Parenteral Nutrition Part 3 Flashcards by Sydney Perry

Hyperglycemia from parenteral nutrition
RBG > _____ mg/dL
the target BG range is _______ mg/dL

180

140-180

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hyperglycemia is caused by

metabolic stress
medications
DM
excess CHO administration
overfeeding

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complications of hyperglycemia

dehydration
increased CO2 production
hepatic steatosis

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TO PREVENT HYPERGLYCEMIA

Administer dextrose in amounts _____ mg/kg/min

________ solution
Avoid _______

At risk patients, limit dextrose to _______ g/day on Day 1

Capillary glucose monitoring every ___ hrs

<4-5

Mixed substrate
overfeeding

100-150

6-8

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Hyperglycemia Treatment

reduce dextrose content in PN to _____

addition of regular _____ to PN
____ unit for every gram of dextrose

≤ 4 mg/kg/min

insulin
0.1

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Refeeding Syndrome (RS) is ________ that occur within the 1st few days after refeeding a starved patient

Metabolic alterations

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Refeeding Syndrome (RS)

Rapid shift of electrolytes from _______ to _____ due to _______

electrolyte abnormalities include ________, __________, and ________

bloodstream
cells
insulin

hypophosphatemia*
hypokalemia
hypomagnesemia

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_______ deficiency may manifest as a result of RS

Refeeding Syndrome (RS) Can cause=>
_________, ______, ______, ________, _______

Can be life-threatening

Thiamin

Respiratory failure
parethesias
muscle weakness
cardiac arrhythmias
hemolysis

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Individuals at Risk for RS

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

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individuals are at SIGNIFICANT risk for refeeding syndrome if they have any ____ of the following

BMI?
Wt loss?
Caloric intake?
Low levels of _______ before feeding

evidence of ____________
evidence of _____________

<16

7.5% in 3 month OR
>10% in 6 months

none for >7 days OR
<50% of EER for >5 days during acute illness or injury OR
<50% of EER for >1 month

K+, Phos, Mg

severe subcutaneous fat loss
severe muscle loss

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individuals are at MODERATE risk for refeeding syndrome if they have any ____ of the following

BMI?
Wt loss?
Caloric intake?
Low levels of _______ before feeding

evidence of ____________
evidence of _____________

16-18.5

5% in 1 month

none for 5-6 days OR
<75% of EER for >7 days during acute illness or injury OR
<75% of EER for >1 month

K+, Phos, Mg

severe subcutaneous fat loss
severe muscle loss

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REFEEDING SYNDROME PREVENTION AND TREATMENT

Identify patients at _____
Replete __________ levels

Include adequate amounts of __________ in initial PN solutions

Supplement with ______ before initiating feeding

Continue with _______ for _______ or longer in patients with _________, ____________, or if signs of deficiency

risk
low serum electrolyte

K+, Mg, Phos & vitamins

100 mg thiamin

100 mg/d
5–7 days
severe starvation
alcohol use disorder

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REFEEDING SYNDROME PREVENTION AND TREATMENT

Initiate kcal at _______ kcal/kg for the 1st _____

Limit initial CHO to _______ g/d on Day 1
_______ g/kg protein

Increase PN gradually by increasing by ______ kcal every ____ days as tolerated

Monitor serum electrolytes & fluid status as PN is advanced

10-20
24 hrs

100-150
1.2-1.5

100-300
1-3

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OVERFEEDING
Results in=>________, _______, _______

Particularly a concern for _________ patients

Consider other sources of kcal (e.g., TF, propofol, dextrose from IVF, PD, CRRT)

hyperglycemia
hypercapnia
lipogenesis

critically ill

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Hypertriglyceridemia is caused by

Excessive administration of ILE (total amount or rapid rate)

Hyperlipidemia

Dextrose overfeeding

Medications

Carnitine deficiency

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Hypertriglyceridemia Treatment

Increase infusion time: >10 hrs/d

Decrease lipid administration:
Provide <30% of kcal from fat or <1 g/kg/d

If chronic, EFAD replacement only

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EFAD is caused by

Inadequate fat administration

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To prevent EFAD
Provide a minimum of ____% of energy as _______ or ____% of energy from lipid

Minimum: _____ ml of ____% lipid ___/wk or _____ ml of ____% lipid once per week

2-4%
linoleic acid
10%

250
20%
2x
500
20%

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Prerenal Azotemia is

build up of nitrogenous waste

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Prerenal Azotemia is caused by

excessive protein administration

dehydration

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treatment for Prerenal Azotemia

decrease protein content of PN
increase fluid intake
monitor BUN

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complication from long term PN

metabolic bone disease

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can also do this to hopefullly get enough EFA

2 tbs safflower oil on skin every day

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metabolic bone disease come with ______ and ___________

bone pain
pathological fractures

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causes of metabolic bone disease

limited Ca intake hypercalciuria metabolic acidosis aluminum toxicity corticosteroids prolonged immobilization

METABOLIC BONE DISEASE Recommendations for prevention=> Provide adequate ____, _____, and ____ avoid _________ and ______ loads Rx ____________

Ca (10-15 mEq/d) Phos (20-40 mmol/d) Mg metabolic acidosis high protein weight-bearing exercise

Risk for GI for PN

atrophy bacterial translocation PNALD

GIT Atrophy & Bacterial Translocation etiology

Lack of intestinal stimulation by enteral nutrients

GIT Atrophy & Bacterial Translocation symptoms

enteric bacteremia sepsis

GIT Atrophy & Bacterial Translocation prevention

early use of GIT

GIT Atrophy & Bacterial Translocation treatment

Transition to enteral/oral feedings as tolerated

PN-Associated Liver Disease (PNALD) possible etiology

Overfeeding Dextrose-based PN with minimal ILE Excessive ILE EFAD

PN-Associated Liver Disease (PNALD) symptoms

Elevation of LFTs

PN-Associated Liver Disease (PNALD) prevention and management

Cyclic PN Avoid overfeeding Avoid dextrose infusion >5 mg/kg/min Use mixed substrate solution Decrease ILE to <1g/kg/d Rule out other causes

Catheter-Related complications

Catheter-Related Infections pneumothorax phlebitis catheter occlusion

Catheter-Related Infections possible etiology

Inappropriate technique in line placement Poor catheter care Contaminated solution

Catheter-Related Infections symptoms

Elevated WBC fever red hardened area around catheter site

Catheter-Related Infections prevention

Development of strict protocols for line placement and catheter care

Catheter-Related Infections treatment

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

pneumothorax possible etiology

Catheter placement by inexperienced personnel

pneumothorax symptoms

Dyspnea tachycardia

pneumothorax prevention

Catheter placement by experienced personnel

pneumothorax treatment

A large pneumothorax may require chest tube placement

Phlebitis possible etiology

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

Phlebitis symptoms

Redness swelling & pain at peripheral site

Phlebitis prevention

Minimize osmolarity of solution use of a mixed substrate solution

Phlebitis treatment

Change peripheral line site Consider TPN

Catheter Occlusion possible etiology

Venous thrombosis Fibrin sheath Solution precipitates

Catheter Occlusion symptoms

Inability to infuse fluid swelling or pain in the arm & neck

Catheter Occlusion prevention

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

Catheter Occlusion treatment

Anti-coagulation therapy with urokinase or streptokinase

What is the result of Calcium & Phosphorus Precipitation? This can cause ?

Forms an insoluble calcium-phosphate salt catheter occlusion & respiratory distress

Calcium & Phosphorus Precipitation Risk factors

Excessive Ca &/or Phos in PN Increased temperature Increased pH Order of mixing

Calcium & Phosphorus Precipitation Prevention

Avoid excessive Ca & Phos in PN solution [2 x Phos] + Ca must be <45 per liter of PN Provide additional Phos or Ca via a separate IV line

Example Ca-Phos Precipitation Calculation Patient is receiving 1.8 L of a 3-in-1 PN order which contains 15 mEq Ca and 35 mmol Phos. - How much per liter? - Assessment?

[2 x 35 mmol Phos] + 15 mEq Ca = 85 85/1.8 L = 47 per L Increased risk for Ca-Phos precipitation

Nutritional Needs for Patients on PN Energy: _____ kcal/kg Patients with obesity: _____ kcal/kg IBW Protein: Stable patients: ________ g/kg Critically ill patients: _______ g/kg Patients with obesity: ________ g/kg IBW

20-30 22-25 0.8–1.5 1.2-2.5 2.0-2.5

Volume guidelines for day 1 PN Based on estimated fluid needs and ________

patient tolerance

CHO guidelines for PN day 1 Begin with ______ grams For individuals with DM, hyperglycemia, or refeeding syndrome risk begin with ______ grams

150-200 100-150

Protein for day one PN __________________

Goal amount can usually be given

Lipid guidelines for PN DAY 1 Provide ILE if _________ is adequate

TG clearance

Standard Electrolytes for PN day 1

Recommend adjustments as needed

Standard vitamins & trace elements for PN day 1

Consider need for additions or restriction

Guidelines for Advancing PN If tolerating=> Increase to goal on day _____ _______ acceptable Glucose: ______ mg/dL TG ________ mg/dL Electrolytes=> adjust as needed based on serum levels

2 Fluid status ≤180 <400

Cyclic PN Begin with a ________________ and then ____________ provided daily (while _________) until goal hours achieved Achieved over ______ days Stable patients can tolerate _____ hours/day cycle

24-hr continuous infusion decrease hours increasing infusion rate 3-4 8-12

Cyclic PN—Glucose Fluctuations when _________________ Rebound _____________ Taper rate to ______ the goal infusion rate for _____________ Monitor glucose __________, __________, and _____________ and also monitor until ____________ is established

beginning & ending TPN hypoglycemia half first and last hour 2 hrs after initiation mid cycle 2 hrs after cycle completed tolerance

Discontinuing PN Therapy Do not abruptly stop TPN=> ______________ Taper TPN=>Reduce infusion rate by ____% for the ____ _______ and ____% in the _____ before discontinuation Or can hang an __________ Monitor serum _______

rebound hypoglycemia 50 1st hour 50 2nd hour IV solution of D10 glucose