Parenteral Nutrition Flashcards
When solely on PN how fast can essential fatty acid deficiency occur
2-4 weeks without linoleic or alpha linolenic acid
Symptoms of essential fatty acid deficiency
Dry scaly rash, impaired wound healing, increased infection risk, immune dysfunction, alopecia
The Holman Index
Triene to Tetraene ratio to test for essential fatty acid deficiency
EFAD can develop faster in lipid free PN secondary to
Insulin levels in PN are increased as there is typically a high dextrose dose which prevents lipolysis of adipose tissue which would be the fail safe for releasing EFAs that would be stored
TPN in the critical care unit should initially be
hypocaloric and lipid free
Should PN be started in the acute phase of severe sepsis with elevated triglycerides
No
Alpha Linolenic Acid is the precursor for
DHA and EPA (omega 3 fatty acids)
Contents of the Injectable Lipid Emulsion (ILE)
An oil in water emulsion, 1 triglyceride, glycerol and phospholipid emulsifier, vitamin E, K phytosterols and cholesterols
Which vitamins are in ILE’s
vitamin E and K
Long chain fatty acids require ____ to be oxidized for energy
L-Carnitine
What are needed to prevent essential fatty acid deficiency?
alpha linolenic acid and linoleic acid (Omega 3’s)
What percentage of calories is needed of alpha linolenic acid to prevent EFAD
0.25-0.5% omega 3 (alpha linolenic acid)
What percentage of calories is needed of linoleic acid to prevent EFAD?
1-4% omega 6 (linoleic acid)
In which type of oils are the highest concentration of linoleic acid found
Soybean and Corn Oil (Omega 6)
In which type of oils are the highest concentration of alpha linolenic acids found in?
Soybean and Canola Oil (Omega 3)
How much ILE is needed weekly to prevent EFAD
500mL/week
Maximum PN ILE infusion daily
2.5 g/kg/day
If a patient is critically ill, don’t exceed ____ amount of lipids IV a day
1g/kg/day
When using 100% soybean oil IV, hold lipids x _____ unless there is a concern for EFAD, then give _____
For 1 week, OR
100grams/week
Give IVFE at no more than _____ rate to avoid toxicity of rapid infusion (fat overload syndrome)
0.11 g/kg/hr
Why does PPF (10% ILE) lead to hypertriglyceridemia
10% ILE’s contain lipoprotein X which competes with triglycerides for lipoprotein lipase which is responsible for the breakdown of TCG’s, therefore they build up and cause hypertriglyceridemia
What should happen if serum triglycerides exceed 400mg/dL
- Decrease fat emulsion or hold
- Monitor serum TCGs 2x/week
- Remove lipids if also on PPF
- Try to start a patient on trophic enteral feeding
Omega 9 fatty acids
Olive Oil/Oleic acid used to lower cholesterol and triglycerides without lipid peroxidation often used in EN formulas
What is the suspected role of omega 3 fatty acids in parenteral nutrition
it contains fish oil which may cause LESS inflammation. Limited evidence is available at this time to be recommended.
Should omega 3 fatty acid ILEs be used in PN per ASPEN?
Limited Evidence by ASPEN
How can plant based ILEs lead to the development of liver dysfunction related to PN
phytoserols in plant based ILE’s are structurally similar to cholesterol which interferes with bile synthesis, transport of bile, increased lipid peroxidation causing free radical damage to the liver
typical IV dose of calcium
10-15 mEq/day (calcium gluconate) (also add magnesium)
typical IV dose of magnesium
5-8 mEq/L, or 80-20 mEq/day (magnesium sulfate)
how often should patients get MVI in PN
every day unless toxicity is suspected
what is added to PN that have demonstrated therapeutic effects in bone marrow transplants
glutamine supplementation
normal calcium requirements for PN with normal renal function
15mEq/day
what is the suggested adult PN thiamine daily dose
3 mg
when is PN recommended for burn patients
when EN is contraindicated or unlikely to meet nutritional needs (shouldn’t be the first route)
TPN terminates in the ____________ which can tolerate high osmolarity
superior vena cava
a central line should be placed if TPN is suspected for ___to ____ days in the hospital setting
7-14 days
PPN is indicated for _____ term use. Less than ______
short term use, <2 weeks
PPN is generally not recommended for malnutrition because
it cannot provide enough calories
what are 2 parameters for being a candidate for PPN
- good peripheral venous access
2. ability to tolerate large volumes o fluid 2.5-3 L
PPN should only be considered when PO or EN is not possible to meet a person’s nutrition needs for > than _____ days
5 days
You would consider PPN vs TPN when only indicated for use between ____ and ____ days
5-12
significant malnutrition, severe metabolic disturbance, marked nutrient needs, fluid restriction, and renal/liver compromise, and need for <2 weeks are contraindications to this type of PN
PPN
Thrombophlebitis can be caused by
high PN osmolarity or potassium
the term for providing up to 80% of energy needs until a patient’s condition improves, usually in the ICU
permissive underfeeding
the term for providing EN/PN of 60-75% of energy needs and high protein needs for the obese with BMI >30
hypocaloric feeding
this type of PN minimizes the energy deficit that accumulates during periods of no nutrition or undernutrition when EN is insufficient to meeting energy needs
supplemental PPN
indications for starting PN
- unable to meet nutrition requirements from EN
- when a patient cannot ingest or absorb oral or EN tube feedings
- paralytic ileus
- bowel obstruction
- GI fistula except when EN access can be placed posterior to the fistula,
- unable to use the gut for 7-10 days
- when EN access is contraindicated/failed attempts
when should PN be held off from starting
- azotemia
- severe hyperglycemia
- severe fluid/electrolyte imbalances
in the critically ill PN should not be considered until after ____ days when the patient has normal nutrition or no risk of malnutrition
7 days
when deciding to start PN be careful when blood sugar is over
300 mg/dL
when deciding to start PN, be careful when the patient is azotemic which means BUN is > than
100 mg/dL
when deciding to start PN, be careful when the patient is hypernatremic with a sodium > than
150 mEq/L
when deciding to start PN, be careful when the patient is hyperchloremic with metabolic acidosis with a chloride > than or hypochloremic with metabolic alkalosis with chloride
115 mEq/L , 85 mEq/L
Is PN recommended over EN for pancreatitis
no
if PN is indicated in pancreatitis what is important to manage, what are the kcal needs
25-35 kcal/kg, glucose control, consider glutamine to help minimize effect of GI integrity
PN can be used in the pre-operative phase in _______ _______ and should be at least ____ to ____ days for maximum benfit
severe malnutrition, 7-10 days
who in critical illness are appropriate for starting PN
malnourished at baseline, not able to ingest/absorb significant nutrition in 7-10 days, have adequate resuscitation from any hemodynamic compromise with paralytic ileus acute GIB or complete bowel obstruction
is PN clinically indicated in cancer
no; chemo/radiation can cause infectious complications, no improvement clinically
ASPEN recommendation for when to start PN in cancer
only when malnourished AND unlikely to ingest/absorb adequate nutrition in 7-14 days
is PN preferred for hematopoietic cell transplant
No
successful PN depends on these factors.
- adequate ordering transcribing, compounding, dispensing and administration of PN and interdisciplinary care/nutrition support team
Errors of PN
- infection of IV catheter
- over/under feeding
- errors during Rx, transcription or prep
Most errors that occur from PN occur from
prescribing PN order
What can help decrease errors in PN
- create nutrition guidelines
- multi step double check process
- verify electronically transcribed order against actual written order
if a patient who is critically ill and previously well nourished ins PN recommended
no
in severely malnourished patients in the ICU when is PN indicated
when unable to use GI tract in 7 days
other indications to start PN (precluding the use of the GI tract)
- unable to meet estimated nutrition needs with EN alone or at high risk of malnutrition
- TPN when needed for > 2 weeks and PPN when needed <2 weeks
patients with significant hyperglycemia, azotemia, encephalopathy, or severe fluid/electrolyte abnormalities should not start _____ until resolved
PN
patients with theses issues may not tolerate large volumes with PN
CHF, renal failure, liver failure with ascites
when providing high fluid in PN what should be monitored
pulmonary edema, blood pressure, pulse
what should initially be monitored when PN reaches goal rate
fluid status, renal status, routine blood glucose monitoring, LFT/TCGs periodically, serum visceral proteins weekly, nitrogen balance/urine output with functioning kidneys
periodically monitor triglycerides levels if ____ given
lipids
goal of parenteral nutrition
maintain a patient’s nutrition status until some form of EN is tolerated
how can rebound hyperglycemia be prevented when stopping PN
taper down for 1-2 hours before stopping
if a patient is on TPN and EN does TPN need to be tapered before stopping
no
Dextrose in TPN contains _____ kcal/kg
3.4 kcal/kg
ranges of dextrose concentrations available for PN
2.5-70%
pH of dextrose solutions in pN
3.5-6.5
why are concentrations of dextrose for peripheral PN usually <8%
concentrations >10% can cause phlebitis in peripheral veins
Standardized Commercially Available PN (SCAPN)
PN that contains glycerol/glycerine as their sugar alcohol providing 4.3 kca/kg, created for peripheral administration which has less of an insulin response
Protein provided in PN solutions come from _______ amino acids
crystalline
16% nitrogen + ___ g amino acids and ____ g nitrogen
6.25 g amino acids, 1 gram nitrogen
standard amino acid solutions in PN contain ___- and ___ amino acid
essential and nonessential
concentrations of PN amino acids range from
3-20%
amino acid formulations used for special disease states are called
modified amino acids
amino acid formulations made for hepatic encephalopathy contain
increased BCAAs and decreased aromatic amino acids
altered protein metabolism in liver failure increases the transport of ______ amino acids which cross the blood brain barrier and create neurotransmitters that cause altered mental status _____ amino acids do not cross the blood brain barrier reducing this effect
aromatic amino acids (bad), branched chain amino acids (good)
amino acid formulations made for stress, trauma and thermal energy contain
BCAAs, increased leucine, isoleucine and valine to improve nitrogen balance
amino acids made for _____ are highly concentrated between 15-20% amino acids
fluid restriction
20% Injectable Lipid Emulsions (ILE’s) contain 100%
soybean oil (long chain fatty acids)
100% soybean ILE’s contain these fatty acids
linoleic acid (omega 6) , oleic acid, alpha linolenic acid, stearic acid, and palmitic acid
30% ILE’s provide ____ kcal/mL and are only available for _____ PN
3 kcal/mL, TNA mixtures
10% ILE’s are found in ______ and have a higher phospholipid/triglyceride concentration than 20% ILE’s, increasing free phospholipids interfering with lipoprotein lipase clearance causing _______
propofol, hypertriglcyeridemia
the only other form of lipid approved by the FDA for PN use to reduce the amounts of omega 6 fatty acids are
SMOF lipid
SMOF lipid contains sources of fatty acids from
Soybean, mCt’s, olive oil and fish oil as well as EPH and DHA
SMOF lipid is a ______% concentration
20%
contraindications to using SMOF lipid
Egg, soybean, fish or peanut allergies
when is the use of SMOF considered for PN
if a patient cannot tolerate soy bean oil with metabolic stress or in carnitine deficiency as the medium chain triglycerides don’t require carnitine to transport into the mitochondria which will reduce risk of essential fatty acid deficiency
IV lipids contain ____ as an emulsifier
egg
how many mmols of phos to ILE’s contain
15 mmol
what is the pH range of ILE’s
6-9
what is the maximum infusion rate of ILE administration
0.11 g/kg/hour
high rate of ILE infusion can lead to hypertriglyceridemia and infection called
fat overload syndrome
headaches, seizures, fever, jaundice, abdominal pain, and shock are all symptoms of
fat overload syndrome
ILE’s should not exceed total energy of _____g/kg/day
2.5 g/kg/day
per ASPEN recommendations for ILE’s in the ICU
withhold soybean based oil ILE or limit to 100 g during the first week if the patient is at risk for EFAD
lipids that are lab derived made up of chemically altered triglycerides with specific fatty acids at the 3 binding sites
structured lipids
Are structured lipids used in the US
no, they are not commercially available in the US
Fish oil ILE’s contain more _____ which is thought to decrease inflammation
omega 3
are just fish oils recommended for PN use
no, they can lead to EFAD as they are low in arachidonic and alpha linolenic acid
Clinolipid contains ____ oil and is enough to protect against EFAD
olive oil (contains at least 20% omega 6 fatty acids)
what are the preferred cations for calcium and magnesium which will produce the least incompatibilities in PN
Calcium Gluconate
Magnesium Sulfate
electrolyte requirements for sodium per day in PN
1-2 mEq/kg/day
requirements for potassium IV per day in PN
1-2mEq/kg/day
chloride and acetate are added _____ for acid base balance
as needed
calcium requirements for PN per day
10-15 mEq
magnesium requirements for PN per day
8-20 mEq
phosphate requirements for PN per day
20-40 mmol
single IV vitamins for PN are not available for
biotin, panthothenic acid, riboflavin, vitamin A, D or E
MVI’s in PN come in ____ vitals
10mL
how many micrograms of vitamin K are in 10mL IV MVI
150 mcg
what make up the trace elements in PN (multi trace)
zinc, copper, manganese, selenium, iron (ferric chloride), iodine, molybdate, fluoride, chromium
only iron ____ is approved for addition to PN and are contraindicated with the use of ______
dextran, lipids
role of glutamine in PN
intestinal integrity, immune function, protein synthesis during stress
is glutamine added to regular crystalline amino acids
NO
there is no FDA approved IV form of ___ for the critically ill due to lack of mortality benefit
glutamine
a quaternary amine needed for transport and metabolism of long chain fatty acids into the matrix of the mitochondria for beta oxidation
carnitine
carnitine deficiency can lead to
impaired fatty acid oxidation increasing the chance hepatic steatosis
is carnitine available in IV form for PN
no but IV L-Carnitine is available for carnitine deficiency esp. for neonates
10% amino acid solutions for PN should only be used for
fluid restriction patients
reserve IV MVI for
patients ONLY getting PN as sole nutrition or medical need
Liquid MVI contains sorbitol which can cause ______
diarrhea
if in a shortage of IV MVI how should MVI be rationed
50% or 3 times a week
12-MVI doesn’t contain
vitamin K
the typical form of IV MVI is
13-MVI
In shortage if 13-MVI occurs 12-MVI should be given, what needs to be separately
vitamin K 150 mc/day or 5-10 mg/week
if there is a shortage of calcium gluconate (the preferred form) what should be done?
eliminate from PN, order/monitor a serum ionized calcium and monitor fore evidence of calcium deficiency
if in a shortage calcium chloride needs to be infused for low calcium/calcium deficiency what should be done
infuse it SEPERATLY in a separate IV as it will cause precipitation if mixed w/ PN
what is one of the most dangerous PN incompatabilities
formation/infusion of calcium phosphate precipitates using calcium chloride which is less soluble than calcium gluconate
when providing 2 in 1 + piggy backed lipids what should be the hang time for ILE
12 hours
desired dextrose in a TNA TPN solution is
> 10 %
desired amino acid in a TNA TPN solution is
> 4%
a desired glucose concentration of >10% and and amino acid concentration >4 % in a TNA mixture is to prevent
lipid destabalization
Advantages of TNA 3:1 TPN solutions
aseptically compounded, more efficient for the pharmacy, less manipulation which decreased chance of bacterial contamination, more cost effective, easier to store at home
Disadvantages of TNA 3:1 TPN solutions
large particle sizes for the filter, less stable and prone to separation of lipids, more sensitive to destabilization of divalent/monovalent electrolytes, patients may be unstable for a low final concentration of ILE, the bag is opaque 2/2 the lipids which makes it difficult to observe destablation, less stable over time
who’s role is it to ensure that PN is prepared safely
pharmacist
as part of the National Standards for Compounded Sterile Preparations, what is an essential part of the compounding process
compound an accurate formulation free of microbes/particulate matter
USP
a private non profit company that sets standards for drug purity/safety
Compounding TPN in a closed system with aseptic transfer is considered ____Risk per USP standards
low
Reconstitution of several sterile products for transfer into several small volume or large volume PN preparation is considered ____ risk per USP standards
medium
Preparation from bulk, non=sterile ingredients exposed to ISO standard class 5; no particles, 0.5 micr mols or larger or 100 particles by cubic inch is considered ____ risk per USP standards
high
PN becomes _____ risk when L glutamine is compounded from non-sterile powder
high
ACD stands for
Automated Compounding Decice
PN that is compounded under computerized control is called
an ACD
Why were ACD’s created for PN compounding
helped streamline the manufacturing sequence for multiple ingredient preparations such as PN
advantages of ACD compounding
enhanced accuracy
can create unique volumes
more easily tailored to patient’s needs
reduces potential of contamination
disadvantages of ACD compounding
tubing must be changed daily
your facility should be using PN often in order to be cost effective
large
If PN using an ACD is made for adults, pedi and neonates PN should be infused ____ for each population
separately
what is the best method to reduce transcription errors during the PN ordering process
the PN order should be electronically integrated without requiring re entry of data
as part of quality control of the PN process the pharmacist should visually _______ each PN for physical defects, phase separation, package integrity
visually inspect
_____ determines whether PN formulations have been compounded properly, using refractive index of dextrose/amino acids
Refractometry
if refractive measures differs from ____ values in refractometry, the formula could be improperly admixed
predicted values
_____ _____ must be developed to ensure that PN is not exposed to extremes in temperature or light
written procedures
2-in-1 or 3-in-1 TPN solutions that are kept in internal membrane that separates the macronutrients into different chambers and is broken so the components can be mixed just before administration are called
Standardized Commercially Available PN Formulations (SCAPN)
SCAPNs require addition of ______ injection before administration because they are not stable for >24 hours
MVI
SCAPN bags contain procal amino acid/glycerol based product which does not undergo the Maillard reaction and precludes the heat of sterilization so they must be protected form ______ until admin
the light
the degradation of nutritional components that changes their original characteristics or the ability o PN additives to maintain their chemical integrity/pharmacological activity is definition of the ____ of PN
stability
overtime when exposed to light, IV dextrose and amino acids in PN will form a brown color is known as
the maillard reaction
Photodegradation from light exposure results in the loss of some vitamins including
B12, folic acid, pyridoxine, riboflavin, thiamin and retinol
_____ of PN involves evaluating the formation of precipitates in PN
compatibility
what are 2 possible precipitates of PN
solid/crystalline precipitates
phase separation of oil and water
addition of iron dextran to ILE’s will cause ______ ___ of the ILE component, which is an example of incompatibility of PN
phase separation
Medications should not be added to PN formulations unless clear evidence from
literature
fat molecules over ____ micrometers will make the emulsion unstable
1 micrometer
if fat droplets in PN become too large it is unsafe as they could dislodge and cause
pulmonary compromise
what factors alter the charge of lipids
reduced pH
addition of electrolyte salts
additives with a low pH below 5 or above 10 can crack the emulsion
what is the favorable range of pH for ILE’s
6-9
yellow streaks or an amber oil layer on top of a TPN bag can indicate
oil phase separation (cracked emulsion)
amino acids with a concentration above ____% may cause TPN instability
15%
TNA’s should be avoided with this type of PN because the concentrations of dextrose and amino acids would be too low and cause TNA instability
PPN (due to osmolarity restrictions only can use 8% dex and 3% amino acids)
optimal concentration of ILE for TNA is
20% ILE
low osmolarity PN increases the risk of _______ precipitations
calcium/phosphate
to prevent lipid destabilization, divalent cations should be provided between ____ to ____ mEq/L
16-20
final concentration of dextrose and amino acids should be above ____ in a 3 in 1 TPN
> 10% dex, > 4% amino acids, >20% ILE
______ _____ precipitates can cause respiratory distress or microvascular pulmonary emboli
calcium phosphate
what are the 2 factors that influence calcium and phosphate solubility in PN
increased calcium phos precipitation and increased calcium phosphate solubility
what increases the risk of calcium phosphate precipitation
increased calcium concentration, increased phosphate, calcium chloride instead of CaGluconate and increased temperature
what can help increase calcium phosphate solubility
- increased amino acid concentrations
- increased dextrose concentration
- lower pH
____ primarily dictates the solubility of calcium/phosphate
pH
____ pH favors the presence of mono basic calcium phos which is more soluble
lower pH
an ____ in pH increases the amount of di-basic phosphate to bind with free calcium ions, increasing the chance of precipitation
increase
for PN in neonates ____ is added to lower the PH of TPN to increase calcium/phos solubility as they need higher amounts of calcium and phos for bone growth
L cysteine hydrochloride
L-cysteine, a semi-essential amino acid for neonates in PN are added to lower the pH which is bad for the ILE environment and should not be used in _____ PN solutions
TNA
_________ ________ are used to check the solubility of calcium and phos before compounding TPN
calcium/phosphorous solubitliy curves
________ ______ provide the best guidance in determining calcium phosphate solubility
solubility curves
this organ regulates the elimination of aluminum
kidneys
in 1994 the FDA required the addition of _____ due to high instance of calcium phosphate precipitates
filters
large pore filters are considered ____ micromoles which can remove CaPhos precipitates and plastic fragments from the PN bag
5 micromoles
Filters are a good substitute for good compounding practices true or false
False
______ micrometer filters can remove pathogenic microorganisms from PN
0.22 micrometers
use a ____ micromolar filter for TNAs and separately infused ILE’s, but this wont filter out staph epidermis or E.coli
1.2
use a _____ micromolar filter for 2 in 1 dextrose/amino acid admix with a SEPERATE infusion of ILE
0.22
ILE’s filter size should be
1.2 micromoles
how often should PN filters be exchanged for dextrose-amino acid solutions
every 24 hours or new infusion
how often should PN filters be exchanged for lipids
every 10-12 hours for separately infused ILE’s
0.22 micron filters cannot be used for ____ forms of TPN
3 in 1, not suitable for the ILE
tubing and PN containers should be ________ and kept away from _____
refrigerated, away from light exposure
when transitioning from PN to EN , the most common complication is
hyperglycemia (limit GIR to <4 mg/kg/min)
47 year old female admit with recurring GI problems has had a 8.4 kg wt loss, 11% wt loss in 35 days, eating <25% of estimated nutrition needs, her abdominal scan demonstrated bowel obstruction with pockets of fluid collections consistent with intra abdominal abscess what type of feeding would be appropriate
PN
critically ill patients with normal nutrition/no risk of malnutrition should avoid PN for
7 days
is PN recommended as the first line of nutrition therapy in acute Chron’s or Ulcerative Colitis flare
no
peri operative PN can be used in ____ with a risk assessment
severe malnutrition
most errors when ordering PN happened during these steps in the process
transcription, prescription and administration
a patient’s clinical condition should lead decision of whether to start or withhold therapy in these settings
hyperglycemia, azotemia, encephalopathy, hyperosmolality, severe fluid/electrolyte abnormalities
once PN is infusing at goal rate in the hospital, what should be monitored
fluid ,electrolyte/renal status, daily BG, TCG/LFT periodically , visceral protein weekly, urine output
this type of amino acid PN formulation is used for hepatic encephalopathy
branched chain amino acids and decreased aromatic amino acids
patients under metabolic stress, trauma, thermal energy have increased needs for these types of amino acids
branched chain, essential
patients with severe fluid restriction may need this special amino acid formula with ___ to ___ % acids
15-20%
this type of lipid formulation for PN may be able to reduce risk of PNALD
SMOF
ILE provide ___mmol/L of phosphorous
15
this type of ILE has 100% fish oil
Omegaven
single IV vitamin products are not available in these micronutrients
biotin, pantothenic acid, riboflavin, vitamin A,D or E
a typical 10mL dose of MVI contains this much vitamin K
150 mcg
single entity or multi trace elements provide ____ mg of zinc
3-6.5 mg
single entity or multi trace elements provides ___ mg of copper
1-1.3
single entity or multi trace elements provides ____ mcg of selenium
0-60 mcg
per ASPEN recommendations when multiple ____ products are inappropriate for PN use ____ products should be used to meet a patient’s needs
element
single entity
when using single entity copper reduce the amount to
0.3-0.5 mg/day
trace element contamination in PN formulas can be limited to < ____ mg/day of copper and _____ mcg of manganese to reduce organ accumulation of copper, manganese, and chromium
0.1 mg, 40mcg
only iron ____ is approved for addition to PN and should only be considered for dextrose amino acid formulations because ILE formulations are disrupted by iron
dextran
PN _____ is no longer recommended for critically ill patients due to lack of infectious/mortality benefit or even high mortality rates when IV is gen
glutamine
there is currently no form of IV glutamine because
not FDA approved, poor solubility/stability
carnitine only comes in the form of _____ in parenteral nutrition for those with carnitine deficiency such as neonates and infants
L-carnitine
in the setting of ILE shortage who should be prioritized
long term TPN needed for > 2 weeks, high risk for essential fatty acid deficiency, critically ill patients NOT on propofol, pregnant patients, severely malnourished, glucose intolerant
in the setting of IV MVI shortage who should be prioritized
patients only on IV nutrition, medical need
if there is a shortage of MVI, what alternatives are there
- consider oral/enteral MVI when EN or PO intake is started
- avoid liquid MVI as can cause GI upset
- Ration IV MVI to 50% 3x/week
- If MVI-13 not available, use MVI 12 (no vit K) and give separate IV vitamin K 150mcg/d or 5-10 mg/ week
how much vitamin K IV is needed a day/week
150mcg/day
5-10 mg/week
_____MVI’s should never be substituted for adults MVI
Pediatrics
Adult IV MVI should be given to neonates because
they have propylene glycol, polysorbate and aluminum which can be toxic to neonates
During an IV MVI shortage reserve electrolytes for _____ PN patients or patients with ______ need
sole
medical
consider oral/enteral electrolytes when a patient is on enteral feeding or po diet during an IV MVI or trace element shortage excluding those with
malabsorption or non functioning GI tract
if a multi mineral/trace element formula for IV is not available, use ____ formulations
single IV
withhold IV adult multi trace elements for the first month to _____ adult PN patients who are not critically ill or have pre existing deficits
newly initiated
if calcium chloride is given in substitute for calcium gluconate in PN during a shortage, what must be taken into consideration
calcium chloride is much more INSOLUBLE that calcium gluconate and should be given in a separate IV line to avoid PN compatibility issues.
the desired dextrose concentration for a TNA TPN solution is > ____ and >___% for amino acids to prevent ______destabilization
10% dextrose,
4% amino acids
lipid
who’s responsibility is it to ensure that PN is prepared safely
Pharmacy
an essential part of the PN compounding process is to create
a compound with an accurate formulation, free of microbes and particulate matter
Review Current USP guidelines for PN safety/purity
- enforced for compounding sterile preparations
- assigns low, med, high risk
- Low risk - closed system aseptic transfer, medium risk = reconstitution of several sterile products that transfer into several small volume PN preparations or large volume PN preps
trace elements can lead to contamination from these 6 substances
aluminum arsenic chromium zinc manganese copper
the amount of contamination in PN depends on these 3 factors
manufacturer
vial size
concentrations
The 2004 federal regulation state that _______ content must be labeled in large volume PN formulations, pharmacy bulk packaging and small volume PN formulas
aluminum
the max amount of aluminum per liter allowed in Large Volume PN is
25mcg/L
Storage of PN products in _____ which a high affinity for aluminum should instead by stored in ______ to decrease aluminum contamination
Don’t store in glass
STORE in plastic
less than ___% of aluminum is absorbed by the GI tract
<1 %
this organ is an effective barrier for aluminum
the lungs
Extra aluminum during toxicity will deposit in these 4 areas
Lungs
Bones
Liver
Brain
Which patients are at the highest risk for aluminum toxicity in PN
Renal Dysfunction (cannot excrete) High intake of PN products Iron deficiency (transferrin assist with excretion) Infants/Pedi patients
what are the signs/symptoms of an aluminum toxicity
encephalopathy, osteomalacia, reduced PTH secretion, erythropoietin resistant microcytic anemia
the FDA defines the upper limit of aluminum to be ___ and requires a ____ in the manufactures product
4-5mcg/kg/day; requires a warning statement
to decrease post op complications of severely malnourished patients who require surgery, they should receive pre operative PN for a minimum of how many days
7-10 (perioperatively)
the threshold for starting PN in an elderly person is ____ than a younger adult because of age related decrease in muscle mass and organ function with diminished reserves as well as impaired compensatory mechanisms
lower
name 2 absolute indications for the use of PN
high output fistula especially if over 500mL/day and GI obstruction limiting po intake >1 week
routine use of perioperative PN is indicated for severely malnourished patients to prevent preoperative complications when used for
> 7 days
in a home PN patient TNA TPN, what should added immediately before infusion
multivitamin
what are the recommended maximum PN components for fluid, g/kg carb, g/kg fat and g/kg protein
30-40mL/kg fluid
7g/kg carb
2.5 g/kg/day fat
2 g/kg protein (depending on the disease)
the best way to express the dextrose content in PN to avoid misinterpretation
grams per 24 hour infusion
max lipid infusion rate to avoid infusion complications
- 11 g/kg/hour lipid
1. 1 g/kg/day
provide at least ___ to __% of linoleic acid to avoid EFAD
2-4%
provide at least 0.25 to 0.5 % _____ to avoid EFAD
alpha linolenic acid
avoid providing IVFE if serum triglycerides exceed
400mg/dL
avoid infusion of >_____g/kg/hour of fat to a void hypertriglyceridemia
0.125 g/kg/hour
when 2 oils are mixed together into an emulsion this is known as a ___ mixture
physical
medium chain fatty acids and long chain fatty acids that are created through hydrolysis of triglycerides and go through transesterification of fatty acid to make TCG molecules
structured lipids
what is the primary advantage of using structured lipids in TPNA
lowers serum triglyceride levels because they are utilized at a slower rate
how many milliliters per liter of fat emulsion are needed to provide a final concentration of 5% when using 20% Intralipid as a stock solution
5% means 5 grams in 100mL. 1 L = 1000mL so in 1000mL , there will be 50 grams of fat (5 x 10). There are 10kcal per gram of fat, so 10 kcal x 50 grams, gives you 500 kilocalories. There are 2kcals per mL of lipids in IVFE so 500/ 2 is 250 mL of ILE
these 2 amino acids are synthesized primarily in the intestines. When PN is started, there is an alteration to intestinal metabolism impairing the synthesis of these amino acids and they become conditionally essential, they are
glutamine and arginine
this amino acid has shown to provide the benefit of reducing length of stay and post operative infection rates when added and is conditionally essential
arginine
the most appropriate PN amino acid solution for the non-dialysis patient with acute renal failure contains
a balance of essential and non essential amino acids
metabolic alkalosis is PN is mostly likely contributed by
amino acids; they have large amounts of endogenous acetate which metabolizes into excess bicarbonate
the addition of______ to PN has the benefit of unaltered GI permeability
glutamine diphosphate
the disadvantage of adding glutamine to PN is it can cause
hyperammonemia
renal parenteral formulas have higher amounts of ____ compared to the standard
essential amino acids
the addition of glutamine may be contraindicated in
hepatic failure
Glutamine diphosphate can be added into PN as long as it is added within ___ hours compounding
48 hours
this is a non-essential amino acid that is the primary fuel for the small bowel
glutamine
A patient with an ileostomy getting TPN is likely to need supplemental
sodium, potassium and acetate (loss of bicarb through stool)
what PN additive may cause throbocytopenia
heparin
_____ is added to adult MVI preparations and IV fat emulsion solutions for PN, therefore when a patient is on Coumadin and starting or ending PN _____ should be monitored
INR
_____ time should be monitored regularly in adults getting IV fat emulsions and who are on Coumadin/Warfarin with PN as they contain ______ in the emulsion
vitamin K
____ cannot be added to IVFE as it has the highest risk over time destabilizing the fat emulsion due to phase separation and liberation from oil due to high cation valence. There is NO safe concentration of this in any TNA for this reason.
Iron dextran
the higher the ___ of an element, the higher the destabilizing power
valence
the DRI for PN ____ vitamins provided in PN are less than the DRI’s for ___ vitamins orally, given that there is no loss from the GIT when given intravenously
fat soluble vitamins
DRI for PN _____ vitamins are given in higher concentrations than oral supplementation as patients are in a state of high stress and may require a greater intake
water soluble vitamins
increased endogenous insulin levels that don’t adjust to the decrease in dextrose infusion following the discontinuation of PN is called
rebound hypoglycemia
after stopping PN, blood glucose should be monitored for how long to prevent rebound hypoglycemia
30 minutes-1 hour
patients with hypothyroidism are at increased risk of _____ when PN is stopped as the thyroid controls metabolism associated with glucose control. T3 and T4 hormones, directly impact glucose homeostasis
rebound hypoglycemia
