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PN Flashcards

1
Q

What is the British Specialist Nutrition Association?

A

British Specialist Nutrition Association:
* A trade association representing manufacturers of high quality nutrition designed to meet the needs of people with specialist nutritional requirements.
* Trade association that represents high quality specialist nutritional & aesptically compounded products
* Via EN, PN

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2
Q

Which people use the British Specialist Nutrition Association products?

A

People who use the British Specialist Nutrition Association products:
* Infants from 0-12m (infant formula, baby foods)
* Young children <3Y
* Patients with diseases, disorders or medical conditions
* People who are critically ill
* People with chronic illnesses

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3
Q

Which stakeholders do BSNA (British Specialist Nutrition Association) liaise with?

A

The BSNA (British Specialist Nutrition Assocition liaise with:
* Government bodies
* Health organisations (e.g. NHS, BAPEN, BDA)
* Policy makers
* Healthcare professionals

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4
Q

Why do the BSNA liaise with a range of stakeholders?

A

The BSNA liaise with a range of stakeholders to:
* ensure that patients have suitable access to product
* increase the understanding and awareness of PN
* explore the attitudes towards PN use in certain areas of care (e.g. palliative oncology)
* ensure that the views and interests of BSNA members are protected

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5
Q

Which 3 companies are represented by the British Specialist Nutrition Association for PN?

A

3 companies are represented by the British Specialist Nutrition Association for PN:
* Fresenius Kabi
* BRAUN
* Baxter

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6
Q

Why is adequate clinical nutrition important?

A

Adequate clinical nutrition importance:
* Improved wound healing
* Reduced incidence of complications
* Reduced length of hospital stay
* Increased survival
* Faster recovery
* Better quality of life

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7
Q

When might PN use be indicated?

A

PN use might be indicated when:
* Intestinal failure: short bowel syndrome, ileus
* ENT tolerance is poor
* Gut is inaccessible
* Gut is not functioning
* Critical care
* Gastroparesis
* To support fluid intake
* To help meet requirements entirely or partially

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8
Q

Stepwise nutritional interventions for nutrition support

A

Stepwise nutritional interventions for nutrition support:
1. Food fortification
2. Oral nutritional supplements
3. Enteral feeding tube
4. Parental feeding

May be used as a combined approach

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9
Q

If only a portion of nutritional needs can be met by EN due to vomiting, malabsorption, excessive losses etc. what might be used?

A

If only a portion of nutritional needs can be met by EN due to vomiting etc. PN may be required.

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10
Q

Identification of nutritional needs for Parenteral Nutrition

A

Identification of nutritional needs for Parenteral Nutrition:
Assessment
* Essential to have comprehensive assessment before PN is commenced
* Nutrition Support Team: NCEPOD
* Detailed dietetic ax A-F: progressing to appropriate care plan considering optimum artificial feeding techniques
* Support from MDT
* Detailed examination of metabolic, nutritional or functional variables usually by members of a nutrition team.
* Think beyond weight

Screening
* Rapid simple process conducted by admitting staff (usually nurses and/or HCAs)
* All patients should be screened
* NICE 2006: Screening should result in early identification of patients who might have otherwise been missed
* Identify malnutrition and those at risk of malnutrition
* Examples of screening tools (MUST BE VALIDATED): MUST, NRS-2002, STRONGKIDS, NUTRIC, Renal iNUT

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11
Q

NCEPOD findings

A

NCEPOD findings:
* Found that patients on PN that were under the nutrition support team received better care in comparison to those that did not have a NST when receiving PN

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12
Q

Considerations for PN assessment

A

Considerations for PN assessment:
* Is the GI tract functioning?
* Is the GI tract accessible?
* Are there any factors that may impact electrolyte, fluid or nutrient requirements e.g. kidney function
* Is the patient malnourished?
* Are they able to meet all or only some of their requirements?
* Micronutrient status
* PN formulas are not usually nutritionally complete (micronutrients need to be added to standard bags)
* Is the patient at risk of refeeding?
* Who will be managing the PN?

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13
Q

What is it important to consider when identifying malnourished patients?

A

When identifying/assessing malnourished patients it is important to consider that:
* BMI is not the best indicator of malnourishment
* Muscle mass can be a key indicator of risk of malnutrition related outcomes
* E.g. patients with a similar BMI could have a different composition of muscle & fat
* Other methods could be used with BMI: other anthropometric measures: BIA (bioelectrical impedence), HGS: measure for function of muscle, skinfold measures: TSF, calf measurements, circumference measures.
* Has the patient lost weight? Previous wts?
* Sarcopenia: could be hidden if not taking measures other than wt
* It is important not to just use BMI/weight when assessing patients. Dietitians have other knowledge

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14
Q

What is Bioelectrical Impedence Analysis?

A

Bioelectrical Impedence Analysis:
* Body composition analysis equipment
* it is able to make an estimation of body composition (e.g. quantities of fat mass and fat-free mass) by running a small electrical current through the body.
* Different body tissues have different electrical electrical conductivity is different between various bodily tissues (e.g. muscle, fat, bone, etc.) due to their variation in water content
* The small electrical current passes through the tissues at different speeds.
* Using the speed that the electrical current passes through, the machine is able to calculate the impedance (i.e. the resistance of the electrical current [Z]) of the current and estimate body composition

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15
Q

Whon might be included in the MDT team for PN?

A

Healthcare professionals who may be included in the MDT team for PN (depends on patient’s presenting complaint):
* Doctor/ Physician
* Nurse
* Pharmacist
* Dietitian
* Surgeon
* Radiologist
* Microbiologist
* Psychologist
* Biochemist

The patient is at the centre of care

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16
Q

What does evidence suggest about the involvement of the MDT in PN?

A

Evidence suggests that MDT input improves patient assessment prior to beginning PN and review when PN is established.

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17
Q

What is Intestinal Failure?

A

Intestinal failure:
* inability to maintain adequate nutrition
and/or fluid balance via the intestines
* inability to maintain protein-energy, fluid, electrolyte or micronutrient balance
* The small intestine is unable to digest and absorb the correct amounts of nutrients
* The body does not reabsorb fluids produced normally by the intestines, such as digestive juices.

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18
Q

What are the causes of intestinal failure?

A

Causes of intestinal failure:
* Obstruction
* Dysmotility
* Surgical resection
* Congenital defect
* Disease-associated loss of absorption

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19
Q

Classification of intestinal failure

A

Classification of intestinal failure:
Type 1: Short Term, Self limiting
* Usually the result of abdominal surgery
* Short period
* Patient care: managed in non-specialist units
* Patients receive: fluid, electrolytes, enteral and/or parenteral nutritional support for a short period
* Patients make full recovery without complication
* Causes: Intestinal obstruction/pseudo-obstruction, Acute intestinal inflammation e.g. IBD, Ileus e.g. abdominal trauma, intra-abdo sepsis

Type 2: Severely ill patients
* Usually in patients with major resection who are also septic and have metabolic/nutritional complications post-op
* Patient care: usually ICU/CC/HDU for part/all of stay
* Metabolically unstable
* Management by specialist intestinal failure MDT is often needed
* Causes: post-operative complications e.g. anastomotic leakage, intestinal obstruction. GI diseases e.g. Crohn’s, radiation enterititis
Type 3: Chronic IF requiring long term nutritional support
* Patient care: Home parenteral nutrition (HPN) if usually indicated for these patients
* Need PN at home to survive
* Causes: intestinal resection (s) e.g. Crohn’s disease, small bowel infaction. GI disease e.g. Crohn’s disease. Small bowel dysfunction e.g. pseudo-obstruction

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20
Q

What is ileus?

A

Ileus: intolerance of oral intake due to inhibition of the gastrointestinal propulsion without signs of mechanical obstruction

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21
Q

Classification of intestinal failure: Type 1: Short Term, Self Limiting

A

Classification of intestinal failure:
Type 1: Short Term, Self limiting
* Usually the result of abdominal surgery
* Short period
* Patient care: managed in non-specialist units
* Patients receive: fluid, electrolytes, enteral and/or parenteral nutritional support for a short period
* Patients make full recovery without complication
* Causes: Intestinal obstruction/pseudo-obstruction, Acute intestinal inflammation e.g. IBD, Ileus e.g. abdominal trauma, intra-abdo sepsis

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22
Q

Classification of intestinal failure: Type 2: Severely Ill Patients

A

** Classification of Intestinal Failure: Type 2: Severely ill patients**
* Usually in patients with major resection who are also septic and have metabolic/nutritional complications
* Patient care: usually ICU/CC/HDU for part/all of stay
* Metabolically unstable
* Management by specialist intestinal failure MDT is often needed
* Causes:
1. post-operative complications e.g. anastomotic leakage, intrabdominal abcesses, intestinal obstruction, post-operative intestinal iscahemia
2. . GI diseases e.g. Crohn’s, radiation enterititis, obstructive malignancy

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23
Q

Classification of intestinal failure:

Type 3: Chronic IF requiring long term nutritional support

A

Classification of intestinal failure:

Type 3: Chronic IF requiring long term nutritional support
* Patient care: Home parenteral nutrition (HPF) if usually indicated for these patients
* Need PN at home to survive
* Causes:
1. intestinal resection (s) e.g. Crohn’s disease, small bowel infarction, short bowel syndrome, high output fistulae
2. GI disease e.g. Crohn’s disease, radiation enteritis, obstruvtive malignancy
3. Small bowel dysfunction e.g. pseudo-obstruction, fistulae

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24
Q

What is Short Bowel Syndrome?

A

Short Bowel Syndrome:
A large part of the small intestine is missing, removed or damaged.

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25
Q

What are 3 common types of intestinal resection & anastomosis observed in patients with short bowel syndrome?

A

3 common types of intestinal resection & anastomosis observed in patients with short bowel syndrome:
* Ileocolonic anastomosis: reconnects ileum (the end of small intestine) to the remaining part of the colon
* Jejunocolic anastomosis: reconnects jejunum (mid part of the small intestine) to the remaining part of the colon
* End-jejunostomy: no colon

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26
Q

Is it possible for a patient to go back and forth between classifications of intestinal failure?

A

Yes, it is possible for a patient to go back and forth between the 3 classifications of intestinal failure.

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27
Q

British Society of Gastroenterology: LT fluid/nutritional support needed by patitents with a short bowel. SBS Guidelines

A

BSG: LT fluid/nutritional support needed by patitents with a short bowel. Guidelines for management of patients with a short bowel (diagram from lecture)
Jejunum-Colon
* 0-50cm: PN
* 51-100cm: ON
* 101-150cm: None
* 151-200cm: None

Jejunostomy
* 0-50cm: PN + PS
* 51-100cm: PN + PS (at 85-100cm may need PS only)
* 101-150cm: ON + OGS
* 151-200cm: OGS

PN= Parenteral Nutrition
PS= Parenteral saline
ON= Oral or enteral nutrition
OGS= Oral or enteral glucose/saline solution

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28
Q

Which nutrients are typically absorbed in the Ileum?

A

Nutrients absorbed in the ileum:
* Vitamin B12
* Water (moderate)
* Na (moderate)
* Bile acids
* Intrisic factor (not a nutrient per say, helps to absorb B12)

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29
Q

Which nutrients are typically absorbed in the jejunum?

A

Nutrients typically absorbed in the jejunum:
* CHOs: Monosaccharides
* Ca
* Folate
* Fat soluble vits: A,D,E, K
* Fat: Monoglycerides & Free fatty acids
* Small amount of : B12, Na
* Moderate amount of: water

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30
Q

What is prolonged ileus?

A

Prolonged ileus:
Temporary slowing in GI motility in the absence of a mechanical intestinal obstruction following physiological stress.

Physiological stressors include:
* Surgery
* Sepsis
* Metabolic derangements
* GI disease

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31
Q

What are potential physiological stressors that cause Prolonged Ileus?

A

Potenial Physiological stressors that cause Prolonged Ileus include:
* Surgery
* Sepsis
* Metabolic derangements
* GI disease

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32
Q

Following abdominal surgery, how long is a period of ileus expected in the:
* Small intestine
* Stomach
* Colon (large intestine)

A

Following abdominal surgery, a period of ileus expected in the:
* Small intestine for: 0-24H
* Stomach for: 24-48 H
* Colon (large intestine: 48-72H

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33
Q

What is obstipation?

A

Obstipation:
a severe form of constipation that results in a person being unable to have a bowel movement.

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34
Q

When is prolonged postoperative ileus indicated?

A

Prolonged Postoperative Ileus is indicated when:
* Patient has signs or symptoms of paralytic ileus: obstipation and intolerance of oral intake
* Signs and symptomsof paralytic ileus occur for >3-5days

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35
Q

What are signs & symptoms of proplonged postoperative ileus?

A

Signs & symptoms of prolonged postoperative ileus:
* Obstipation (severe form of constipation when patient is unable to have a bowel movement) for > 3-5days
* Intolerance of oral intake for >3-5days

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36
Q

What is a fistulae?

A

Fistulae:
* An abnormal opening that connects to or more organs or spaces inside or ouside of the body.

In GI tract can be divided into 2 groups:
* Internal: abnormal opening between adjacent hollow viscera
* External: abnormal opening between the GI tract and the surface of the body

Malnutrition is present in 55-90% of external fistula patients

37
Q

What to do when considering PN in patients with Prolonged Ileus?

A

Considering PN in Prolonged Ileus (/IF):
* Liaise with surgeons
* Is the patient malnourished?
* Is it an elective surgery?
* Could a trial be beneficial?

38
Q

The higher up the fistulae is in the GI tract the ? at risk the patient is of malnutrition

A

The higher up the fistulae is in the GI tract the more at risk the patient is of malnutrition

39
Q

Malnutrition is present in ?-?% of external fistula patients

A

Malnutrition is present in 55-90% of external fistula patients

40
Q

What are neonates?

A

Neonates: A newborn baby <4weeks old

41
Q

Is PN commonly indicated in preterm (premature) babies?

A

Yes PN is commonly indicated in preterm (premature) babies. It is typically led by pharmacists/ specialist medical practitioners.

42
Q

Why is PN particularly important in preterm babies?

A

PN particularly important in preterm:
* Preterm babies have an immature gut
* They have limited energy stores

43
Q

Organizations & indications/ advice of when to commence PN
* ESPEN: ICU
* ESPEN: Surgery
* ESPEN: Geriatrics

A

Organizations & advice of when to commence PN
ESPEN: ICU
* If oral & EN are contraindicated: initiate PN within 3-7days
* It is suggested in agreement with low to very low evidence that EN should be preferred over PN.
ESPEN (2020): Surgery
* Unable to meet nutritional requirements via oral/enteral (<50% of energy) for >7days: combo of EN and PN is advised to increase energy intake.
* If contrainidication of EN: PN should be commenced as soon as possible.
Study (Woodcock et al., 2001):
* Pragmatic, prospective study of 562 patients (more males than females).
* Patients with gastric obstruction given TPN, those without given EN, people with observed but uncertain potential issues with IF randomised to EN or TPN.
* People with doubts about gut function should be given TPN
* EN was related with inadequate oral intake
* Limitation: the study didn’t include people with or without gut obstruction receiving both EN or TPN
ESPEN: Geriatrics
* Older adults with reasonable prognosis.
* Oral/enteral intake impossible for >3days or below at least half of energy requirements for >1week.

44
Q

Indication of PN:
ESPEN Guideline: Clinical Nutrition in Surgery (2020)
& critique of evidence

A

ESPEN (2020): Surgery
* Unable to meet nutritional requirements via oral/enteral (<50% of energy) for >7days: combo of EN and PN is advised to increase energy intake.
* If contrainidication of EN: PN should be commenced as soon as possible.
Study (Woodcock et al., 2001):
* Pragmatic, prospective study of 562 patients (more males than females).
* Patients with gastric obstruction given TPN, those without given EN, people with observed but uncertain potential issues with IF randomised to EN or TPN.
* People with doubts about gut function should be given TPN
* EN was related with inadequate oral intake
* Limitation: the study didn’t include people with or without gut obstruction receiving both EN or TPN

45
Q

Parenteral Nutrition may not be suitable for:

A

Parenteral Nutrition may not be suitable for:
* Patients prognosis doesn’t warrant aggressive nutritional support: e.g. high mortality risk
* Patients with a functional and usable GI tract that is capable of nutrient absorption
* Risks of PN exceed benefits
* Other methods of nutrition support are more appropriate/cost effective/could be better tolerated

46
Q

NIHR RCT Critically Ill patients EN vs PN (2016)

A

NIHR RCT Critically Ill patients EN vs PN (2016):
* No significant differences in deaths between the two groups
* No significant differences for length of stay in CC, infection complications, organ support
* Vomiting & hypoglycaemia more common in EN group
* Cost was higher for PN r (£2421)

47
Q

What is Parenteral Nutrition?

A

Parenteral Nutrition:
* Provision of nutrition intravenously via a central or peripeherally placed line directly into the systemic circulation (via the blood)

48
Q

Why is Parenteral Nutrition usually used?

A

Parenteral Nutritionis usually used to meet nutritional needs when oral/enteral feeding isn’t enough or feasible

49
Q

Can Parenteral Nutrition only be used in specific age groups?

A

No, Parenteral Nutrition can be used in ALL age ranges.

50
Q

Since Parenteral Nutrition is administer intravenously, what happens?

A

Since Parenteral Nutrition is administer intravenously is bypasses all metabolism steps that occur in the digestive system and the enzymes.

51
Q

It is important that parenteral nutrition is ? and ? ? as it is bypassing the steps of metabolism that usually occur

A

It is important that parenteral nutrition is sterile and particle free as it is bypassing the steps of metabolism that usually occur

52
Q

What is typically included in parenteral nutrition?

A

Typically included in parenteral nutrition:
* Glucose 4kcal/g
* Fat 9-10kcal/kg: LCT, MCT, TAG?
* Amino acids
* Electrolytes: Na, K, Ca, Mg, Cl, PO4
* Vitamins
* Trace elements
* Water

53
Q

What are the different types of PN pumps?

A

Different types of PN pumps:
IV pumps for Home PN
* Ambulatory: allows for patient mobility
* IV route
* No drip stand required
* Essential safety features (air in line detection/occlusion pressure alarms)
* Battery operated with additional main power option
IV pumps for hospital
* Static for bedside use
* IV route
* Drip stand required
* Essential safety features (air in line detection/occlusion pressure alarms)
* Mains powered

54
Q

Nutritional Considerations for Peripheral PN

A

Nutritional Considerations for Peripheral PN
* Osmolarity is limited due to placement of line (in small veins)
* Midline can be used for higher osmolarity
* ESPEN & ASPEN advise: 850-900 mOsm
* Can only be used for a short period of time (days-weeks)
* PN can be initiated immediately after placements

55
Q

What are the two routes of feeding for PN?

A

Two routes of feeding for PN:
* Peripheral
* Central

56
Q

Advantages/Disadvantages of Peripheral PN

A

Advantages/Disadvantages of Peripheral PN
* Short cannula: doesn’t require specialist equipement or training for placement
* No delay for PN initiation
* Midlines can be used for higher osmolarity solutions

Disadvantages:
* Only for a short period days (cannula), weeks (midline)
* Limits osmolarity of solution that can be used

57
Q

What are the two types of Peripheral PN lines?

A

Two types of Peripheral PN lines:
* Peripheral short catheter/cannula
* Midline catheter

58
Q

Nutritional Considerations for Central PN

A

Nutritional Considerations for Central PN
* No limitation on osmolarity of solution
* Can be left in place for months (PICC) or years (tunnelled line/port)
* More likely to meet nutritional needs

59
Q

Advantages/Disadvantages of Central lines

A

Advantages/Disadvantages of Central lines
Advantages:
* No limit to osmolarity
* Can last months-years
* No risk of phlebitis
* Can have multiple dedicated lines so that medications and feed can be administered without interaction (important for them to be separate)

Disadvantages:
* Requires placement by a specialist team: radiographers/ ultrasound or xray confirmation needed
* There can be a delay for placement

60
Q

Types of Central lines for PN

A

Types of Central lines for PN:
* Peripherally inserted central catheter (PICC)
* Tunnelled CVC (Hohn, Hickman, Broviac)
* Non-tunnelled central venous catheter (CVC): for short term use
* Totally implantable devices (ports)

61
Q

What are the two types of PN bags?

A

Two types of PN bags:
* Standardised (multi chamber bags): contain nutrients to a set standard. (No micronutrients, but can be added?)
* Compounded (unlicensed): formulated to meet nutritional requirements of a specific patient

62
Q

What is osomolarity?

A

Osmolarity:
the number of particles of solute per liter of solution

63
Q

What do ESPEN & ASPEN advise about the osmolarity of PN for Peripheral Lines?
What does the evidence say to support/oppose this?

A

ESPEN & ASPEN guidance RE osmolarity of Peripheral Parenteral Nutrition:
* ASPEN Paediatrics (Duggan et al., 2013) maximum: 900 mOsm/l.
There was a higher incidence of phlebitis (inflammation of blood vessel in 352 paediatric patients who received PN peripherally >1000mOsm/l over a 2 year period than those that received <1000mOsm/l. (statistically significant p=0.02)

However 2 of every 5 children still developed phlebitis when receiving <1000mOsm/l.

Limit of 900 also based on study of 15 adult patients receiving PPN of 400mOSm/L and 900 mOsm/L with and without heparin and cortisol. The also analysed incidence of patients receiving PPN >900 and <900 there were no statistical differences in adverse outcomes.

ASPEN do admit that evidence to support a safe upper limit is lacking and that some patients may tolerate an upper limit.

It has been suggested that higher limits are needed for patients to receive adequate nutrition.

  • ESPEN maximum: 850mOsm/l (Geriatrics PN, 2009;
    But they state that theosmolality of intravenous peripheral nutrition can be tolerated up to 1000mOsmol/l in adult subjects with specific equipment & that other studies suggest up to 900mOsm/l. It is not clear how they decided upon 850mOsm.

Based on this I wouldn’t just use this without considering the patient’s nutritional needs. The cited data for the reasoning of these recommendations doesn’t make sense to me. Out of the two I would be more likely to use 900 as a starting point.

64
Q

What is phlebitis?

A

Phlebitis:
* inflammation of a vein near the surface of the skin.
* evident by local bruising, swelling, and inflammation
* can occlude the vein and thereby reduce effective delivery of the infusion solution

65
Q

What is important to remember about Standard (licensed)/ Multichamber PN bags?

A

It is important to note that Standard (licensed)/ Multichamber PN bags do not contain micronutrients and will not be suitable for all patients.

66
Q

Compound (unlicensed) bags

A

Compound (unlicensed) bags
Advantages
* Only prescribed for patients whose nutritional needs cannot be met by a standardised regimen
* Are usually required for patients on long-term PN, mainly Home PN (HPN), or for patients with complex needs.
* A 2014 American study found that the costs of these bags were cheaper than multichamber bags and suggested that they may be an advantage in hospitals that treat >15 patients per day

Disadvantages
* Take up to 16 minutes to prepare
* Need aseptic facilities for preparation.
* Are made individually or in small batches, requiring more aseptic resources to produce.​

67
Q

Standardardized/multichamber (licensed bags)

A

Standardardized (licensed bags)

Advantages
* Designed for convenience
* Reduced aseptic workload
* Longer shelf life (years)
* Licensed products
* Wide range of regimens available
* May be possible to add additional electrolytes
* Standardisation can reduce prescription errors through improved regimen familiarity and possible administration errors.
* Standardisation can reduce unwarranted variation
* Standardisation can help to increase resource efficiency by reducing demand on aseptic facilities through economies of scale realised through batch production.
* Multichamber: slows down reactions between chemicals

Disadvantages
* Do not contain micronutrients
* Not suitable for all patients

68
Q

Parenteral nutrition is the ? chemically complex injectable medicine that is used in routine clinical practice

A

Parenteral nutrition is the most chemically complex injectable medicine that is used in routine clinical practice

69
Q

Two things that are very important for TPN

A

In TPN it is very important that:
* The product is sterile
* All nutrients are provided in their basic form as they are bypassing the steps of metabolism

70
Q

Points to remember about TPN: Glucose

A

Points to remember about TPN: Glucose
* Glucose produces a rise in CO2 production
* Insulin may be required
* Metabolically stressed patients do not tolerate high-rate infusions, stepwise approach achieves better results

71
Q

Points to remember about TPN: Fat

A

Points to remember about TPN: Fat
* Administration of up to 2g/kg/day is not associated with complications in short term
* Lipid emulsions produce less CO2 than glucose
* Fat intolerance can occur (Turbid plasma or lipaemia)

72
Q

Points to remember about TPN: Protein

A

Points to remember about TPN: Protein
* Calculated as nitrogen
* NICE recommendation for basal provision = 0.13 – 0.24gN/kg
* To convert nitrogen to protein x 6.25

73
Q

To calculate the amount of nitrogen for a patient’s protein requirements

A

To calculate the amount of nitrogen for a patient’s protein requirements:
divide by 6.25

74
Q

Why is macronutrient balance important?

A

Macronutrient balance is important:
* to improve patient outcomes and reduce mortality
* Overfeeding of energy has been associated with increased mortality (REE: >110%)
* Overfeeding of glucose over time could cause fatty liver
* Increase of protein benefit can only be witnessed if energy is at correct balance

75
Q

Things that shouldn’t be in a bag of PN

A

What shouldn’t be in PN bag:
* Bacteria
* Particles
* Precipitates
* Plasticisers
* Degradation products

76
Q

What does Aseptic preparation require?

A

Aseptic preparation requires:

Controlled, sterile environment

Close and continuous control of systems and processes

Good technique

Cohesion of staff, equipment and facility

77
Q

What needs to be considered when checking if a PN bag is safe?
How do we check?

A

What do we need to consider?

Composition – lipid/precipitates

Temperature

Light protection: insufficient could affect micronutrients especially

Expiry date

How do we check?

Manufacturers guidance

78
Q

Why are Patients requiring PN are more likely to be micronutrient depleted ?

A

Patients requiring PN are likely to be micronutrient depleted due to:

Poor long-term diets/insufficient recent intake

Inadequate GI absorption or excessive GI losses​

Abnormalities in vitamin storage, processing or metabolic demands​

The effects of alcohol and other drugs​

By the time specific signs of a micronutrient deficiency are evident, biological disorders will have already begun.​

Micronutrient deficiency examples:

Starved patients may require additional thiamine​

Pancreatic fistula fluids have a high content of micronutrients especially zinc​

Biliary fistula fluid is rich in copper and manganese

79
Q

Olive oil is ?

A

Olive oil is immunoneutral

80
Q

Precipitates

A

Precipitates:
Substances that can form once different components of PN interact with one another

81
Q

Multichamber bags can be stored for up to ? years if micronutrients haven’t been added

A

Multichamber bags can be stored for up to 2 years if micronutrients haven’t been added

82
Q

Advice about the manufacterers guide

A

Advice about the manufacterers guide:
* Follow it to a tee
* Bring up concerns
* Don’t go over expiry date

83
Q

Which technique is becoming more popular for the estimation of REE?

A

Indirect calorimetry is becoming more popular in a clinical environment for the estimation of REE

84
Q

Indirect calorimetry

A

Indirect calorimetry:
* Measures resting energy expenditure (REE) through the measurement of oxygen consumption and carbon dioxide production.
* Provides a more accurate indication of a patient’s energy needs, considering disease state.
* Non-invasive, accurate.
* Expensive
* Patient cannot move during measurement
* Becoming more available in clinical settings

85
Q

Risk of refeeding syndrome was identified in ?% of PN patients in a 192-participant audit conducted in the North of England

A

Risk of refeeding syndrome was identified in 75% of PN patients in a 192-participant audit conducted in the North of England

86
Q

Abnormal LFTs could indicate ?

A

Abnormal LFTs could indicate sepsis

87
Q

Possible complications during clinical management of PN

A

Possible complications during clinical management of PN:

Dehydration/Overhydration - inadequate monitoring and adjustment of fluid therapy​

Liver enzyme abnormalities – sepsis, hepatotoxic medication​

Electrolyte imbalances – metabolic response to illness, poorly managed intakes​

Fatty infiltration of the liver – over provision of glucose (highly unlikely with short-term PN)​

Respiratory distress – over provision of fluid​

Sepsis – poor line care​

Phlebitis – inadequate vascular access monitoring​

Metabolic bone disease – inadequate supply of calcium, phosphate, vitamin D, control of acidosis

88
Q

Intestinal failure can result in progressive ? dysfunction through a variety of mechanisms such as reduced enteral stimulation, reduced bile salt flow, recurrent sepsis, nutrient imbalances​

A

Intestinal failure can result in progressive liver dysfunction through a variety of mechanisms such as reduced enteral stimulation, reduced bile salt flow, recurrent sepsis, nutrient imbalances

89
Q

Is there a difference between infection risk of EN and PN?

A

No, there is no difference between infection risk of EN & PN.

CCD (14 decks)

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