Parenteral Nutrition Part 1 Flashcards
the delivery of nutrients directly into the bloodstream intravenously
Parenteral Nutrition
PN is indicated in conditions that preclude the use of the GIT for more than ____ days
these include ?
7-10
a non-functioning GI tract
bowel rest
bowel issues
EN not available
condition that cause non-functioning GI tract
prolonged small bowel ileus
severe malabsorption
intractable vomiting or diarrhea
severe short bowel syndrome
small bowel ischemia
severe GIB
needing PN for bowel rest from _________ or ___________
severe exacerbation of IBD
radiation enteritis
bowel indications for PN
bowel obstruction
bowel perforation
high output small bowel fistula
PN needed if EN _____ is not feasible or failed trials of EN (________)
access
post-pyloric
Contraindications to PN
Functioning GIT
Treatment < 7 days
Inability to obtain venous access
Prognosis that does not warrant aggressive nutrition support
carbohydrate in PN is in form of _______
provides ____ kcal/g
commercially available in concentrations (______)
dextrose monohydrate
3.4
5-70%
DEXTROSE
______ mg/kg/min for stable patients
_____ for patients with DM or hyperglycemia
_____ mg/kg/min for critically ill patients
4-5
low end (4)
<4
Excessive dextrose/carb administration can results in _________, ________, and ______.
hyperglycemia
increased CO2 production
fatty liver
calculation for maximum CHO dose
4 or 5 mg X wt in kg X 1440 (min in day)
divide by 1000 to convert to g
You have a 60 kg patient who has Type 1 DM. What is the max amount of CHO the patient should be given in a day?
345.6
Source of Protein in PN is ___________
Contain all ____ and some ____
Concentrations: ______%
Provides ___ kcal/g
crystalline amino acids
EAA
NEAA
3% - 20%
4.0
Currently ________ is not included in crystalline AA solutions because it is ____
glutamine
unstable
Lipids in PN are called _________
Lipid injectable emulsions (ILEs)
Source of ILEs: _________
usually ________ and also may contain ______ and ________
Long-chain fatty acid emulsions
Soybean oil
egg yolk phospholipid & glycerol
ILEs are _____ dense and _______
Calorie
Isotonic
Alternative Lipid Injectable Emulsions Available in the U.S. is a __________ called ________.
mixed oil lipid injectable emulsion
smoflipid
smoflipid consists of
30% soybean oil
30% MCT oil
25% olive oil
15% fish oil
There is a mixed oil PN formula for pediatric patients with _______
this formula is called ______
PN associated cholestasis
omegaven
Omegaven is rich in _______ and believed to have _________ effects
omega-3 FA
anti-inflammatory effects
most commonly used percent of lipid emulsion
20%
10% Lipid emulsion:
_____ kcal/mL or ____ kcal/g
1.1
11
20% Lipid emulsion:
____ kcal/mL or ___ kcal/g
2.0
10
30% Lipid emulsion [only available for ______]: ____ kcal/mL or ___ kcal/g
Total Nutrient Admixture (TNA)
3.0
10
minimum requirements
_____% of total kcal needs from _____ acid
____% of total kcal needs provided as lipid in PN should prevent EFAD
2-4
linoleic
10
OPTIMAL FAT INTAKE
______% of kcal from fat; or
____ g/kg/d for stable patients and ___ g/kg/d for critically ill patients
Reduces the complications of solely dextrose-based PN=>hyperglycemia, respiratory compromise
Provide _____, ____ infusion (>___ hrs/d)
20-30
1
<1
slow, continuous
10
CONSEQUENCES OF FAT OVERLOAD
Hypertriglyceridemia
hypertriglyceridemia from fat overload can cause ________, ________, ________, and ______
Impaired immune response
Hepatic steatosis
Acute Pancreatitis
Impaired vascular integrity
impaired immune system from fat overload can cause __________________
impaired immune system function comes from_______, which inhibits _______ immune response
hepatic reticuloendothelial system (RES) dysfunction
linoleic acid
cell-mediated
CONTRAINDICATIONS OF LIPIDS
- ________
- ________
use with caution in _______ and ______
Egg allergy
severe hyperlipidemia
severe sepsis
multiple organ dysfunction syndrome (MODS)
Lipid clearance is monitored by ______
check levels _____________
serum TG
prior to initiation and after
Hold ILE if serum TG level is >____ mg/dL
If serum TG continues to be >_____ mg/dL=> ______________________
400
400
limit ILE to minimum amount to prevent EFAD
Cofactor necessary for the transport of LCFA for beta-oxidation is _______
carnitine
is carnitine in PN formulas?
no
At risk for deficiency of carnitine=>
_______ and _______
premature infants
dialysis patients
Deficiency of carnitine can result in…
_______
______
______
______
hypertriglyceridemia
fatty liver
muscle weakness
cardiomyopathy
How to treat carnitine deficiency
An IV form of L-carnitine
Vitamins provided together in a ____ dose of “standard vitamins”
Requirements ____ from DRI’s
Parenteral requirements for many vitamins are ______ for many of the vitamins due to __________ in PN
10 ml
differ
higher
decreased stability
ASPEN Recommendations for PN vitamins
dont think I need to know this
Thiamin: 6 mg
Riboflavin: 3.6 mg
Niacin: 40 mg
Folic acid: 600 mcg
Pantothenic acid: 15 mg
Pyridoxine: 6 mg
Vitamin B12: 5 mcg
Biotin: 60 mcg
Ascorbic acid: 200 mg
Vitamin A: 990 mcg
Vitamin D: 5 mcg
Vitamin E: 10 mg
Vitamin K: 150 mcg
Trace elements
Commercial preparation: _____ ml/day
Parenteral requirements for most trace elements are ______ than the DRIs because there is _________ when given IV
1
lower
100% absorption
ASPEN Recommendations for PN Trace Elements
Zinc
Copper
Manganese
Chromium
Selenium
Zinc: ___ mg/d
Additional __ mg/d for _____ patients
Patients with EC fistulae, diarrhea, & intestinal drainage may require up to _____ of lost fluid
3-5
2
hypermetabolic
12–17 mg/L
Copper: _____ mg/d
0.3-0.5
Manganese: ___ mcg/d
55
Chromium: ____ mcg/d
10-15
Selenium: _____ mcg/d
60-100
Not routinely included in standard trace element preparations=> _____, ____, and ____
Cholestatic liver disease=> ___ and ___ should be omitted from PN
Iron
Iodine
Molybdenum
Cu & Mn
Daily Electrolyte Guidelines for PN include which ones
sodium
potassium
magnesium
calcium
phosphorous
chloride
acetate
Sodium: _____ mEq/kg
1-2
Potassium: ____ mEq/kg
1-2
Magnesium ____ mEq
8-20
Calcium ____ mEq
10-15
Phosphorus ____ mmol
20-40
Chloride: _____
as needed to maintain acid-base balance
Acetate: ______
as needed to maintain acid-base balance
Available forms of Sodium:
phosphate
chloride
acetate
Available forms of Potassium:
phosphate
chloride
acetate
Available forms of Calcium:
gluconate
Available forms of Magnesium:
sulfate
ELECTROLYTE ADJUSTMENTS
May need to increase if abnormal ______(urinary, GI or dermal) or ______
May need to decrease if=> _____ or _____
Individual electrolytes can be adjusted to correct imbalances
losses
refeeding syndrome
renal failure
CHF
ACID-BASE BALANCE
Usually maintained by using ______ & ______ (___ ratio)
Metabolic acidosis=> provide more _____
Metabolic alkalosis=>provide more _____
chloride
acetate
1:1
acetate
chloride
Major problem in the U.S. is PN shortages
Shortages due to=> manufacturing issues, company ________, drug recalls, companies can’t keep up with _____
Affecting both macro- and micronutrients
Resulting in=> serious adverse patient outcomes
- Use of suboptimal alternatives, errors, inadequate nutrition & deficiencies
closures
demand
Strategies for Managing PN Shortages
1. Assess each patient for need for PN
2. Use _____________ when possible
3. Assess at individual level the need for _________
4. Prioritize patients
5. Rationing
oral or enteral nutrients
specific nutrients
Rationing examples
providing ____% dose of MVI
MVI ____/week; ILE ___/week
If MVI not available, administer individual parenteral _____, _____, _____, and _____ daily.
50
3x
1x
thiamin
ascorbic acid
pyridoxine
folic acid
