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PHRM 825 > PHRM 825: Parenteral and Enteral Nutrition > Flashcards

PHRM 825: Parenteral and Enteral Nutrition Flashcards

1
Q

The provision of nutrients can be through what routes?

A
  • Oral
  • Enteral
  • Parenteral
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2
Q

Purposes of provision of nutrients

A
  • Weight maintenance or gain
  • Support of anabolism and nitrogen balance
  • Preserve/restore lean body mass
  • Correct nutritional deficiencies
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3
Q

Providing optimal nutrition support therapy requires convergence of which skills of patient care

A
  • Assessment of pt nutritional status/requirements
  • Identifying proper route and techniques for nutrition therapy
  • Relating the pathophysiology of patient/s diseases, clinical conditions, diagnostic tests, lab parameters, and medication therapy
  • Evaluating medication-nutrient interactions
  • Appropriately formulate, administer, monitor, and adjust nutrition support therapy
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4
Q

What are the 3 routes of nutrition support

A
  • Enteral nutrition (EN)
  • Parenteral nutrition (PN)
  • Combination feeding
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5
Q

How long is short-term nutrition used?

A

<3 weeks

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6
Q

What types of tubes are used to administer short-term enteral nutrition?

A
  • Nasogastric (NG)
  • Nasoenteric (duodenal (ND), jejunal (NJ)
  • Orogastric tube (OG), oroenteric (duodenal (OD), jejunal (OJ)
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7
Q

What type of tubes are used to administer long-term enteral nutrition?

A

-PEG
-Gastrostomy
-Jejunostomy
(These are surgically placed)

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8
Q

What system is enteral nutrition placed in?

A

Digestive system

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9
Q

What system is parenteral nutrition placed in?

A

Cardiovascular system

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10
Q

What should never be given in a peripheral vein?

A

TPN

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11
Q

What does TPN stand for?

A

Total parenteral nutrition

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12
Q

What does PPN stand for?

A

Peripheral Parenteral Nutrition

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13
Q

How is PPN administered?

A
  • Peripheral vein

- Midline catheter access

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14
Q

How long should a peripheral vein be used to administer PPN?

A

<7-10 days

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15
Q

How long should a central venous catheter be used to administer central parenteral nutrition?

A

> 6 weeks

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16
Q

What types of tubes are used to administer central parenteral nutrition?

A
  • Central venous catheter (subclavian (SC), internal jugular (IJ), femoral)
  • Peripherally inserted central catheter (PICC)
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17
Q

What is combination therapy?

A

Administration of both EN and PN

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18
Q

What is bridge therapy?

A
  • Type of combination therapy

- EN patients unable to meet caloric/protein requirements may require PN supplementation

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19
Q

Combination therapy preserves _____ and ____ of the GI tract

A

enterohepatic circulation; barrier function

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20
Q

5 risk factors for malnutrition

A
  • Unintentional weight change
  • Body weight 20% under BMI
  • NPO (>7-10 days)
  • Increased metabolic needs
  • Inadequate nutrient intake
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21
Q

What is a concerning amount of unintentional weight change?

A

> 10% within 6 months or >5% within 1 month

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22
Q

What can cause an increase in metabolic needs for a patient?

A
  • Trauma

- Burn patients

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23
Q

What patients are at risk for inadequate nutrient intake?

A
  • Alcoholics/substance abusers

- Chronic disease states with impaired ability to ingest or absorb food adequately

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24
Q

2 classifications of malnutrition

A

Acute and chronic

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25
Q

What is acute malnutrition?

A

Status of a protein-depleted patient with adequate fat reserves

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26
Q

What is chronic malnutrition?

A

Depletion of protein and fat stores, with the classic emaciated-appearing malnourished patient

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27
Q

What is Kwashiorkor

A

Type of malnutrition considered to be caused by dietary deficiency (particularly protein) that develops over several weeks/months

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28
Q

Features of Kwashiorkor

A
  • Hypoalbuminemia
  • Anemia
  • Edema
  • Muscle atrophy
  • Delayed wound healing
  • Impaired immunocompetence
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29
Q

In the developed world, a syndrome with characteristics similar to kwashiorkor follows what?

A

The stress response (Can be persistent and severe if feedig is not commenced within 7-10 days)

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30
Q

What is Marasmus?

A

Type of malnutrition classically considered to be caused by dietary deficiency of protein and calories that develops over months to years

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31
Q

Features of Marasmus

A
  • Weight loss
  • Reduced basal metabolism
  • Depletion of subcutaneous fat and tissue turgor
  • Bradycardia
  • Hypothermia
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32
Q

What does marasmus result from?

A

A mild injury response caused by chronic disease that produces anorexia or semi-starvation, with loss of lean tissue

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33
Q

What subjective and objective data is obtained from the nutritional assessment?

A
  • Clinical evaluation (weight, BMI, deficiencies)
  • Nutritional history
  • Medical history (diseases, medications)
  • Anthropometric measurements
  • Biochemical/laboratory assessment
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34
Q

What are examples of anthropometric measurements and who are they done by?

A
  • Done by dietitions

- Measurements of skinfold thickness, mid-arm muscle circumference, wast circumference, bioelectrical impedance

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35
Q

What are examples of biochemical/laboratory assessments done during the nutritional assessment

A
  • Visceral proteins
  • Nitrogen balance studies
  • Serum concentrations of trace elements, minerals, vitamins
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36
Q

Daily protein requirements can be individualized by what?

A

Measuring 24-hour urine collection (UUN)

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37
Q

What is nitrogen balance?

A

Measurement of urinary excretion of nitrogen as urea nitrogen

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38
Q

What is nitrogen balance used to assess?

A

Adequacy of protein repletion

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39
Q

Nitrogen released from protein catabolism is converted to ___ and excreated in ___

A

urea; urine

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40
Q

Protein demands increase during ____

A

stress

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41
Q

What non-urinary sources is nitrogen lost from?

A
  • Sweat
  • Feces
  • Respirations
  • GI fistulas
  • Wound drainage
  • Burns
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42
Q

What is the nitrogen IN equation?

A

Nitrogen IN = 24 hour protein intake (grams)/6.25

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43
Q

What is the nitrogen OUT equation?

A

24 hour UUN (grams) + 4

4 is a correction factor that accounts for non-urinary nitrogen losses

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44
Q

What does UUN mean?

A

Urinary urea nitrogen

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45
Q

What is the goal for nitrogen balance?

A
  • Zero for maintenance
  • +3-5 grams for repletion
  • Use 4 grams as general goal
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46
Q

How many kcal/g in protein?

A

4

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47
Q

How many kcal/g in carbohydrates?

A

3.4

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48
Q

How many kcal/g in lipids

A

9

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49
Q

How many kcal/g in propofol?

A

1.1

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50
Q

What does refeeding syndrome cause?

A

Rapid fall in Mg+2, Phos, and K+ levels

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51
Q

What are the goals of nutrition support?

A
  • Balance calorie and protein intake to body’s metabolic capacities to ensure efficient nutrient utilization
  • Accurately estimate or measure the patient’s calorie and protein requirements, avoid overfeeding (and potentially beneficial is short-term permissive underfeeding)
  • Closely monitor patient’s response to nutrition support therapy
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52
Q

Adjustments to therapy should be guided by ____; rather than relying solely on protein and energy ____

A

the patient’s tolerance; requirement estimates/measures

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53
Q

What does BEE stand for?

A

Basal energy expenditure

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54
Q

What is basal energy expenditure?

A

Metabolic activity required to maintain life (i.e. respiration, body temperature, other essential functions)

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55
Q

What does basal energy expenditure also mean?

A

Basal metabolic rate

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56
Q

What is the harris-benedict equation used to find?

A

basal energy expenditure (aka basal metabolic rate)

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57
Q

What is the resting energy expenditure (REE) also known as?

A

resting metabolic rate (RMR)

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58
Q

What is the resting energy expenditure?

A
  • number of calories required during 24 hours in a non-active state
  • ~10% higher than BEE
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59
Q

What is total energy expenditure (TEE)?

A

-Calories required to maintain current body weight

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60
Q

What is the total energy expenditure equation?

A

TEE = BEE X activity or stress factor

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61
Q

If actual BW <130% of IBW what weight should you use?

A

Actual BW

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62
Q

If actual BW >1300% of IBW what weight should you use?

A

Nutritional BW

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63
Q

In obese patients with Actual BW > 150% of IBW what weight should you use?

A

Ideal BW

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64
Q

_____ in obesity is associated with better outcomes

A

permissive underfeeding

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65
Q

What is the standard percentage of non-protein calories that are fat?

A

30%

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66
Q

What is the standard percentage of non-protein calories that are dextrose?

A

70%

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67
Q

What does indirect calorimetry measure?

A

Volume of oxygen consumpton (VO2) and carbon dioxide production (VCO2)

68
Q

What is the respiratory quotient (RQ) equation?

A

RQ = VCO2/VO2

69
Q

What is the RQ for fat?

70
Q

What is the RQ for proteins?

71
Q

What is the RQ for carbohydrates?

72
Q

What is the goal RQ?

73
Q

What happens if RQ > 1?

A

Overfeeding and lipogenesis is occurring

74
Q

What happens if RQ < 0.7?

A

Underfeeding patient

75
Q

What is enteral nutrition (EN)?

A

Nutrition provided by long-term (gastrostomy or jejunostomy) or short-term (nasogastric, nasoduodenal, or nasojejunal) tube feedings

76
Q

What is the rule when deciding whether to use parenteral or enteral nutrition?

A

“If the gut works, use it” –> always use enteral when possible

77
Q

What is the first line of nutrition when the gut works but energy needs cannot be met via oral route?

A

Enteral nutrition

78
Q

Physiologic advantage of EN over PN

A

Maintain gut integrity, prevent villi atrophy

79
Q

Immunologic advantage of EN over PN

A

Fewer infectious complication than PN, prevent bacterial translocation

80
Q

Safety advantage of EN over PN

A

EN avoids catheter sepsis, embolus, arterial laceration, pneumothorax

81
Q

Cost advantage of EN over PN

A

Less expensive than PN, less equipment/personnel

82
Q

Indications for EN

A

Inability to consume or absorb adequate nutrients due to inability to consume or where oral consumption is contraindicated

83
Q

Conditions that would result in an inability to consume food or where oral consumption is contraindicated

A
  • CVA; dysphagia
  • Dementia
  • Head & neck surgery
  • Esophageal obstruction
  • Trauma/burn
84
Q

Contraindications for EN

A
  • Expected need less than 5-10 days
  • Severe acute pancreatitis
  • High-output proximal fistulas
  • Inability to gain access
  • Intractable vomiting and diarrhea
  • GI ischemia
  • Ileus
85
Q

The ___ and ____ of the intestines dictate the volume, type, and choice of EN

A

length and absorptive capacity

86
Q

What is the range of caloric density for EN?

A

1-2 kcal/mL

87
Q

When is 1 kcal/mL used for EN?

A

Most of the time –> It is the most common density

88
Q

When is 2 kcal/mL used for EN?

A

For patients with fluid restrictions (CKD, etc.)

89
Q

What is included in an EN formulation?

A
  • Carbohydrates
  • Protein
  • Fat
  • Fiber
  • Water
  • Electrolytes
  • MVI
  • Trace elements
  • Immune-modulating nutrients
90
Q

What are examples of EN protein supplements and how many grams of protein do they contain?

A

Prostat 1 gel tube = 15 g protein

Beneprotein 1 packet = 6 g protein

91
Q

What are examples of EN carbohydrate supplements?

A
  • Polycose
  • Duocal
  • Benecalorie
92
Q

What is an example of EN fiber supplement?

93
Q

What mechanical complications can occur with EN?

A
  • Feeding tube misplacement, clogging, aspiration

- Airway/GI injury leading to respiratory compromise or abdominal abscess/infection

94
Q

What gastrointestinal complications can occur with EN?

A
  • Gastroparesis
  • GERD (large gastric volume, increased abdominal pressure)
  • Diarrhea
  • Constipation
95
Q

What metabolic complications can occur with EN?

A
  • Hyperglycemia
  • Electrolyte, vitamin and mineral deficiencies
  • Refeeding syndrome
  • Dehydration
96
Q

When monitoring EN, what 4 factors should you initially look at?

A
  • Intake and output
  • Weight
  • Feeding tube position
  • Gastric residual volume
97
Q

Can drugs be administered via feeding tube?

98
Q

Many meds can be ___ and administered down a feeding tube, then ___

A

crushed; flushed

99
Q

When should you not crush medications and put them down a feeding tube?

A

When they have a special delivery system (sustained-release or enteric coated)

100
Q

Mixing liquid medications with EN formuations can cause _____, which can result in ___ or ___

A

Physical incompatibilities; drug malabsorption or clogging of feeding tubes

101
Q

How to unclog feeding tubes

A

Pancreatic enzyme table, sodium bicarbonate tablet, 10 mL of warm water

102
Q

What drug-EN interactions can occur?

A

Reduced bioavailability or suboptimal pharmacologic effect

103
Q

What is parenteral nutrition (PN)?

A

Means by which protein, energy, nutrient and metabolic requirements, can be delivered by direct venous infusion for those patients who are unable to tolerate, absorb or accumulate sufficient nutrients by the usual enteral route

104
Q

What is PN composed of?

A
  • Macronutrients
  • Micronutrients
  • Medications
105
Q

What macronutrients are found in PN?

A
  • Crystalline amino acids as protein

- Non-protein calories: dextrose and fat emulsions

106
Q

What micronutrients are found in PN?

A
  • Electrolytes
  • Vitamins
  • Trace elements
107
Q

What does TNA stand for?

A

Total nutrient admixture

108
Q

What is 3-in-1 TNA?

A
  • Carbohydrates, fat, and amino acids in the same IV admixture
  • Milky appearance
109
Q

What is 2-in-1 TNA?

A
  • Carbohydrates and amino acids in the same IV admixture
  • Several commercially prepared pre-mixed formulations
  • Fat infused separately
110
Q

How is central PN delivered?

A

Delivered by a large diameter vein

111
Q

What is a PICC line used for?

A
  • ~2-6 week therapy

- Home use

112
Q

How is peripheral PN (PPN) delivered?

A

Delivered by a peripheral vein, usually of the hand or forearm

113
Q

What are the limitations of PPN?

A
  • Dextrose (12.5%)
  • Calcium and phosphorus content
  • Osmolarity max 900-1100 mOsm/L
114
Q

PPN is not recommended for who?

A

Patients with severe stress, malnutrition, considerable caloric/electrolyte requirements, or PN >5days

115
Q

Indications for PN

A
  • Nonfunctioning/inaccessible GI tract

- Prolonged NPO course >7 days

116
Q

What makes the GI tract nonfunctioning or inaccessible resulting in need for PN?

A
  • Bowel ischemia
  • Intractable vomiting diarrhea
  • Hyperemesis gravidum
  • Gastrointestinal bowel obstruction/ileus
  • Severe inflammatory bowel disease
  • Short bowel syndrome
117
Q

What are contraindications for PN?

A
  • Functioning GI tract
  • Treatment anticipated <7 days in patients without severe malnutrition
  • Inability to obtain venous access
  • A prognosis that does not warrant PN
  • When the risks of PN exceed the benefits
118
Q

What is custom PN?

A

PN solution order individualized for a particular patient and compounded in the pharmacy

119
Q

What are standard central or peripheral premixed formulas?

A
  • Sterile ready-to administer packages of IV nutrients
  • Intended for direct dosing to patients with minimal adaptation
  • With or without electrolytes
  • Usually used for patients started on PN during weekends, short-term therapy, ileus, supplement to oral or enteral nutrition
120
Q

What mechanical complications can occur with PN?

A
  • Infusion pump failure
  • Catheter-related complications: pneumothorax, migration to wrong vein, improper positioning within cardiac chambers, arterial puncture bleeding
121
Q

What infectious complications can occur with PN?

A
  • Central venous catheter (CVC) infection

- Infection 2/2 solution contamination

122
Q

What metabolic complications can occur with PN?

A

PN associated liver disease, hypertriglyceridemia, hyperglycemia, refeeding syndrome, essential fatty acid deficiency, metabolic bone density

123
Q

What is refeeding syndrome?

A
  • Severe fluid and electrolyte abnormalities associated with metabolic complications that develop during nutritional repletion in underweight, severely malnourished, or severely starved patients
  • Associated with parenteral, enteral , or oral nutrition
124
Q

How to prevent refeeding syndrome

A
  • Identify patients at risk
  • Correct electrolyte abnormalities before initiating nutrition support
  • Determine nutritional goals AVOID OVERFEEDING
  • “Start low and go slow” (for patients at risk, start ~25% and increase to goal over 3-5 days
125
Q

What factors influence the chemical/physical stability of IV admixtures?

A
  • pH
  • Concentrations
  • Temperature
  • Order/time of mixing
126
Q

Medications frequently used with PN

A
  • Typical additives (electrolytes, vitamins, trace elements)
  • Insulin
  • Histamine-2 receptor antagonists
127
Q

How to reduce the risk of destabilization of PN

A
  • Keeping the final amino acid concentration at 2.5% or more
  • Maintaining a final pH >5
  • Keeping final dextrose concentration at 3.3% or greater
  • Avoiding trivalent cations (iron dextran)
  • Avoiding mixing dextrose and lipid directly
  • Add lipid last, after all other components (except vitamins) are mixed
128
Q

What 2 elements are common essential electrolytes

A

Calcium and phosphorus

129
Q

What happens if the calcium and phosphorus concentrations are too high?

A

It can result in an insoluble precipitate

130
Q

Calcium-phosphorus precipitation is especially problematic in what type of TPN?

131
Q

What are the 8 steps for writing a TPN?

A
  • Gather pertinent information from the patient’s chart
  • Calculate patient’s goal calorie needs
  • Calculate patient’s goal protein needs
  • Check units
  • Electrolytes/additives
  • Calculate flow rate
  • Start slowly, advance over 2-3 days
  • Order appropriate monitoring parameters
132
Q

What information is important to gather when preparing to write a TPN?

A
  • Weight, IBW, NBW
  • Height
  • Age
  • PMH, surgical hx
  • Current medications
  • Baseline labs, I/Os
  • Line access
133
Q

How to calculate protein calories

A

Protein calories = grams protein X 4 kcal/gram

134
Q

What is the equation for non-protein calories?

A

non-protein calories = total kcal - protein kcal

135
Q

How to calculate flow rate for TPN?

A
  • Convert all components’ calories to mL
  • Check solutions used by institution
  • Add up TPN volume (all components)
  • Divide by 24 hours = rate/hour
136
Q

Initiation of TPN administration

A
  • Calculate total nutrition requirements, plan day 1 calories, order appropriate labs for monitoring, along with accuchecks and possible sliding scale insulin
  • Administer with appropriate filter
  • Increase to meet goals
137
Q

Discontinuation of TPN

A

-Taper TPN as patient makes way to transitional feedings; be sure to d/c insulin

138
Q

Cycling TPN administraiton

A

Not recommended to administer >200 mL/hour

139
Q

How does nutrition vary in people with short bowel syndrome?

A
  • Dietary recs base on presence/absence of a colon
  • With colon: high carb-low fat diet
  • Vitamin B12 supplement should be considered
140
Q

How does nutrition vary in people with diabetes?

A
  • Maintain glucose levels between 110-220 mg/dL
  • Give 30% of total kcal as fat
  • Gastric atony and delayed emptying is typical in type 1 diabetes
141
Q

How does nutrition vary in people with cardiac disease?

A
  • Avoid overfeeding

- Fluid restriction

142
Q

How does nutrition vary in people with renal disease?

A
  • Fluid restriction recommended
  • Pre-dialysis: low protein
  • Dialysis: standard protein
143
Q

Pre-dialysis: low protein values for people with renal insufficiency

A
  • Renal insufficiency, otherwise “normal” patient: 0.5-0.8 g/kg
  • Renal insufficiency who are post-op: 0.5-1 g/kg
144
Q

Dialysis: standard protein values for people with renal insufficiency

A
  • Patients receiving intermittent HD: 1-1.3 g/kg

- Patients on continuous renal replacement therapy 1.5-2 g/kg (~20% amino acids filtered off)

145
Q

How does nutrition vary in people with pulmonary failure?

A
  • Calories: 20-30 kcal/kg; give 30-50% of total kcal as fat; protein 1-2 g/kg
  • Limit carbohydrates; avoid overfeeding
146
Q

How does nutrition vary in people with hepatic disease?

A
  • High calorie intake (35 kcal/kg/day)
  • If no encephalopathy, standard protein (1-1.2 g/kg/day)
  • If encephalopathy, protein restriction (0.6 g/kg/day)
  • Sodium restrictio if ascites or edema
147
Q

How does nutrition vary in people with GERD?

A

-Make sure H2 antagonist or PPI is ordered, place in TNP if available (famotidine)

148
Q

How does NG suctioning affect nutrition in patients?

A

May cause hyponatremia, hypokalemia, and/or hypochloremia

149
Q

How does N/V affect nutrition in patients?

A

May lead to hypovolemia, Na+, imbalance, hypokalemia

150
Q

How does dialysis affect nutrition in patients?

A

Removes ~10-20% amino acids

151
Q

How does wound healing affect nutrition in patients?

A

Consider adding zinc, vitamin C

152
Q

How do loop diuretics affect nutrition in patients?

A

May cause hypokalemia, Na+ imbalances

153
Q

How do steroids affect nutrition in patients?

A

May increase blood sugars, may need to add insulin

154
Q

Continuous reassessment of nutrition is required because nutrition requirements are ____

155
Q

Medications may affect ___ and ___

A

Nutritional monitoring parameters and goals

156
Q

You should not attempt to correct ___ via TPN

A

Acute electrolyte disturbances

157
Q

Goal daily calories (kcal/kg/day) for non-stressed, non-depleted patients

158
Q

Goal daily calories (kcal/kg/day) for trauma/stress/surgery/critically ill patients

159
Q

Goal daily calories (kcal/kg/day) for major burn patients

160
Q

Goal daily calories (kcal/kg/day) for obese patients (>150% IBW)

A

22-25 (IBW)

161
Q

Goal daily protein (grams/kg/day) for maintenance (non-hospitalized) people

162
Q

Goal daily protein (grams/kg/day) for mild-moderate (repletion/medical floor)

163
Q

Goal daily protein (grams/kg/day) for moderate-severe (trauma, surgery, ICU)

164
Q

Goal daily protein (grams/kg/day) for burn patients

165
Q

Goal daily protein (grams/kg/day) for obese >150% IBW

PHRM 825 (36 decks)

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