Parenteral Nutrition Part 3 Flashcards
Hyperglycemia from parenteral nutrition
RBG > _____ mg/dL
the target BG range is _______ mg/dL
180
140-180
hyperglycemia is caused by
metabolic stress
medications
DM
excess CHO administration
overfeeding
complications of hyperglycemia
dehydration
increased CO2 production
hepatic steatosis
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
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
Refeeding Syndrome (RS) is ________ that occur within the 1st few days after refeeding a starved patient
Metabolic alterations
Refeeding Syndrome (RS)
Rapid shift of electrolytes from _______ to _____ due to _______
electrolyte abnormalities include ________, __________, and ________
bloodstream
cells
insulin
hypophosphatemia*
hypokalemia
hypomagnesemia
_______ 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
Individuals at Risk for RS
Anorexia nervosa
Alcohol & substance use disorders
Cancer
Mental health disorders
Malabsorption
Starvation
Critical illness
AIDS
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 _____________
1
<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
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 _____________
2
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
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
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
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
Hypertriglyceridemia is caused by
Excessive administration of ILE (total amount or rapid rate)
Hyperlipidemia
Dextrose overfeeding
Medications
Carnitine deficiency
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
EFAD is caused by
Inadequate fat administration
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%
Prerenal Azotemia is
build up of nitrogenous waste
Prerenal Azotemia is caused by
excessive protein administration
dehydration
treatment for Prerenal Azotemia
decrease protein content of PN
increase fluid intake
monitor BUN
complication from long term PN
metabolic bone disease
can also do this to hopefullly get enough EFA
2 tbs safflower oil on skin every day
metabolic bone disease come with ______ and ___________
bone pain
pathological fractures
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
