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CNSC Exam > Parenteral Nutrition > Flashcards

Parenteral Nutrition Flashcards

1
Q

When solely on PN how fast can essential fatty acid deficiency occur

A

2-4 weeks without linoleic or alpha linolenic acid

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2
Q

Symptoms of essential fatty acid deficiency

A

Dry scaly rash, impaired wound healing, increased infection risk, immune dysfunction, alopecia

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3
Q

The Holman Index

A

Triene to Tetraene ratio to test for essential fatty acid deficiency

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4
Q

EFAD can develop faster in lipid free PN secondary to

A

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

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5
Q

TPN in the critical care unit should initially be

A

hypocaloric and lipid free

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6
Q

Should PN be started in the acute phase of severe sepsis with elevated triglycerides

A

No

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7
Q

Alpha Linolenic Acid is the precursor for

A

DHA and EPA (omega 3 fatty acids)

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8
Q

Contents of the Injectable Lipid Emulsion (ILE)

A

An oil in water emulsion, 1 triglyceride, glycerol and phospholipid emulsifier, vitamin E, K phytosterols and cholesterols

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9
Q

Which vitamins are in ILE’s

A

vitamin E and K

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10
Q

Long chain fatty acids require ____ to be oxidized for energy

A

L-Carnitine

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11
Q

What are needed to prevent essential fatty acid deficiency?

A

alpha linolenic acid and linoleic acid (Omega 3’s)

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12
Q

What percentage of calories is needed of alpha linolenic acid to prevent EFAD

A

0.25-0.5% omega 3 (alpha linolenic acid)

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13
Q

What percentage of calories is needed of linoleic acid to prevent EFAD?

A

1-4% omega 6 (linoleic acid)

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14
Q

In which type of oils are the highest concentration of linoleic acid found

A

Soybean and Corn Oil (Omega 6)

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15
Q

In which type of oils are the highest concentration of alpha linolenic acids found in?

A

Soybean and Canola Oil (Omega 3)

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16
Q

How much ILE is needed weekly to prevent EFAD

A

500mL/week

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17
Q

Maximum PN ILE infusion daily

A

2.5 g/kg/day

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18
Q

If a patient is critically ill, don’t exceed ____ amount of lipids IV a day

A

1g/kg/day

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19
Q

When using 100% soybean oil IV, hold lipids x _____ unless there is a concern for EFAD, then give _____

A

For 1 week, OR

100grams/week

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20
Q

Give IVFE at no more than _____ rate to avoid toxicity of rapid infusion (fat overload syndrome)

A

0.11 g/kg/hr

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21
Q

Why does PPF (10% ILE) lead to hypertriglyceridemia

A

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

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22
Q

What should happen if serum triglycerides exceed 400mg/dL

A
  1. Decrease fat emulsion or hold
  2. Monitor serum TCGs 2x/week
  3. Remove lipids if also on PPF
  4. Try to start a patient on trophic enteral feeding
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23
Q

Omega 9 fatty acids

A

Olive Oil/Oleic acid used to lower cholesterol and triglycerides without lipid peroxidation often used in EN formulas

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24
Q

What is the suspected role of omega 3 fatty acids in parenteral nutrition

A

it contains fish oil which may cause LESS inflammation. Limited evidence is available at this time to be recommended.

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25
Q

Should omega 3 fatty acid ILEs be used in PN per ASPEN?

A

Limited Evidence by ASPEN

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26
Q

How can plant based ILEs lead to the development of liver dysfunction related to PN

A

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

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27
Q

typical IV dose of calcium

A

10-15 mEq/day (calcium gluconate) (also add magnesium)

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28
Q

typical IV dose of magnesium

A

5-8 mEq/L, or 80-20 mEq/day (magnesium sulfate)

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29
Q

how often should patients get MVI in PN

A

every day unless toxicity is suspected

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30
Q

what is added to PN that have demonstrated therapeutic effects in bone marrow transplants

A

glutamine supplementation

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31
Q

normal calcium requirements for PN with normal renal function

A

15mEq/day

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32
Q

what is the suggested adult PN thiamine daily dose

A

3 mg

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33
Q

when is PN recommended for burn patients

A

when EN is contraindicated or unlikely to meet nutritional needs (shouldn’t be the first route)

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34
Q

TPN terminates in the ____________ which can tolerate high osmolarity

A

superior vena cava

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35
Q

a central line should be placed if TPN is suspected for ___to ____ days in the hospital setting

A

7-14 days

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36
Q

PPN is indicated for _____ term use. Less than ______

A

short term use, <2 weeks

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37
Q

PPN is generally not recommended for malnutrition because

A

it cannot provide enough calories

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38
Q

what are 2 parameters for being a candidate for PPN

A
  1. good peripheral venous access

2. ability to tolerate large volumes o fluid 2.5-3 L

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39
Q

PPN should only be considered when PO or EN is not possible to meet a person’s nutrition needs for > than _____ days

A

5 days

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40
Q

You would consider PPN vs TPN when only indicated for use between ____ and ____ days

A

5-12

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41
Q

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

A

PPN

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42
Q

Thrombophlebitis can be caused by

A

high PN osmolarity or potassium

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43
Q

the term for providing up to 80% of energy needs until a patient’s condition improves, usually in the ICU

A

permissive underfeeding

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44
Q

the term for providing EN/PN of 60-75% of energy needs and high protein needs for the obese with BMI >30

A

hypocaloric feeding

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45
Q

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

A

supplemental PPN

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46
Q

indications for starting PN

A
  1. unable to meet nutrition requirements from EN
  2. when a patient cannot ingest or absorb oral or EN tube feedings
  3. paralytic ileus
  4. bowel obstruction
  5. GI fistula except when EN access can be placed posterior to the fistula,
  6. unable to use the gut for 7-10 days
  7. when EN access is contraindicated/failed attempts
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47
Q

when should PN be held off from starting

A
  1. azotemia
  2. severe hyperglycemia
  3. severe fluid/electrolyte imbalances
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48
Q

in the critically ill PN should not be considered until after ____ days when the patient has normal nutrition or no risk of malnutrition

A

7 days

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49
Q

when deciding to start PN be careful when blood sugar is over

A

300 mg/dL

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50
Q

when deciding to start PN, be careful when the patient is azotemic which means BUN is > than

A

100 mg/dL

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51
Q

when deciding to start PN, be careful when the patient is hypernatremic with a sodium > than

A

150 mEq/L

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52
Q

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

A

115 mEq/L , 85 mEq/L

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53
Q

Is PN recommended over EN for pancreatitis

A

no

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54
Q

if PN is indicated in pancreatitis what is important to manage, what are the kcal needs

A

25-35 kcal/kg, glucose control, consider glutamine to help minimize effect of GI integrity

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55
Q

PN can be used in the pre-operative phase in _______ _______ and should be at least ____ to ____ days for maximum benfit

A

severe malnutrition, 7-10 days

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56
Q

who in critical illness are appropriate for starting PN

A

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

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57
Q

is PN clinically indicated in cancer

A

no; chemo/radiation can cause infectious complications, no improvement clinically

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58
Q

ASPEN recommendation for when to start PN in cancer

A

only when malnourished AND unlikely to ingest/absorb adequate nutrition in 7-14 days

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59
Q

is PN preferred for hematopoietic cell transplant

A

No

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60
Q

successful PN depends on these factors.

A
  1. adequate ordering transcribing, compounding, dispensing and administration of PN and interdisciplinary care/nutrition support team
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61
Q

Errors of PN

A
  1. infection of IV catheter
  2. over/under feeding
  3. errors during Rx, transcription or prep
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62
Q

Most errors that occur from PN occur from

A

prescribing PN order

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63
Q

What can help decrease errors in PN

A
  1. create nutrition guidelines
  2. multi step double check process
  3. verify electronically transcribed order against actual written order
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64
Q

if a patient who is critically ill and previously well nourished ins PN recommended

A

no

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65
Q

in severely malnourished patients in the ICU when is PN indicated

A

when unable to use GI tract in 7 days

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66
Q

other indications to start PN (precluding the use of the GI tract)

A
  1. unable to meet estimated nutrition needs with EN alone or at high risk of malnutrition
  2. TPN when needed for > 2 weeks and PPN when needed <2 weeks
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67
Q

patients with significant hyperglycemia, azotemia, encephalopathy, or severe fluid/electrolyte abnormalities should not start _____ until resolved

A

PN

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68
Q

patients with theses issues may not tolerate large volumes with PN

A

CHF, renal failure, liver failure with ascites

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69
Q

when providing high fluid in PN what should be monitored

A

pulmonary edema, blood pressure, pulse

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70
Q

what should initially be monitored when PN reaches goal rate

A

fluid status, renal status, routine blood glucose monitoring, LFT/TCGs periodically, serum visceral proteins weekly, nitrogen balance/urine output with functioning kidneys

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71
Q

periodically monitor triglycerides levels if ____ given

A

lipids

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72
Q

goal of parenteral nutrition

A

maintain a patient’s nutrition status until some form of EN is tolerated

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73
Q

how can rebound hyperglycemia be prevented when stopping PN

A

taper down for 1-2 hours before stopping

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74
Q

if a patient is on TPN and EN does TPN need to be tapered before stopping

A

no

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75
Q

Dextrose in TPN contains _____ kcal/kg

A

3.4 kcal/kg

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76
Q

ranges of dextrose concentrations available for PN

A

2.5-70%

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77
Q

pH of dextrose solutions in pN

A

3.5-6.5

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78
Q

why are concentrations of dextrose for peripheral PN usually <8%

A

concentrations >10% can cause phlebitis in peripheral veins

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79
Q

Standardized Commercially Available PN (SCAPN)

A

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

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80
Q

Protein provided in PN solutions come from _______ amino acids

A

crystalline

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81
Q

16% nitrogen + ___ g amino acids and ____ g nitrogen

A

6.25 g amino acids, 1 gram nitrogen

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82
Q

standard amino acid solutions in PN contain ___- and ___ amino acid

A

essential and nonessential

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83
Q

concentrations of PN amino acids range from

A

3-20%

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84
Q

amino acid formulations used for special disease states are called

A

modified amino acids

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85
Q

amino acid formulations made for hepatic encephalopathy contain

A

increased BCAAs and decreased aromatic amino acids

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86
Q

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

A

aromatic amino acids (bad), branched chain amino acids (good)

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87
Q

amino acid formulations made for stress, trauma and thermal energy contain

A

BCAAs, increased leucine, isoleucine and valine to improve nitrogen balance

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88
Q

amino acids made for _____ are highly concentrated between 15-20% amino acids

A

fluid restriction

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89
Q

20% Injectable Lipid Emulsions (ILE’s) contain 100%

A

soybean oil (long chain fatty acids)

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90
Q

100% soybean ILE’s contain these fatty acids

A

linoleic acid (omega 6) , oleic acid, alpha linolenic acid, stearic acid, and palmitic acid

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91
Q

30% ILE’s provide ____ kcal/mL and are only available for _____ PN

A

3 kcal/mL, TNA mixtures

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92
Q

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 _______

A

propofol, hypertriglcyeridemia

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93
Q

the only other form of lipid approved by the FDA for PN use to reduce the amounts of omega 6 fatty acids are

A

SMOF lipid

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94
Q

SMOF lipid contains sources of fatty acids from

A

Soybean, mCt’s, olive oil and fish oil as well as EPH and DHA

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95
Q

SMOF lipid is a ______% concentration

A

20%

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96
Q

contraindications to using SMOF lipid

A

Egg, soybean, fish or peanut allergies

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97
Q

when is the use of SMOF considered for PN

A

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

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98
Q

IV lipids contain ____ as an emulsifier

A

egg

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99
Q

how many mmols of phos to ILE’s contain

A

15 mmol

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100
Q

what is the pH range of ILE’s

A

6-9

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101
Q

what is the maximum infusion rate of ILE administration

A

0.11 g/kg/hour

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102
Q

high rate of ILE infusion can lead to hypertriglyceridemia and infection called

A

fat overload syndrome

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103
Q

headaches, seizures, fever, jaundice, abdominal pain, and shock are all symptoms of

A

fat overload syndrome

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104
Q

ILE’s should not exceed total energy of _____g/kg/day

A

2.5 g/kg/day

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105
Q

per ASPEN recommendations for ILE’s in the ICU

A

withhold soybean based oil ILE or limit to 100 g during the first week if the patient is at risk for EFAD

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106
Q

lipids that are lab derived made up of chemically altered triglycerides with specific fatty acids at the 3 binding sites

A

structured lipids

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107
Q

Are structured lipids used in the US

A

no, they are not commercially available in the US

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108
Q

Fish oil ILE’s contain more _____ which is thought to decrease inflammation

A

omega 3

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109
Q

are just fish oils recommended for PN use

A

no, they can lead to EFAD as they are low in arachidonic and alpha linolenic acid

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110
Q

Clinolipid contains ____ oil and is enough to protect against EFAD

A

olive oil (contains at least 20% omega 6 fatty acids)

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111
Q

what are the preferred cations for calcium and magnesium which will produce the least incompatibilities in PN

A

Calcium Gluconate

Magnesium Sulfate

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112
Q

electrolyte requirements for sodium per day in PN

A

1-2 mEq/kg/day

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113
Q

requirements for potassium IV per day in PN

A

1-2mEq/kg/day

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114
Q

chloride and acetate are added _____ for acid base balance

A

as needed

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115
Q

calcium requirements for PN per day

A

10-15 mEq

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116
Q

magnesium requirements for PN per day

A

8-20 mEq

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117
Q

phosphate requirements for PN per day

A

20-40 mmol

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118
Q

single IV vitamins for PN are not available for

A

biotin, panthothenic acid, riboflavin, vitamin A, D or E

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119
Q

MVI’s in PN come in ____ vitals

A

10mL

120
Q

how many micrograms of vitamin K are in 10mL IV MVI

A

150 mcg

121
Q

what make up the trace elements in PN (multi trace)

A

zinc, copper, manganese, selenium, iron (ferric chloride), iodine, molybdate, fluoride, chromium

122
Q

only iron ____ is approved for addition to PN and are contraindicated with the use of ______

A

dextran, lipids

123
Q

role of glutamine in PN

A

intestinal integrity, immune function, protein synthesis during stress

124
Q

is glutamine added to regular crystalline amino acids

A

NO

125
Q

there is no FDA approved IV form of ___ for the critically ill due to lack of mortality benefit

A

glutamine

126
Q

a quaternary amine needed for transport and metabolism of long chain fatty acids into the matrix of the mitochondria for beta oxidation

A

carnitine

127
Q

carnitine deficiency can lead to

A

impaired fatty acid oxidation increasing the chance hepatic steatosis

128
Q

is carnitine available in IV form for PN

A

no but IV L-Carnitine is available for carnitine deficiency esp. for neonates

129
Q

10% amino acid solutions for PN should only be used for

A

fluid restriction patients

130
Q

reserve IV MVI for

A

patients ONLY getting PN as sole nutrition or medical need

131
Q

Liquid MVI contains sorbitol which can cause ______

A

diarrhea

132
Q

if in a shortage of IV MVI how should MVI be rationed

A

50% or 3 times a week

133
Q

12-MVI doesn’t contain

A

vitamin K

134
Q

the typical form of IV MVI is

A

13-MVI

135
Q

In shortage if 13-MVI occurs 12-MVI should be given, what needs to be separately

A

vitamin K 150 mc/day or 5-10 mg/week

136
Q

if there is a shortage of calcium gluconate (the preferred form) what should be done?

A

eliminate from PN, order/monitor a serum ionized calcium and monitor fore evidence of calcium deficiency

137
Q

if in a shortage calcium chloride needs to be infused for low calcium/calcium deficiency what should be done

A

infuse it SEPERATLY in a separate IV as it will cause precipitation if mixed w/ PN

138
Q

what is one of the most dangerous PN incompatabilities

A

formation/infusion of calcium phosphate precipitates using calcium chloride which is less soluble than calcium gluconate

139
Q

when providing 2 in 1 + piggy backed lipids what should be the hang time for ILE

A

12 hours

140
Q

desired dextrose in a TNA TPN solution is

A

> 10 %

141
Q

desired amino acid in a TNA TPN solution is

A

> 4%

142
Q

a desired glucose concentration of >10% and and amino acid concentration >4 % in a TNA mixture is to prevent

A

lipid destabalization

143
Q

Advantages of TNA 3:1 TPN solutions

A

aseptically compounded, more efficient for the pharmacy, less manipulation which decreased chance of bacterial contamination, more cost effective, easier to store at home

144
Q

Disadvantages of TNA 3:1 TPN solutions

A

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

145
Q

who’s role is it to ensure that PN is prepared safely

A

pharmacist

146
Q

as part of the National Standards for Compounded Sterile Preparations, what is an essential part of the compounding process

A

compound an accurate formulation free of microbes/particulate matter

147
Q

USP

A

a private non profit company that sets standards for drug purity/safety

148
Q

Compounding TPN in a closed system with aseptic transfer is considered ____Risk per USP standards

A

low

149
Q

Reconstitution of several sterile products for transfer into several small volume or large volume PN preparation is considered ____ risk per USP standards

A

medium

150
Q

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

A

high

151
Q

PN becomes _____ risk when L glutamine is compounded from non-sterile powder

A

high

152
Q

ACD stands for

A

Automated Compounding Decice

153
Q

PN that is compounded under computerized control is called

A

an ACD

154
Q

Why were ACD’s created for PN compounding

A

helped streamline the manufacturing sequence for multiple ingredient preparations such as PN

155
Q

advantages of ACD compounding

A

enhanced accuracy
can create unique volumes
more easily tailored to patient’s needs
reduces potential of contamination

156
Q

disadvantages of ACD compounding

A

tubing must be changed daily
your facility should be using PN often in order to be cost effective
large

157
Q

If PN using an ACD is made for adults, pedi and neonates PN should be infused ____ for each population

A

separately

158
Q

what is the best method to reduce transcription errors during the PN ordering process

A

the PN order should be electronically integrated without requiring re entry of data

159
Q

as part of quality control of the PN process the pharmacist should visually _______ each PN for physical defects, phase separation, package integrity

A

visually inspect

160
Q

_____ determines whether PN formulations have been compounded properly, using refractive index of dextrose/amino acids

A

Refractometry

161
Q

if refractive measures differs from ____ values in refractometry, the formula could be improperly admixed

A

predicted values

162
Q

_____ _____ must be developed to ensure that PN is not exposed to extremes in temperature or light

A

written procedures

163
Q

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

A

Standardized Commercially Available PN Formulations (SCAPN)

164
Q

SCAPNs require addition of ______ injection before administration because they are not stable for >24 hours

A

MVI

165
Q

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

A

the light

166
Q

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

A

stability

167
Q

overtime when exposed to light, IV dextrose and amino acids in PN will form a brown color is known as

A

the maillard reaction

168
Q

Photodegradation from light exposure results in the loss of some vitamins including

A

B12, folic acid, pyridoxine, riboflavin, thiamin and retinol

169
Q

_____ of PN involves evaluating the formation of precipitates in PN

A

compatibility

170
Q

what are 2 possible precipitates of PN

A

solid/crystalline precipitates

phase separation of oil and water

171
Q

addition of iron dextran to ILE’s will cause ______ ___ of the ILE component, which is an example of incompatibility of PN

A

phase separation

172
Q

Medications should not be added to PN formulations unless clear evidence from

A

literature

173
Q

fat molecules over ____ micrometers will make the emulsion unstable

A

1 micrometer

174
Q

if fat droplets in PN become too large it is unsafe as they could dislodge and cause

A

pulmonary compromise

175
Q

what factors alter the charge of lipids

A

reduced pH
addition of electrolyte salts
additives with a low pH below 5 or above 10 can crack the emulsion

176
Q

what is the favorable range of pH for ILE’s

A

6-9

177
Q

yellow streaks or an amber oil layer on top of a TPN bag can indicate

A

oil phase separation (cracked emulsion)

178
Q

amino acids with a concentration above ____% may cause TPN instability

A

15%

179
Q

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

A

PPN (due to osmolarity restrictions only can use 8% dex and 3% amino acids)

180
Q

optimal concentration of ILE for TNA is

A

20% ILE

181
Q

low osmolarity PN increases the risk of _______ precipitations

A

calcium/phosphate

182
Q

to prevent lipid destabilization, divalent cations should be provided between ____ to ____ mEq/L

A

16-20

183
Q

final concentration of dextrose and amino acids should be above ____ in a 3 in 1 TPN

A

> 10% dex, > 4% amino acids, >20% ILE

184
Q

______ _____ precipitates can cause respiratory distress or microvascular pulmonary emboli

A

calcium phosphate

185
Q

what are the 2 factors that influence calcium and phosphate solubility in PN

A

increased calcium phos precipitation and increased calcium phosphate solubility

186
Q

what increases the risk of calcium phosphate precipitation

A

increased calcium concentration, increased phosphate, calcium chloride instead of CaGluconate and increased temperature

187
Q

what can help increase calcium phosphate solubility

A
  • increased amino acid concentrations
  • increased dextrose concentration
  • lower pH
188
Q

____ primarily dictates the solubility of calcium/phosphate

A

pH

189
Q

____ pH favors the presence of mono basic calcium phos which is more soluble

A

lower pH

190
Q

an ____ in pH increases the amount of di-basic phosphate to bind with free calcium ions, increasing the chance of precipitation

A

increase

191
Q

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

A

L cysteine hydrochloride

192
Q

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

A

TNA

193
Q

_________ ________ are used to check the solubility of calcium and phos before compounding TPN

A

calcium/phosphorous solubitliy curves

194
Q

________ ______ provide the best guidance in determining calcium phosphate solubility

A

solubility curves

195
Q

this organ regulates the elimination of aluminum

A

kidneys

196
Q

in 1994 the FDA required the addition of _____ due to high instance of calcium phosphate precipitates

A

filters

197
Q

large pore filters are considered ____ micromoles which can remove CaPhos precipitates and plastic fragments from the PN bag

A

5 micromoles

198
Q

Filters are a good substitute for good compounding practices true or false

A

False

199
Q

______ micrometer filters can remove pathogenic microorganisms from PN

A

0.22 micrometers

200
Q

use a ____ micromolar filter for TNAs and separately infused ILE’s, but this wont filter out staph epidermis or E.coli

A

1.2

201
Q

use a _____ micromolar filter for 2 in 1 dextrose/amino acid admix with a SEPERATE infusion of ILE

A

0.22

202
Q

ILE’s filter size should be

A

1.2 micromoles

203
Q

how often should PN filters be exchanged for dextrose-amino acid solutions

A

every 24 hours or new infusion

204
Q

how often should PN filters be exchanged for lipids

A

every 10-12 hours for separately infused ILE’s

205
Q

0.22 micron filters cannot be used for ____ forms of TPN

A

3 in 1, not suitable for the ILE

206
Q

tubing and PN containers should be ________ and kept away from _____

A

refrigerated, away from light exposure

207
Q

when transitioning from PN to EN , the most common complication is

A

hyperglycemia (limit GIR to <4 mg/kg/min)

208
Q

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

A

PN

209
Q

critically ill patients with normal nutrition/no risk of malnutrition should avoid PN for

A

7 days

210
Q

is PN recommended as the first line of nutrition therapy in acute Chron’s or Ulcerative Colitis flare

A

no

211
Q

peri operative PN can be used in ____ with a risk assessment

A

severe malnutrition

212
Q

most errors when ordering PN happened during these steps in the process

A

transcription, prescription and administration

213
Q

a patient’s clinical condition should lead decision of whether to start or withhold therapy in these settings

A

hyperglycemia, azotemia, encephalopathy, hyperosmolality, severe fluid/electrolyte abnormalities

214
Q

once PN is infusing at goal rate in the hospital, what should be monitored

A

fluid ,electrolyte/renal status, daily BG, TCG/LFT periodically , visceral protein weekly, urine output

215
Q

this type of amino acid PN formulation is used for hepatic encephalopathy

A

branched chain amino acids and decreased aromatic amino acids

216
Q

patients under metabolic stress, trauma, thermal energy have increased needs for these types of amino acids

A

branched chain, essential

217
Q

patients with severe fluid restriction may need this special amino acid formula with ___ to ___ % acids

A

15-20%

218
Q

this type of lipid formulation for PN may be able to reduce risk of PNALD

A

SMOF

219
Q

ILE provide ___mmol/L of phosphorous

A

15

220
Q

this type of ILE has 100% fish oil

A

Omegaven

221
Q

single IV vitamin products are not available in these micronutrients

A

biotin, pantothenic acid, riboflavin, vitamin A,D or E

222
Q

a typical 10mL dose of MVI contains this much vitamin K

A

150 mcg

223
Q

single entity or multi trace elements provide ____ mg of zinc

A

3-6.5 mg

224
Q

single entity or multi trace elements provides ___ mg of copper

A

1-1.3

225
Q

single entity or multi trace elements provides ____ mcg of selenium

A

0-60 mcg

226
Q

per ASPEN recommendations when multiple ____ products are inappropriate for PN use ____ products should be used to meet a patient’s needs

A

element

single entity

227
Q

when using single entity copper reduce the amount to

A

0.3-0.5 mg/day

228
Q

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

A

0.1 mg, 40mcg

229
Q

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

A

dextran

230
Q

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

A

glutamine

231
Q

there is currently no form of IV glutamine because

A

not FDA approved, poor solubility/stability

232
Q

carnitine only comes in the form of _____ in parenteral nutrition for those with carnitine deficiency such as neonates and infants

A

L-carnitine

233
Q

in the setting of ILE shortage who should be prioritized

A

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

234
Q

in the setting of IV MVI shortage who should be prioritized

A

patients only on IV nutrition, medical need

235
Q

if there is a shortage of MVI, what alternatives are there

A
  1. consider oral/enteral MVI when EN or PO intake is started
  2. avoid liquid MVI as can cause GI upset
  3. Ration IV MVI to 50% 3x/week
  4. If MVI-13 not available, use MVI 12 (no vit K) and give separate IV vitamin K 150mcg/d or 5-10 mg/ week
236
Q

how much vitamin K IV is needed a day/week

A

150mcg/day

5-10 mg/week

237
Q

_____MVI’s should never be substituted for adults MVI

A

Pediatrics

238
Q

Adult IV MVI should be given to neonates because

A

they have propylene glycol, polysorbate and aluminum which can be toxic to neonates

239
Q

During an IV MVI shortage reserve electrolytes for _____ PN patients or patients with ______ need

A

sole

medical

240
Q

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

A

malabsorption or non functioning GI tract

241
Q

if a multi mineral/trace element formula for IV is not available, use ____ formulations

A

single IV

242
Q

withhold IV adult multi trace elements for the first month to _____ adult PN patients who are not critically ill or have pre existing deficits

A

newly initiated

243
Q

if calcium chloride is given in substitute for calcium gluconate in PN during a shortage, what must be taken into consideration

A

calcium chloride is much more INSOLUBLE that calcium gluconate and should be given in a separate IV line to avoid PN compatibility issues.

244
Q

the desired dextrose concentration for a TNA TPN solution is > ____ and >___% for amino acids to prevent ______destabilization

A

10% dextrose,
4% amino acids
lipid

245
Q

who’s responsibility is it to ensure that PN is prepared safely

A

Pharmacy

246
Q

an essential part of the PN compounding process is to create

A

a compound with an accurate formulation, free of microbes and particulate matter

247
Q

Review Current USP guidelines for PN safety/purity

A
  1. enforced for compounding sterile preparations
  2. assigns low, med, high risk
  3. 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
248
Q

trace elements can lead to contamination from these 6 substances

A 
aluminum
arsenic
chromium
zinc
manganese
copper
249
Q

the amount of contamination in PN depends on these 3 factors

A

manufacturer
vial size
concentrations

250
Q

The 2004 federal regulation state that _______ content must be labeled in large volume PN formulations, pharmacy bulk packaging and small volume PN formulas

A

aluminum

251
Q

the max amount of aluminum per liter allowed in Large Volume PN is

A

25mcg/L

252
Q

Storage of PN products in _____ which a high affinity for aluminum should instead by stored in ______ to decrease aluminum contamination

A

Don’t store in glass

STORE in plastic

253
Q

less than ___% of aluminum is absorbed by the GI tract

A

<1 %

254
Q

this organ is an effective barrier for aluminum

A

the lungs

255
Q

Extra aluminum during toxicity will deposit in these 4 areas

A

Lungs
Bones
Liver
Brain

256
Q

Which patients are at the highest risk for aluminum toxicity in PN

A 
Renal Dysfunction (cannot excrete)
High intake of PN products
Iron deficiency (transferrin assist with excretion)
Infants/Pedi patients
257
Q

what are the signs/symptoms of an aluminum toxicity

A

encephalopathy, osteomalacia, reduced PTH secretion, erythropoietin resistant microcytic anemia

258
Q

the FDA defines the upper limit of aluminum to be ___ and requires a ____ in the manufactures product

A

4-5mcg/kg/day; requires a warning statement

259
Q

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

A

7-10 (perioperatively)

260
Q

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

A

lower

261
Q

name 2 absolute indications for the use of PN

A

high output fistula especially if over 500mL/day and GI obstruction limiting po intake >1 week

262
Q

routine use of perioperative PN is indicated for severely malnourished patients to prevent preoperative complications when used for

A

> 7 days

263
Q

in a home PN patient TNA TPN, what should added immediately before infusion

A

multivitamin

264
Q

what are the recommended maximum PN components for fluid, g/kg carb, g/kg fat and g/kg protein

A

30-40mL/kg fluid
7g/kg carb
2.5 g/kg/day fat
2 g/kg protein (depending on the disease)

265
Q

the best way to express the dextrose content in PN to avoid misinterpretation

A

grams per 24 hour infusion

266
Q

max lipid infusion rate to avoid infusion complications

A
  1. 11 g/kg/hour lipid

1. 1 g/kg/day

267
Q

provide at least ___ to __% of linoleic acid to avoid EFAD

A

2-4%

268
Q

provide at least 0.25 to 0.5 % _____ to avoid EFAD

A

alpha linolenic acid

269
Q

avoid providing IVFE if serum triglycerides exceed

A

400mg/dL

270
Q

avoid infusion of >_____g/kg/hour of fat to a void hypertriglyceridemia

A

0.125 g/kg/hour

271
Q

when 2 oils are mixed together into an emulsion this is known as a ___ mixture

A

physical

272
Q

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

A

structured lipids

273
Q

what is the primary advantage of using structured lipids in TPNA

A

lowers serum triglyceride levels because they are utilized at a slower rate

274
Q

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

A

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

275
Q

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

A

glutamine and arginine

276
Q

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

A

arginine

277
Q

the most appropriate PN amino acid solution for the non-dialysis patient with acute renal failure contains

A

a balance of essential and non essential amino acids

278
Q

metabolic alkalosis is PN is mostly likely contributed by

A

amino acids; they have large amounts of endogenous acetate which metabolizes into excess bicarbonate

279
Q

the addition of______ to PN has the benefit of unaltered GI permeability

A

glutamine diphosphate

280
Q

the disadvantage of adding glutamine to PN is it can cause

A

hyperammonemia

281
Q

renal parenteral formulas have higher amounts of ____ compared to the standard

A

essential amino acids

282
Q

the addition of glutamine may be contraindicated in

A

hepatic failure

283
Q

Glutamine diphosphate can be added into PN as long as it is added within ___ hours compounding

A

48 hours

284
Q

this is a non-essential amino acid that is the primary fuel for the small bowel

A

glutamine

285
Q

A patient with an ileostomy getting TPN is likely to need supplemental

A

sodium, potassium and acetate (loss of bicarb through stool)

286
Q

what PN additive may cause throbocytopenia

A

heparin

287
Q

_____ 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

A

INR

288
Q

_____ 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

A

vitamin K

289
Q

____ 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.

A

Iron dextran

290
Q

the higher the ___ of an element, the higher the destabilizing power

A

valence

291
Q

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

A

fat soluble vitamins

292
Q

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

A

water soluble vitamins

293
Q

increased endogenous insulin levels that don’t adjust to the decrease in dextrose infusion following the discontinuation of PN is called

A

rebound hypoglycemia

294
Q

after stopping PN, blood glucose should be monitored for how long to prevent rebound hypoglycemia

A

30 minutes-1 hour

295
Q

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

A

rebound hypoglycemia

CNSC Exam (32 decks)

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