Parenteral Nutrition (part 3)

Question 1

Hyperglycemia is a common metabolic complication with parental nutrition, this could mean that someone’s random blood glucose is over ____ mg/dL

Answer 1

180

Question 2

Hyperglycemia can be caused by…

Answer 2

-Metabolic stress
-Medication
-Diabetes
-Excess carbohydrate administration
-Overfeeding

Question 3

Complications of hyperglycemia:

Answer 3

-Dehydration
-Increased CO2 production
-Hepatic steatosis

Question 4

Target blood glucose range is between ____-____ mg/dL

Answer 4

140-180

Question 5

How can we prevent hyperglycemia?

Answer 5

-Administer dextrose in amounts less than or equal to 4-5 mg/kg/min
-Mixed substrate solution
-Avoid overfeeding
-At risk patients, limit dextrose to 100-150 g/day on day 1
-Capillary glucose monitoring every 6-8 hours

Question 6

Treatment for hyperglycemia:

Answer 6

-Reduce dextrose content in PN to less than or equal to 4 mg/kg/min
-Insulin therapy: addition of regular insulin to PN

Question 7

How should insulin be dosed for someone on PN?

Answer 7

-0.1 unit of regular insulin for every gram of dextrose provided OR
-2/3 the previous day’s sliding scale insulin requirement

Question 8

____ ____ is metabolic alterations that occur within the first few days after refeeding a starved patient

Answer 8

Refeeding Syndrome

Question 9

Refeeding Syndrome occurs due to a rapid shift of _____ from the bloodstream to cells due to insulin

Answer 9

Electrolytes

Question 10

This shift of electrolytes leads to…

Answer 10

-Hypophosphatemia
-Hypokalemia
-Hypomagnesemia

Question 11

____ deficiency may manifest as a result of refeeding syndrome

Answer 11

Thiamin

Question 12

Refeeding syndrome can cause…

Answer 12

-Respiratory failure
-Paresthesias
-Muscle weakness
-Cardiac arrhythmias
-Hemolysis
-Death

Question 13

Individuals at risk for refeeding syndrome are those with:

Answer 13

-Anorexia nervosa
-Alcohol and substance use disorders
-Cancer
-Mental health disorders
-Malabsorption
-Starvation
-Critical illness
-AIDS

Question 14

Individuals at significant risk of refeeding syndrome have any 1 of the following:

Answer 14

-BMI <16
-Weight loss of 7.5% in 3 months or >10% in 6 months
-Caloric intake: none or negligible for >7 days or <50% of EER for >5 days during acute illness/injury or <50% of EER for >1 month
-Low levels of K+, phos, or magnesium before feeding
-Evidence of severe subcutaneous fat loss
-Evidence of severe muscle loss

Question 15

Individuals at moderate risk of refeeding syndrome have 2 of the following:

Answer 15

-BMI: 16-18.5
-Weight loss 5% in 1 month
-Caloric intake: none or negligible for 5-6 days or <75% of EER for >7 days during acute illness/injury or <75% of EER for >1 month
-Low levels of K+, phos, or magnesium before feeding
-Evidence of moderate subcutaneous fat loss
-Evidence of moderate or mild muscle loss

Question 16

Prevention and treatment of refeeding syndrome:

Answer 16

-Identify patients at risk
-Replete low serum electrolyte levels
-Include adequate amounts of potassium, magnesium, phosphorus, and vitamins in initial PN solutions
-Supplement with 100 mg thiamin before initiating feeding; continue with 100 mg/d for 5-7 days or longer in patients with severe starvation, alcohol use disorder, or if signs of thiamin deficiency

Question 17

To prevent refeeding syndrome, we should initiate PN kcal at ___-___ kcal/kg for the 1st 24 hours

Answer 17

10-20

Question 18

To prevent refeeding syndrome, we should also limit initial carbohydrates to ___-___ g/d on day 1

Answer 18

100-150

Question 19

To prevent refeeding syndrome, we should provide ___-___ g/kg of protein

Answer 19

1.2-1.5

Question 20

To prevent refeeding syndrome, we should increase PN gradually, advancing by ___% of goal every 1-2 days to reach goal in 3-5 days

Answer 20

33%

Question 21

In those at risk for refeeding, we should monitor serum ____ and ___ ___ as PN is advanced

Answer 21

Electrolytes and fluid status

Question 22

Overfeeding results in…

Answer 22

-Hyperglycemia
-Hypercapnia
-Lipogenesis

Question 23

Overfeeding is particularly common for ____ ____ patients

Answer 23

Critically ill

Question 24

We need to consider other sources of ____, such as from tube feedings, propofol, dextrose from IVF, PD, and CRRT

Answer 24

Calories

Question 25

Hypertriglyceridemia is caused by...

Answer 25

-Excessive administration of lipid injectable emulsions (total amount or rapid rate) -Hyperlipidemia -Dextrose overfeeding -Medications -Carnitine deficiency

Question 26

Treatment for hypertriglyceridemia:

Answer 26

-Increase infusion time: 10 or more hours/day -Deceased lipid administration: provide <30% of kcal from fat or less than or equal to 1 g/kg/d -If chronic, EFAD replacement only

Question 27

Essential fatty acid deficiency is caused by...

Answer 27

-Inadequate fat administration

Question 28

Essential fatty acid deficiency can be prevented by...

Answer 28

-Providing a minimum of 2-4% of energy as linoleic acid or 10% of energy from lipid -Minimum: 250 ml of 20% lipid 2x/week or 500 ml of 20% lipid once per week

Question 29

Prerenal azotemia is caused by...

Answer 29

-Excessive protein administration -Dehydration

Question 30

Treatment for prerenal azotemia:

Answer 30

-Decrease protein content of parenteral nutrition solution as appropriate -Increase fluid intake -Monitor BUN

Question 31

Metabolic ____ disease is a long-term complication of parenteral nutrition

Answer 31

Bone

Question 32

Metabolic bone disease causes...

Answer 32

-Bone pain -Pathological fractures

Question 33

Metabolic bone disease has a multifactorial etiology that includes...

Answer 33

-Limited Ca intake -Hypercalciuria -Metabolic acidosis -Aluminum toxicity -Corticosteroids -Prolonged immobilization

Question 34

Recommendations for the prevention of metabolic bone disease:

Answer 34

-Provide adequate calcium (10-15 mEq/d) -Provide adequate phosphorus (20-40 mmol/d) -Provide adequate magnesium -Avoid metabolic acidosis -Avoid high protein loads -Prescribe weight-bearing exercise

Question 35

Possible etiology of GIT atrophy and bacterial translocation with parenteral nutrition:

Answer 35

-Lack of intestinal stimulation by enteral nutrients

Question 36

Symptoms of GIT atrophy and bacterial translocation:

Answer 36

-Enteric bacteremia -Sepsis

Question 37

Prevention of GIT atrophy and bacterial translocation:

Answer 37

-Early use of GIT

Question 38

Treatment of GIT atrophy and bacterial translocation:

Answer 38

-Transition to enteral/oral feedings as tolerated

Question 39

Possible etiology of parenteral nutrition-associated liver disease:

Answer 39

-Overfeeding -Dextrose-based parenteral nutrition with minimal lipid injectable emulsion -Excessive lipid injectable emulsions -Essential fatty acid deficiency

Question 40

Symptoms of parenteral nutrition-associated liver disease:

Answer 40

-Elevation of liver function tests

Question 41

Prevention and management of parenteral nutrition-associated liver disease:

Answer 41

-Cyclic parenteral nutrition -Avoid overfeeding -Avoid dextrose infusion >5 mg/kg/min -Use mixed substrate solution -Decrease mixed substrate solution -Decrease injectable lipid emulsions to <1 g/kg/d -Rule out other causes

Question 42

Possibly etiology of catheter-related infections:

Answer 42

-Inappropriate technique in line placement -Poor catheter care -Contaminated solution

Question 43

Symptoms of a catheter-related infection:

Answer 43

-Elevated white blood cells -Fever -Red, hardened area around the catheter site

Question 44

Prevention of catheter-related infections:

Answer 44

-Development of strict protocols for line placement and catheter care

Question 45

Treatment of catheter-related infections:

Answer 45

-IV antibiotics -Remove catheter and place at another site (last resort)

Question 46

Possible etiology of a pneumothorax:

Answer 46

-Catheter placement by inexperienced personnel

Question 47

Symptoms of pneumothorax:

Answer 47

-Dyspnea -Tachycardia

Question 48

Prevention of pneumothorax:

Answer 48

-Catheter placement by experienced personnel

Question 49

Treatment of pneumothorax:

Answer 49

-A large pneumothorax may require chest tube placement

Question 50

Possibly etiology of phlebitis:

Answer 50

-Peripheral administration of hypertonic solution (>900 mOsm/L) -Line infiltration

Question 51

Symptoms of phlebitis:

Answer 51

-Redness, swelling, and pain at peripheral site

Question 52

Prevention of phlebitis:

Answer 52

-Minimize osmolarity of solution -Use of a mixed substrate solution

Question 53

Treatment of phlebitis:

Answer 53

-Change peripheral line site -Consider TPN

Question 54

Possible etiology of catheter occlusion:

Answer 54

-Venous thrombosis -Fibrin sheath -Solution precipitates

Question 55

Symptoms of catheter occlusion:

Answer 55

-Inability to infuse fluid -Swelling or pain in the arm or neck

Question 56

Prevention of catheter occlusion:

Answer 56

-Routine catheter flushing -Prophylactic anticoagulation therapy -Monitor solution for precipitation -Calculate the Ca-Phos precipitation check

Question 57

Treatment of catheter occlusion:

Answer 57

-Anticoagulation therapy with urokinase or streptokinase

Question 58

Calcium and phosphorus precipitation causes the formation of an insoluble ____-____ salt

Answer 58

Calcium-phosphorus

Question 59

Calcium and phosphorus precipitation can result in...

Answer 59

-Catheter occlusion -Respiratory distress

Question 60

Risk factors for calcium and phosphorus precipitation:

Answer 60

-Excessive calcium and/or phosphorus in parenteral nutrition -Increased temperature -Increased pH -Order of mixing

Question 61

How to prevent calcium and phosphorus precipitation:

Answer 61

-Avoid excessive calcium and phosphorus in parenteral nutrition -Provide additional phosphorus or calcium via separate IV line

Question 62

Formula for determining if the amount of phosphorus and calcium is appropriate:

Answer 62

[2 x Phos] + Ca must be less than or equal to 45 per liter of parenteral nutrition

Question 63

A parenteral nutrition prescription begins with nutrition assessment, which includes...

Answer 63

-Current clinical condition, GI status, past medical history -Assess for need/validate rationale for parenteral nutrition -Determination of nutrition diagnoses/problems, nutritional status, and goals

Question 64

What else should be done before a parenteral nutrition prescription is made?

Answer 64

-Calculation of energy, protein, max carbohydrate utilization, fluid, electrolyte, and micronutrient needs -Selection of route: TPN vs PPN -Institutional factors (compounding method, product availability)

Question 65

Energy needs for someone on parenteral nutrition:

Answer 65

20-30 kcal/kg

Question 66

Energy needs for an obese patient on parenteral nutrition:

Answer 66

22-25 kcal/kg IBW

Question 67

Protein needs for a stable patient on parenteral nutrition:

Answer 67

0.8-1.5 g/kg

Question 68

Protein needs for critically ill patients on parenteral nutrition:

Answer 68

1.2-2.5 g/kg

Question 69

Protein needs for patients with obesity on parenteral nutrition:

Answer 69

2.0-2.5 g/kg IBW

Question 70

For day 1 of parenteral nutrition, volume should be based on...

Answer 70

-Estimated fluid needs -Patient tolerance

Question 71

For day 1 of parenteral nutrition, we should begin with ____-____ grams of carbohydrates

Answer 71

150-200

Question 72

For those with diabetes, hyperglycemia, or refeeding syndrome risk, we should begin day 1 of parenteral nutrition with ____-____ grams of carbohydrates

Answer 72

100-150

Question 73

On day 1 of parenteral nutrition, the ____ amount of protein can usually be given

Answer 73

Goal

Question 74

We can provide lipid injectable emulsions on day one if _____ clearance is adequate (<400 mg/dL)

Answer 74

Triglyceride

Question 75

On day 1, we can provide standard ____ and recommend adjustments as needed

Answer 75

Electrolytes

Question 76

We can also provide standard ____ and ___ ___ on day 1 of parenteral nutrition, and consider the need to additions or restrictions

Answer 76

Vitamins and trace elements

Question 77

If tolerating, we can increase everything to goal by day ____ of parenteral nutrition

Answer 77

2

Question 78

If someone is tolerating their parenteral nutrition, that would mean that...

Answer 78

-Fluid status is acceptable -Glucose is less than or equal to 180 mg/dL -Triglycerides <400 mg/dL -Electrolytes: adjust as needed based on serum levels

Question 79

With cyclic parenteral nutrition, begin with a 24-hour continuous infusion and then decrease the hours provided daily while increasing ___ ___ until goal hours are achieved

Answer 79

Infusion rate

Question 80

The process of switching from continuous to cyclic parenteral nutrition is achieved over ___-___ days

Answer 80

3-4

Question 81

Stable patients can tolerate ____-___ hour/day cycle

Answer 81

8-12

Question 82

There will be fluctuations in ____ when beginning and ending cyclic parenteral nutrition

Answer 82

Glucose

Question 83

Cyclic parenteral nutrition can cause _____ hypoglycemia

Answer 83

Rebound

Question 84

In order to decrease the risk of rebound hypoglycemia, we should taper the rate to _____ the goal infusion rate for the first and last hour

Answer 84

Half

Question 85

When should we be monitoring glucose in someone one cyclic parenteral nutrition (before tolerance is established)?

Answer 85

-2 hours after initiation -Mid-cycle -2 hours after cycle is complete

Question 86

We should not abruptly stop total parenteral nutrition because it can lead to ____ ____

Answer 86

Rebound hypoglycemia

Question 87

How should we taper TPN in order to discontinue use?

Answer 87

-Reduce infusion rate by 50% for the 1st hour and 50% in the 2nd hour before discontinuation

Question 88

If a TPN taper can not be done, we can also hang an IV solution of ____

Answer 88

D10

Question 89

When we do discontinue PN, we should closely monitor ____ ____

Answer 89

Serum glucose