hour s
82
Q

Cons of TNA?

A
  • Requires larger pore-size filter (1.2 microns) –> IVFE instability risk
  • Higher incidence of medication incompatibility with IVFE
83
Q

Osmolality of CHO?

A

5 x g of CHO

84
Q

Osmolality of protein?

A

10 x g of protein

85
Q

Osmolality of electrolytes, vitamins and minerals?

A

300-300 mOsm/L

86
Q

Osmolality of fat?

A

IV fat is isotonic at 300 mOsm/L

87
Q

Short-term PN complication?

A
  • HyperG
  • Refeeding syndrome
  • Azotemia
88
Q

Long-term PN complications?

A
  • Vascular access sepsis
  • HyperTG
  • Hepatobiliary complications
  • Metabolic bone disease
89
Q

Can short and long-term complications occur at any time?

A

Yes

90
Q

What may cause hyperTG?

A

Dextrose overfeeding or rapid IVFE infusion

91
Q

Hepatobiliary complications which may arise in PN?

A
  • Steatosis
  • Cholestasis
  • Gallstones
92
Q

What is the most common PN-associated complication?

A
  • Hyperglycemia

- Due to stress in critically ill and CHO overfeeding

93
Q

How should dextrose be initiated for the first 24-hours?

A

150-200 g/day

94
Q

How should dextrose be initiated if patient has a low BMI, diabetes or risk of RF syndrome?

A

100 g/day

95
Q

What is the Max CHO rate?

A
  • 4-5 mg/kg/min or 20-25 kcal/kg/day

- Use 3 mg/g/day in critically-ill

96
Q

How often should we monitor blood glucose? What is the goal?

A
  • Every 6-8 h upon initiation

- 8.3-10 mmol/L

97
Q

Why is the glucose target range more liberal?

A

Recall that with PN, we are in a fed state … which means we will not see “normal” BG until feeds are stopped or we are administering insulon
-Also due to the metabolically stressed state

98
Q

What must be controlled prior to advancing feeds?

A
  • All complications

- Most commonly hyperglycemia

99
Q

Insulin therapy?

A

0.5-0.1 units per g dectrose

100
Q

Insulin therapy if already hyperglycemia/

A

0.15-0.3 unites per g dextrose

101
Q

What rapid infusion rate could trigger hyperTG?

A

> 0.11 g/kg/hour

–> Recall our max infusion rate of 1 g/kg/day

102
Q

What may hyperTG cause?

A
  • Pulmonary complications

- Increase risk of pancreatitis if TG >11.30 mmol/L

103
Q

Goal TG? Why is it liberalized?

A

<4.52 mmol/L

  • As we are in fed state most often
  • This will differ if we are feeding TNA or 2-in-1
104
Q

How may HyperTG be managed?

A
  • Reducing dose, or increasing infusion time

- Use <30% pf E or 1g/kg/day

105
Q

What is azotemia?

A

Elevation of BUN and creatinine levels

106
Q

What may azotemia result from?

A
  • Excessive protein administration
  • Dehydration
  • Inadequate non-protein energy
  • Impaired ability to clear urea (patients with hepatic and renal disease)
107
Q

When may patients benefit from reducing AA and the use of hepatic-disease formulations (BCAAs)?

A
  • Those with Azotemia

- Not common in ICU

108
Q

What needs to be monitored in PN?

A 
-Fluid intake
and output
-Weight
-Body temperature
-Glucose tolerance
-Electrolytes
-Hepatic function (LFT's)
109
Q

How can fluid outputs and inputs be monitored?

A
  • IV fluids from all sources, oral intake, flushes

- Urine, fecal losses, drainage, nausea and vomiting

110
Q

How often should weight be monitored?

A

Twice a week

111
Q

How often should body temp be monitored? When should MD be notified? Nutrition implications?

A
  • q8h
  • When temp >38.5
  • Increased fluid and energy needs, less clearance of TGs and CHOs
112
Q

How often should BG be monitored?

A

-q6h, more if hyperG

113
Q

How often should electrolytes be monitored?

A
  • 1x/day

- If stable, progress to once every 1-2 wks

114
Q

How can we monitor protein status in PN?

A
  • Visceral proteins (albumin, pre-albumin, transferrin)
  • CRO
  • Nitrogen balance (+/-2)
115
Q

When is nitrogen balance unreliable?

A
  • Kidney (dialysate)and hepatic disease

- Excessive trauma, burns, oozing wounds

Clinical Nutrition 2 (21 decks)

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