Parenteral Nutrition (TPN) Flashcards by Kim Nguyen

Indications for TPN

GI tract dysfunction from malabsorption, obstruction, or dysmotility
Adjunctive treatment for cancer
Pancreatitis
Critically ill
Perioperative
Hyperemesis
Eating disorders

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Features of central TPN

Provides “complete” TPN, osmolality of components generally exceeds 900 mOsm/L

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Who to choose peripheral TPN in

No significant malnutrition
Have good peripheral vascular access
Can tolerate large volumes of fluid (2.5-3L/day)
Need 5-14 days of parental nutritional support

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Steps to initiating TPN regimen

Establish vascular access
Calculate macronutrient requirements
Evaluate electrolyte needs
Evaluate trace element and vitamin needs
Evaluate fluid requirements
Determine insulin need
Review compatibility

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Daily requirement of sodium and potassium

1-2 mEq/kg

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Daily requirement of chloride and acetate

PRN to balance acid/base status

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Daily requirement of calcium

10-15mEq

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Daily requirement of magnesium

8-20 mEq

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Daily requirement of phosphate

20-40 mMol

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What happens if there’s a vitamin shortage?

Don’t use pediatric product in adults and vice versa; if vitamins are completely out, attempt to give individual vitamins

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Trace element needs

Deficiency syndromes generally occur with un-supplemented, long-term parenteral nutrition; requirements vary on the basis of the patient’s clinical condition

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Increased fluid requirements: environment

Radiant warmer
Increased ambient temperature
Excessive sweating

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Increased fluid requirements: GI losses

Diarrhea, vomiting
Ostomy or fistula drainage
NG tube suction

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Increased fluid requirements: urinary losses

Glycosuria, diuretics, diabetes insipidus

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Increased fluid requirements: miscellaneous

Hyperthyroid, hyperventilation, phototherapy

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Decreased fluid requirements: environment

Heat shields, high humidity

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Decreased fluid requirements: diseases/conditions

HF, ESRD/CKD, SIADH, hypoalbuminemia with starvation, humidified air via mechanical ventilation

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Usual fluid requirements

30-40ml/kg/day or 1ml/kcal/day

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Calcium phosphate compatibility: amino acid concentration

Increases pH, decreases solubility

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Calcium phosphate compatibility: amino acid product composition (pH or PO4 content)

Important to evaluate a change in amino acid product to determine if solubility will be impacted

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Calcium phosphate compatibility: calcium and PO4 concentrations

Increasing the concentration of calcium and/or PO4 decreases solubility

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Calcium phosphate compatibility: calcium salt

Gluconate less dissociated than chloride

NEVER ADD CACL TO A TPN BAG

Calcium phosphate compatibility: dextrose concentration

Lowers pH, increases solubility

Calcium phosphate compatibility: pH of formulation

Low pH favors the presence of monobasic calcium phosphate (aka more soluble)

Calcium phosphate compatibility: temperature

Inverse solubility (increase temp, decrease solubility)

Calcium phosphate compatibility: order of mixing

ADD PHOSPHATE BEFORE CALCIUM

Medication administration in TPN criteria

Compatibility and stability have been established Clinically effective as a continuous solution Drug dosage is stable (can't titrate up!) TPN infusion rate is stable

TPN components

Protein, carbs, lipids

Protein conversion

4 kcal/g | 6.25g protein=1g nitrogen

Most common carb source

Dextrose

Dextrose conversion

3.4 kcal/g

Glycerol conversion

4.3 kcal/g

Lipids (IVFE) are available as what product?

Oil suspensions in an aqueous medium (so basically an emulsion)

Emulsifying agent in IVFE

Egg phospholipid --> avoid in patients with an egg allergy

Lipid emulsions are also a source of what vitamin?

Vitamin K, which can interfere with warfarin!

Oil in a lipid emulsion

Soybean oil (IVLE)--> avoid in patients with a soybean allergy

Lipid conversion

9 kcal/g

Lipid emulsions: monitoring

Monitor for infusion reactions, especially on the first dose Hypertriglyceridemia Hepatic toxicity (PNALD) with chronic TPN

Refeeding syndrome

Rapid, severe depletion of potassium, magnesium, and phosphate in starved patients

Refeeding syndrome treatment

Aggressive supplementation of lytes plus thiamine 50-100mg/day

The more nutritionally depleted a patient is, what does that do to the rate of administration?

The rate decreases

TPN complications: economic

It's very expensive; labor intensity, frequency of monitoring and management of complications contribute to cost

TPN complications: mechanical

Pneumothorax, thrombosis, thrombophlebitis (PPN)

TPN complications: infectious

Line sepsis/fungemia, increased bacterial translocation

TPN complications: metabolic

Electrolyte abnormalities, hyper/hypoglycemia, hypertriglyceridemia, fluid overload, osteoporosis/osteomalacia

TPN complications: GI tract

Hepatobiliary (PNALD)

How often to monitor fluid and weights during TPN

Daily

How often to monitor glucose during TPN

q1-6h

How often to monitor electrolytes during TPN

daily-three times a week

How often to monitor LFTs during TPN

1-2x/week

How often to monitor visceral proteins during TPN

1-2x/week

How often to monitor CBC, PT/PTT during TPN

1-2x/week

How often to monitor protein turnover during TPN

weekly

How often to monitor lipids during TPN

weekly