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850 > Parenteral Nutrition > Flashcards

Parenteral Nutrition Flashcards

1
Q

Central PN (TPN) Advantages/Disadvantages

A

Advantages
-Provides optimal nutrition (macro and micronutrients)

Disadvantages

  • Must be administered through central line due to high osmolarity
  • Increased risks with central lines
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2
Q

Peripheral PN (PPN) Advantages/Disadvantages

A

Advantages

  • Can be run in a peripheral line
  • Avoids need for central line if no other IV lines needed

Disadvantages

  • Typically not able to provide optimal PN due to limitations with osmolarity
  • Max: 900 mOsm/L osmolarity
  • Not for long term use
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3
Q

Indications for PN

A
  • Paralytic ileus
  • Mesenteric ischemia
  • Small bowel obstruction
  • Severe necrotizing pancreatitis
  • Radiation or chemo-related enteritis
  • Failure of enteral feeding trial through feeding tube placed distally to GI fistula with high input (>500 mL/day)
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4
Q

CI for PN

A
  • Patients with functioning GI tract who can eat and meet their nutritional needs via EN
  • Duration of PN < 5 days
  • Advanced directives that do not warrant aggressive nutrition support
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5
Q

Delivery of PN

A

Continuous

  • Nutritional components delivered over 24 hours
  • Generally better tolerated in critically ill patients

Cyclic

  • Administer nutrition over less than 24 hours
  • Commonly used in patients on long term PN

Specialized delivery methods
-Intradialytic PN: not ideal route and very rare currently

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6
Q

PN Components

A

Macronutrients

  • Protein source: amino acids
  • Non-protein calories: carbs (dextrose), fat (IV lipid emulsion)

Micronutrients

  • Electrolytes
  • Vitamins
  • Trace Elements

Additives

  • Additional vitamins
  • Medications
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7
Q

Amino Acids

A
  • Caloric value: 4kcl/g
  • Crystalline amino acid solution
  • Provide essential, semi-essential, and non-essential amino acids
  • Administration usually combined and administered with dextrose and other TPN components
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8
Q

Amino Acid Solutions

A
  • Multiple products available with range of concentrations: 3-15%
  • Contain between 44-50% AA as essential
  • Exact AA compositions and buffers to balance pH vary between products
  • EX: Clinisol, Aminosyn, Travasol
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9
Q

Specialty Amino Acid Solutions

A

-Modified AA to meet disease/age requirements

Neonates/Infants

  • Add taurine, decreased methionine
  • EX: TrophAmine, Premasol

Hepatic

  • Increased branched chain, decreased aromatic AA, and methionine
  • EX: HepatAmine
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10
Q

AA AE

A
  • Azotemia (high nitrogen in blood)
  • Phlebitis/thrombosis (vesicant)
  • Fluid/electrolyte disturbances
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11
Q

Dextrose

A
  • Carb Source
  • Caloric value: 3.4 kcal/g
  • Main source of energy
  • Available in 5-70% concentrations
  • D70 only used to compound PNs
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12
Q

Dextrose Disadvantages

A
  • Increased osmolarity of concentrated solutions
  • Uptake into cells is insulin dependent
  • Limited ability to oxidize glucose for energy (max oxidation rate: 5-7 mg/kg/min)
  • Excess glucose converted to fat => lipogenesis
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13
Q

Dextrose AE

A
  • Hyperglycemia
  • Electrolyte disturbances
  • Vein irritation: 12.5% max in peds/neonates, <10% in adults
  • Increase CO2 production
  • Fatty liver
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14
Q

IV Lipid emulsions

A
  • Fat source, IVLEs
  • Caloric value 9kcal/g
  • Account for glycerin in calculation of calories (1.1 kcal/mL: 10%, 2.0 kcal/mL:20%, 3.0 kcal/mL: 30%)
  • Lipids can be administered piggybacking TPN/PPN or mixing with other PN componenets
  • Emulsifier: egg yolk phospholipids: 15 mMol Phos/L, amekes emulsions “milky”
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15
Q

IVLE Advantages

A
  • Concentrated source of calories
  • Reduces requirement for dextrose
  • Provides essential fatty acids (EFAs) and long-chain polyunsaturated fatty acids (LC-PUFAs, linoleic acid)
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16
Q

IVLE Disadvantages

A
  • Cannot meet body’s requirements of glucose, max: 60% (preferred ~30%)
  • Compatibility issues
  • Oxidative stress: PUFAs => lipid peroxidation
  • Inflammation: pro-inflammatory eiconsanoids soybean oil
  • Immune system dysfxn/increased risk of infections
  • Hepatobiliary complications: worsened liver dysfxn and PN-associated liver disease
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17
Q

IVLE Dosing/Administration

A
  • Adult: up to 1 g/kg/day
  • May be less in the critically ill
  • Administer: run over 12 hours only
  • May be “liver protective”
  • Potential concern for bacterial growth in bag if ran >12 hours
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18
Q

Soy Lipid Emulsions

A
  • Intralipid (20% and 30%) and Nutrilipid (20%)
  • 30% only for compounding admixtures
  • Clinolipid: 4:1 ratio olive oil:soybean oil
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19
Q

SMOFLipid 20% Emulsion

A
  • Alternative IVLE to soybean-based
  • SMOF stands for fatty acids it contains
  • Advantages unclear: some show lower TGAs/LFT elevations, may decrease inflammation/infection, not shown to be better than soybased in morbidity/mortality or overall superiority
20
Q

SMOF

A 
S = Soybean oil
M = Medium chain Triglycerides (rapidly cleared energy)
O = olive oil (omega-9 source)
F = Fish oil (EPA/DHA source)
21
Q

Omegaven 10% Emulsion

A
  • Approved for treating pediatric patients with PN-associated cholestasis/liver disease
  • 10% emulsion only, 1.1 kcal/mL
  • Dose: 1 g/kg/day over 12 hours
  • Concern for developing EFAD (essential fatty acid deficiency)

UNMH Indications:
Pediatric/Neonate already on SMOF AND
-Direct bilirubin >5 OR
-Direct bilirubi >2.5 AND no surgical procedures/septic events in 1 month
Switch back to SMOF once direct bili <2

22
Q

Calculating Macros/Fluids

A

Start from Scratch

  1. Determine total fluid volume/rate (goal 30-40 mL/kg/day, minimal to fit macros for critically ill)
  2. Determine total energy/caloric requirement
  3. Determine protein requirement
  4. Determine non-protein requirement (split 70% dextrose and 30% lipids)
    * *Typical dietician way**

Given Macros/Fluid

  1. Total fluid volume/rate/macros in g/g%/mL provided
  2. Can determine caloric content across the macros
    * *Pharmacists situation**
23
Q

Electrolytes

A

Approximate Daily Requirements assuming Normal Baselines

  • Sodium: 1-2 mEq/kg/day
  • Potassium: 1-2 mEq/kg/day
  • Magnesium: 8-20 mEq/day
  • Calcium: 10-15 mEq/day
  • Phosphorous: 20-40 mMol/day
  • Chloride/Acetate PRN to maintain acid/base balance
24
Q

Reasons to Increase Electrolytes

A
  • Na/K: diarrhea, vomitting, NG suction, DI losses
  • K only: meds, refeeding
  • Calcium: high protein intake
  • Magnesium: GI losses, meds, low K+, refeeding
  • Phosphate: high dextrose intake, refeeding
  • Chloride: metabolic alkalosis, volume depletion
  • Acetate: renal insufficiency, metabolic acidosis, GI losses of bicarbonate
25
Q

Vitamins

A
  • Needed for appropriate nutrition
  • Fat Soluble: A, D, E, K
  • Water Soluble multiple B vitamins and C
  • Commercial combo multivitamin product: 13 vitamins total, 10 mL dose to adults
  • Additional vitamins can be added to PN based on patient’s condition/deficiency: Vitamin C, thiamine, folic acid, Vitamin K
26
Q

Trace Elements

A
  • Combo product in US: Tralement
  • 3 mg Zinc, 0.3 mg Copper, 55 mcg Magnesium, 60 mcg selenium per 1 mL
  • Add additional 2mg on zinc at UNMH
27
Q

Other Potential Additives

A
  • H2 receptor antagonist (famotidine)
  • Insulin
  • Neonatal PNs only: heparin, iron dextran
28
Q

GI Conditions + PN

A
  • Some conditions impair nutrient absorption like short bowel syndrome, chronic diarrhea (Tufting enteropathy, Microvillus inclusion disease), and chronic pancreatitis
  • May require different electrolyte and vitamin needs depending on condition
  • Short bowel requires more magnesium and zinc
29
Q

Pediatric Patients + PN

A
  • Improve growth and development rather than meeting baseline needs
  • More aggressive macros, more Ca/Phos to promote bone growth
  • Higher dextrose and AA per kg than adults (protein in neonates is up to 4 g/kg/day)
  • May require different electrolytes amounts
30
Q

PN Component Incompatibilities

A

Calcium + Phosphate

  • Dependent on [AA} and pH
  • Use calcium gluconate, NOT chloride
  • Separate order of mixing (add phos before calcium)

Bicarbonate

  • Forms insoluble carbonates with Ca, Mg, and release CO2 gas
  • Use acetate salts instead (Na or K acetate)
31
Q

Drug + PN Interactions

A
  • Ceftriaxone: incompatible with calcium, don’t give while PN running in same IV line
  • Safest option is to have a dedicated PN and/or IVLE IC line
32
Q

Non-Soybean Compatibility Issues

A
  • SMOF incompatible with hydrocortisone and dopamine
  • Long list of SMOF compatible
  • Omegaven: compatible with PN only
  • Treat unknowns as incompatible
33
Q

Serious PN Complications

A

Metabolic

  • Hyper/hypoglycemia from abruptly stopping PN, starting with too high dextrose when patient hasn’t been eating or NPO, ramping the rates up/down
  • Refeeding syndrome: K, Phos, Mg

Hepatotoxicity

  • Intestinal failure-associated liver disease (IFALD)
  • Steatosis and cholestasis
  • More common in long term PN, especially short bowel patients
34
Q

Refeeding Syndrome

A
  • Potential severe shifts in fluids and electrolytes in malnourished patients receiving EN/PN
  • Help prevent by slowly initiating/advancing PN
  • Signs/symptoms: Hypophosphatemia**, hypokalemia, hypomagnesemia
  • Also changes in glucose, protein, and fat metabolism
  • Monitor: glucose, K, Mg, and Phos (replete electrolytes as needed)
35
Q

IFALD

A

-Direct bili > 2 for 2 consecutive weeks without other cause

Risk Factors

  • PN > 2 weeks
  • Low gestational age and birth weight in neonates
  • Short bowel syndrome
  • Recurrent episodes of sepsis
  • Excessive caloric intake
  • Intralipid use (soybean based)
  • Inability to tolerate EN or lack of EN
36
Q

Additional TPN Complications

A
  • HyperTGA: related to lipids, decrease rate or hold
  • Acid/base disorders and electrolyte disturbances: monitor and adjust as needed
  • Central line infection: important to keep clean
  • Thrombosis: increased risk with central line and if patient is < 1 y.o.
37
Q

EFAD

A
  • Essential Fatty Acid Deficiency
  • Dry thick, desquamating skin, alopecia, decreased wound healing, hepatic dysfxn, growth retardation
  • Prevent be giving adults minimum of 100g of IVLE per week (250 mL 20% IVLE 2x/week)
  • Triene:Tetraene ratio to evaluate for EFAD (>0.2 consider EFAD)
38
Q

Starting/Stopping PN

A
  • Increase dextrose and lipid amounts over several days and assess tolerance (glucose < 180, TGA < 250)
  • Do not abruptly D/C: could lead to hypoglycemia and other electrolyte shifts
39
Q

Cycling PN

A
  • Provide same PN content over a shorter duration
  • Common in long-term of home TPNs
  • Typically goal to run over 12-14 hours (initiate on continuous to transition to goal cycle rate)
  • Titrate up/down over first and last hours to prevent hypo/hyperglycemia
40
Q

PN Administration Pearls

A
  • When D/C continuous TPNs, run 1/2 of prior rate for 2 hours before stopping
  • Do not administer other drugs through PN IV line if possible (check compatibilities if necessary)
  • Max hang PN for 24 hours and lipids for 12
  • Filter PN with 0.2 micron filter, lipids with 1.2 micron filter
41
Q

Monitoring PN Initially

A
  • Daily weights and “ins and outs”
  • Capillary glucose every 4-6 hours (can space out more when/if stable)
  • electrolytes at baseline then daily of QoD (2x per week once past 1-2 weeks of PNs)
  • LFTs and TGAs at baseline, then after 1-2 days of TPNs, then weekly
42
Q

2-in-1 Products

A
  • Dextrose and AA in same PN bag
  • EX: Clinimix bags, Clinimix E has electrolytes
43
Q

3-in-1 Products

A

-Dextrose, AA, and lipids all in same bag

Ex: Kabiven

44
Q

Combination Product Requirements/Limitations

A

-Require activation to mix the components together before infusing

  • Limitations
  • Macro/micro contents must be appropriate for patient to use
  • Not appropriate for patients with abnormal electrolytes or large/small macro needs
45
Q

Outpatient PNs

A
  • More common to go home on PN with home infusion companies
  • Can do 3 or 2-in-1,, 3 is easier but many require custom formulations and use 2-in-1
  • Cyclic PN over short duration is easier at home and often run overnight
46
Q

Pharmacist/Dietician Roles in Hospital

A

Pharmacist

  • Work with dietician to manage PN
  • Understand malnutrition implications
  • Monitor fluid and electrolyte status
  • Manage PN ingredient shortages

Dietician (RD)

  • Complete nutrition assessments
  • Aid in diagnosis of malnutrition’
  • Manage EN
  • Work with PharmDs to manage PN

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