PN Complications Flashcards
the most common complication of PN
hyperglycemia
____ associated hyperglycemia occurs in acutely ill and septic patients from insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion
stress hyperglycemia
common causes of hyperglycemia in health care and PN
extra provision of glucose, hepatic steatosis, increased CO2 production
what is ASPEN’s target BG in adult hospitalized patients getting nutrition support
140-180 mg/dL
what is the SCCM target range for BG for the ICU population
150-180 mg/dL
what are some methods in the treatment of PN associated hyperglycemia
- start PN at 1/2 of energy needs
- start with 150-200 g dextrose in 1st 24 hours or <100 g if poor glucose control
- <4-5 mg/kg/min GIR
how often should blood glucose be monitored with short acting subcutaneous insulin
every 6-8 hours
how often should blood glucose be monitored in critically ill with insulin infusion therapy
every 4 hours
provide __ to __ units of insulin per gram of dextrose or ___ to ____ in the PN bag for those who are already hyperglycemia
0.5 to 1 or 0.15-0.2 units/gram of dextrose
when a patient on PN is hyperglycemic supplement ___ insulin
short or rapid acting insulin
when adding insulin to PN, add ____ of of the patients total insulin needs required over 24 hours added to the next day’s PN
2/3
only ____ insulin should be added to PN formulation to account for the duration of insulin therapy
regular
increase proportional amounts of ___ in the PN to increase energy when patients are hyperglycemic
fat/lipids
in rare cases ___ deficiency can make insulin less effective and would require supplementation in PN
chromium
what are the consequences of hyperglycemia
poor wound healing
increased infection risk
dehydration, coma, death
hypoglycemia often occurs because of excess ____ provision in PN
insulin
when a patient is hypoglycemic while on PN provide a___% dextrose infusion or ampule of ___% dextrose /stop insulin provision
10% or 50% ampule
rebound hypoglycemia often occurs when abruptly stopping
IV/PN infusion of dextrose
to avoid rebound hypoglycemia, how should TPN be tapered
Taper the PN rate down for 1-2 hours o f the infusion or 1/2 the infusion rate for 1-2 hours before PN discontinuation
If a patient is NPO and PN is stopped, when should a blood glucose be checked
30 mins to 1 hour after PN discontinuation
_____ and ____ cannot be produced by the body and therefore can lead to the development of essential fatty acid deficiency if not provided in PN
omega 3 and omega 6 fatty acids
what are the clinical symptoms of essential fatty acid deficiency
scaly dermatitis, alopecia, hepatomegaly, fatty liver anemia
the ___ test with a ratio over 0.2 indicates EFAD
triene to tetraene ratio
EFAD can develop within ___ to ___ weeks with lipid free PN
1-3 weeks
__ to __ % of daily energy requirements must come from linoleic acid and ___% from alpha linolenic acid or ___mL of 10% soy based ILE over 8-10 hours 2x/week
1-2 % total energy from linoleic
0.5% total energy from alpha linolenic acid
500mL or 500mL 20% IL2x/week
Provision of ____% Intravenous Lipid Emulsion 2x/week at a dose of 500mL can prevent the development of EFAD
20%
___ based ILEs can suppress the immune system from reticuloendothelial dysfunction, an exaggerated inflammatory response and the activation of the arachidonic pathway
Soy based
____ can occur with overfeeding of dextrose or rapid ILE administration > 0.11`g/kg/hour
hypertriglyceridemia
what are the implications of hypertriglyceridemia
impaired immunity
altered pulmonary hemodynamics
increased risk of pancreatits
what are some methods to manage PN associated hypergtriclyderidemia
Reduce ILE dose
Decrease the duration of ILE infusion
Provide <30% of kcals from lipids or 1g/kd/day
Only infuse over 8-10 hours a day if piggy backed
decrease or dc ILE in patients on PPF
if a blood triglyceride level over ____mg/dL occurs, stop ILE provision or decrease the amount
400 mg/dL
____ can develop due to ILE induced hypertriglyceridemia when TCG’s exceed 1000mg/dL
pancreatitis
patients with a(n) ____ allergy can develop a reaction due to the composition of ILE’s
eggs
symptoms of an egg allergic reaction results in
cyanosis, dyspnea, flushing, sweating, dizziness, headache, nausea, vomiting
which vitamin is likely to suffer extensive photodegradation if the PN bag is exposed to light
vitamin A
In a hypoalbuminemic patient, the use of albumin within PN solutions has consistently demonstrated
improved serum albumin concentrations
what is most likely to contribute to PN associated alterations in renal tubular function
bactermenia/fungemia
which vitamin may be restricted in end stage renal disease patients requiring PN
vitamin A
TNA PN preparations have a higher risk of this PN preparation issue than 2 in 1
precipitation of calcium salts
when a TNA bag of TPN develops a translucent band at the surface of the emulsion that separates from the remaining dispersion; this is known as
creaming
is PN still safe to use in the first stages of creaming (when the emulsion starts to breakdown)
yes, other individual droplets are generally preserved
_____ is an inherent contamination of PN solutions
aluminum
which disease states are at highest risk for developing an aluminum toxicity while on PN
renal dysfunction (limited ability to excrete)
contamination of aluminum in PN is usually from introduction of
raw materials during MANUFACTURING
____ deficiency from PN use can cause hepatic steatosis
choline
the most common hepatic complication of PN is
steatosis
to help offset hepatic dysfunction of PN, PN can be ____ to allow the body time to oxidize fat or start early _____ to stimulate bile flow
cycled enteral feedings (small)
____ and ____ should NOT be added to PN in hepatobiliary disease to prevent toxicity
copper & manganese
with prolonged hyperbilirubinemia, a prudent step is to avoid routine administration of
copper & manganese
what are 2 methods to prevent PN induced cholestasis
early start of oral/EN feeds to stimulate cholecystokinin release for bowel motility and gallbladder emptying
starting Ursodiol, a medication that improves biliary flow
a medication (given orally) that is used to improve bile flow
Ursodiol
in cholestasis or biliary obstruction which labs are elevated
alkaline phosphorus and total bilirubin
what are the 2 main proposed causes of PNALD
overfeeding dextrose and lipids, or providing manganese/coper
Often patients who develop PNALD will see elevated liver function tests within
1-4 weeks
_____ is a result of decreased calcium intake or increase calcium excretion
hypocalcemia
what are possible causes of hypercalciuria
excessive calcium provision inadequate phosphorous supplementation amino acids in PN cycling PN chronic metabolic acidosis
what are interventions when a patient has hypercalciuria
reduce amino acid concentration in PN, correct metabolic acidosis by adding more acetate
what poses the greatest risk of developing metabolic bone disease while on PN
long term PN /corticosteroid use
what is the most accurate way to diagnose metabolic bone disease
bone mass asessment
in a home PN patient displaying signs of metabolic bone disease, the following adjustment would be the most appropriate
decrease protein because it causes more calcium losses
what is the max glucose utilization rate in PN for adults
5 mg/kg/min
what is an adverse effect of excessive IV lipid emulsion
thrombocytopenia (too much vitamin K)
in a patient getting PN with MVI containing vitamin K and warfarin, the most appropriate course of action would be to
maintain consistent vitamin K provision even after PN is discontinued, and adjust anticoagulation therapy as needed
the deficiency of this vitamin can result in abnormal prothrombin time
vitamin K
what is the max hang time for lipid emulsions when they are infused alone
12 hours
when lipids are a part of a TNA, what is the max hang time
24 hours (TNA’s have a lower pH, making it less likely for microorganisms to grow)
compounding PN with manual or automated devices, adding multiple injections, detachments and nutrients are considered ___ risk
medium
Transferring, measuring, and mixing PN in sealed packages when preformed promptly is considered ____ risk
low
addition of non sterile ingredients or devices are at _____ risk
high
visual absence of physical signs of particulates or incompatibilities, ______ mean the PN is safe event with TPN admixes. A final visual inspection should still occur
DOES NOT
amino acid concentration, calcium concentration, calcium salt formation, dextrose/phosphate concentration, pH/temperature, presence of additives and order of mixing all influence
solubility of calcium phosphate precipitation
what items are mandatory on the PN Order Form
general statement of warning for incompatibilities contact # of the prescriber hang time location of venous access height, weight, dosing weight
what items are mandatory on the PN Label
amount of micronutrients/day
dosing weight
route of administration
PN prescribing errors occur when ______
there is inadequate knowledge of PN therapy
inadequate knowledge of conditions affecting PN such as age, impaired renal function, contraindications, miscalculation of PN dosing and prescribing nomenclature
what biochemical evidence indicates essential fatty acid deficiency
triene to tetraene ration >2 (holman index)
in a patient in the ICU receiving concurrent infusions of lipid injectable emulsion and propofol, these concurrent infusions could potentially cause
hypertriglyceridemia
Propofol is a ____% emulsion
10%
which component of PN is most likely to impact anticoagulation in a patient on warfarin
ILE’s as they contain vitamin K
when a patient is on coumadin/warfarin and on PN with ILE,s what should be monitored
vitamin K and INR to make sure they are in therapeutic range
when initiating PN that contains regular insulin, how often should capillary blood glucose levels be monitored
every 6 hours (once stable they can be monitored less often)
what risk is associated with abrupt cessation of a PN solution
rebound hypoglycemia
which patients are at the highest risk of rebound hypoglycemia when terminating a PN solution
patients on high doses of insulin and not on an EN or PO diet
how long should PN be tapered down when stopping PN to prevent rebound hypoglycemia
1-2 hour taper down in rate
in adult PN patients, IVLE use should be limited when serum TCGs rise above
400 mg/dL
the FDA currently recommends that daily intake of parental aluminum should not exceed
5 mcg/kg/day
PN products that are a concern for aluminum contamination are
calcium/phosphate salts
heparin
albumin
aluminum toxicity can cause
altered bone formation
altered PTH secretion
altered urinary calcium excretion
populations at risk for aluminum toxicity are
infants
children
renal insufficient
chronic PN
when is cycling PN recommended
patients at risk for liver dysfunction
long term PN patients
patients on a continuous rate of PN develop _______ that causes hepatic fat deposition causing a rise in LFT’s
hyperinsulinemia
what is most likely to contribute to metabolic bone disease in PN dependent patients
aluminum toxicity
aluminum toxicity impairs ____ and _____ fixation, inhibits the conversion of __________ vitamin D to the active form of vitamin D called _______, and decrease the secretion of this hormone
- calcium and bone fixation
- 25 hydroxyvitamin d to active 1,25 dihydroxyvit D
- parathyroid hormone
the upper limit for aluminum is ___ mcg/kg/day
5
what is a risk factor for the development of PN associated liver complications in PN dependent patients
prolonged use of soy bean based lipid injectable emulsions because omega 6 fatty acids are pro inflammatory and have potential toxic phytosterols which impair bile flow
prolonged use of soy bean based ILE’s in PN can lead to the development of liver complications in patients, because soybean emulsions contain and high concentration of _______ polyunsaturated fatty acids which are _____ in nature, and also may contain potential toxic _____ which are thought to impair bile flow
- omega 6 fatty acids
- pro inflammatory
- toxic phytosterols
what are some methods to reduce the risk of developing liver complications when using ILE’s in PN
- cycle PN
- supplement with EN
- consider adding ursodiol
- increase the omega 3 to 6 ratio with different ILEs
A 70 kg adult patient receiving PN that is providing 3,000 kcals a day, presents with mild to moderate elevations of serum aminotransferases, mild elevation of bilirubin and serum alk phos. This pt is most likely exhibiting what type of PN associated liver disease
hepatic steatosis (overfeeding from hyperinsulinemia which leads to fat deposition)
what are the 3 types of hepatobiliary disorders associated with long term PN
steatosis (overfeeding)
cholestasis (primarily in children 2/2 impaired biliary secretion)
gallbladder stones/sludge from lack of GI stimulation
Hepatic steatosis is a complication of PN associated liver disease which causes mild elevations in ____,____ and ____ and is caused by ________
alk phos, ALT, bilirubin
OVERFEEDING
Cholestasis is a complication of PN associated liver disease which causes an elevation of _____ and primarily occurs in children due to __________
conjugated bilirubin
impaired biliary secretion
Gallbladder stones/sludge are complications of PN associated liver disease which is due to ________
the lack of EN/GI stimulation from long term PN use
A 55 year old male is admitted with an undesired weight loss of 20 lbs during the past month secondary to ongoing Chron’s flare ups. The patient is found to be at high risk for refeeding syndrome. Which micronutrient should be supplemented?
thiamine
hyperglycemia in a patient receiving PN, is associated primarily with what type of sodium/fluid imbalance
Hypertonic, hyponatremia
hypertonic hyponatremia can result from _____ or ______ free solutions
hyperglycemia
sodium free hypertonic solutions
in hypertonic, hyponatremia; an increase in blood glucose causes a shift of water ____ of the cells and into the extracellular space which decreases serum ________
OUT of the cells
decreased serum sodium
for every 100 mg/dL increase in blood sugar greater than 100mg/dL , serum sodium will increase by ____ mE/qL
1.6 mEq/L
how is pseudohyponatremia (hyponatremia from high dextrose concentration) treated
treat the hyperglycemia, don’t use fluids as it is NOT a true sodium or water imbalance
A long term PN patient presents with involuntary movements, tremor, and ridgitiy. What etiology may explain this
manganese toxicity
____ deficiency is associated with Keshan Disease (cardiomyopathy) and increased oxidative damage
selenium
selenium toxicity can cause
hair/nail loss, tooth decay, peripheral neuropathy
in order to prevent rebound hypoglycemia upon discontinuing PN, it is recommended the PN infusion rate to be decreased over what time span
1-2 hours
in what timeframe should a blood glucose be taken upon the cessation of PN
30-60 minutes after
what would be the most serious complication of hypertriglyceridemia in a patient getting PN
pancreatitis
what are some potential causes of hyperglycemia in a patient receiving PN?
excessive carb administration (>5mg/kg/min or 20-25kcal/kg/day); increases blood glucose with causes hepatic steatosis and increased production
obesity from insulin resistance
sepsis from stress associated hyperglycemia, insulin resistance, increased gluconeogenesis and increased glycogenolysis
what are some risk factors for the development of rebound hypoglycemia after cessation of PN (things that effect glucose regulation)
malnutrition
hepatic dysfunction
renal insufficiency
rebound hypoglycemia occurs when elevated endogenous insulin levels don’t adjust to the reduced ___ infusion
dextrose
the preferred site for placement of a central venous access device is
subclavian
the density of skin flora at the _______ is a major contributing factor for catheter related bloodstream infections
catheter site
catheter related thrombosis caused by fibrin buildup with blood vessels adhering to a central venous catheter is called
mural thrombosis
the layer of fibrin that develops around the outside of a central venous catheter due to aggregation
fibrin sheath
the use of 0.1N hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of
calcium-phosphate salts. this crystalloid solution are acidic which will help Ca-Phos solubility
direct infusion of 0.1N hydrochloric acid can cause
fever, phlebitis, sepsis
for catheter occlusions due to precipitates associated with medications with a high pH such as tobramycin or phenytoin ______ is used to treat them
1 mEq/L NaBicarb
70% ethanol is the effective solvent to dissolve
lipid residue
A 40 year old male on chronic PN (started 15 yrs ago), secondary to a massive bowel resection develops metabolic bone disease. His current PN 12 hour cyclic formula provides 5 g/kg/day dextrose, 2 g/kg/day protein and 1 g/kg/day fat. What is the most appropriate intervention to reduce hypercalciuria
decreased amino acid content
the most important contributor of metabolic bone disease is
a negative calcium balance which can be due to protein in long term PN patients
long term PN patients should typically not exceed _____g/kg/day protein to avoid negative calcium balance and MBD
1.5g/kg/day
causes of hypocalcemia
low calcium intake
increased urinary calcium excretion (hypercalciuria)
causes of hypercalcemia
excessive calcium provision inadequate phosphorous supplementation excessive protein in PN cyclic PN infusion chronic metabolic acidosis
the best approach to prevent PN induced cholelithiasis is the administration of _________ to stimulate ______ secretion, bowel ________ and ______ emtpying
- oral or enteral feeding
- cholecystokinin
- motility
- gallbladder
Ursodiol is NOT the best approach for treating PN induced cholelithiasis because
it can only be given orally and has mixed results in studies
what are some short term complications of home PN
dehydration
refeeding syndrome
catheter malposition
electrolyte abnormalities
what is most likely to cause elevated serum bicarb levels in a home PN patient?
excess acetate salts in PN
excess chloride salts, significant diarrhea and acute renal failure are all causes of metabolic _______
acidosis
what are clinical signs and symptoms of refeeding syndrome
sodium retention hypo K phos and mag pulmonary hypertension fluid overload cardiac decompensation
severe hypophosphatemia can lead to
respiratory failure/seizures
hypokalemia and hypomagnesemia can lead to
cardiac arrhythmias, neuromuscular adverse effects including weakness and muscle cramps
A 75yo female with moderate malnutrition is status post radical cystectomy with an ileal conduit. She weighs 50 kg and she has a 20 guage IV access in the left cephalic vein. She is initiated on PPN with a solution running at 125mL/hr. This formula gives 210 grams of dextrose, 75 grams of amino acids, and 45 g of fat. What complication (s) is she at the greatest risk for developing
fluid overload as 125mL/hr x 24 hours is 3000mL of water which provides 60mL/kg. TPN should only provide 30-40mL/kg.
current guidelines recommend that the maximum contents for PN should be __________,mL/kg of fluid, maximum of ________g/kg of CHO , maximum of _____ g/kg/of fat , and max of ______g/kg of protein
30-40mL/kg fluid
7 g/kg/day carbohydrates
2.5g/kg/day fat
2 g/kg/day protein (1.5 g/kg/day LTPN)
PPN should be administered for at last _____ days with no more than _____ weeks total
5 days minimum
2 weeks maximum
Patients who get PPN must have good _________, the ability to tolerate large ______, and contraindication to _______
peripheral access
large volumes
central access
contraindications to starting PPN are
significant malnutrition severe metabolic stress large nutrient or electrolyte needs fluid restriction >2 week need for PN renal/liver compromise
A 68yoF with normal liver function tests, a lactate of 1mmol/dL, is in AKI status post a colon resection. She is getting PN. She has an arterial blood gas with a pH of 7.31, pCO2 of 36 mmHg, and a serum bicarb of 20 mEq/L. What is the most appropriate PN intervention
decrease chloride to acetate ratio
this patient is in metabolic acidosis 2/2 renal failure
pH is acidic, PCO2 is normal , and serum bicarb is decreased
what feature of a Groshong central venous catheter reduces the risk of catheter occlusion
pressure sensitive 3 way valve
a Groshong CVC has a pressure sensitive 3 way valve restricts ______ and _____ by remaining closed when not in use
blood backflow
air embolism
what are pros of a Groshong CVC’s
no need for clamping
no need for heparin flushes for cath. patency
should flush w/ NS after meds/blood aspiration
A patient receiving chronic PN therapy develops an intraluminal clot in their central venous access device. What is the most appropriate pharmalogical intervention to clear this access device
alteplase 2mg/mL
conventional therapy for an occluded central venous access device due to an intraluminal clot or fibrin sheath is _________in a single or repeated bolus
local thrombolytic therapy
_________ is the only FDA approved thrombolytic agent for CVAD occlusions
cathflow altepase
a patient is receiving PN through a tunneled catheter in an IJ. He has a low grade fever of 38.1 degrees C and is mildly tachycardic with a HR of 110 degrees, but blood cultures are negative. There is some mild redness and tenderness but no purulence at the catheter exit site. How is this exit site infection best managed?
initiate systemic antimicrobial therapy
a. blood cultures are negative (not bacteremia)
b. has temp, increased heart rate
erythema, tenderness or purulence within 2 cm of the catheter exit site is called a
an exit site infection
A PN dependent pt with an average daily ileostomy output of 3L presents with a BUN/serum Cr ratio of 30:1 and mild hyponatremia. What is the most appropriate PN intervention
increase fluid and increase sodium
Patients with an ileostomy or small bowel fistula output are at risk for loss of _____, _____ and ____
water, sodium and electrolytes
Sodium content from high output ileostomy can be up to ____mEq/L
100mEq/L
a high BUN: Cr ratio over 20:1 indicates
volume depletion
___occurs when fluid replacement doesn’t contain adequate sodium to account for ileostomy losses
hyponatremia
the use of 70% ethyl alcohol is most effective for clearing catheter occlusions 2/2 the precipitation of
lipid residue
the most common route of infection for a tunneled central venous access device is
contamination of the catheter hub/intraluminal contamination
pathogenesis of a non tunneled CVAD is known as
extraluminal colonization
A patient arrives in your clinic complaining of intermittent catheter malfunction. You identify that the catheter malfunction is relieved by raising the patient’s arm where the catheter is located. Which condition should be suspected
pinch off syndrome
_______ occurs when a central catheter is being compressed between the first rib and the clavicle, causing intermittent compression and pinching. This causes intermittent occlusion.
Pinch off syndrome
the hallmark sign of pinch off syndrome is
occlusion being resolved when the patient raises then lowers their arm
treatment of pinch off syndrome includes
removing the catheter and replacing in in a more lateral position in the subclavian or IJ vein
what types of conditions predispose a patient to refeeding syndrome
chronic alcoholism
malabsorption syndromes/ gastric bypass
weight loss
prolonged fasting >7 days
A patient with refractory hypokalemia should be assessed for what electrolyte disorder
hypomagnesemia
____ is an important regulator of intracellular potassium. Hypomagnesemia can cause refractory hypokalemia 2/2 accelerated renal potassium loss.
magnesium
Manganese toxicity is a concern for long term PN patients 2/2 its presence in trace element mixtures and as a contaminant from PN components. Symptoms of MN toxicity are associated most commonly with accumulation of the mineral in which organ
the brain causing Parkinson’s like symptoms
A critically ill 75 year old male with PNA and sepsis who weighs 63 kg is receiving PN containing 2800 kcals, 100 g of amino acids/day. He has the following ABG: pH 7.32, pCO2 49, serum bicarb 25. What is the most appropriate PN intervention
- decrease calorie content as he is being overfed at 45cal/kg
- pH is low (<7.35 so he is acidic), pCO2 is elevated (normal range 35-45 so he is retaining CO2) and bicarb is WNL (22-26 normal range) so it is respiratory acidosis from too much CO2 production
the most accurate method of diagnosing PN associated metabolic bone disease is to measure
bone mineral density
what are some co morbidities that are risk factors for the development of MBD for a patient on LTPN
- Malabsorption disorders (Chron’s)
- Cancer (decreased food intake, altered vit D metabolism, decr. absorption 2/2 chemoradiation
- Steroid use from Chron’s, short bowel syndrome
a rise in which lab values would most likely indicate cholestasis
conjugated bilirubin, increased gamma glutamyltranserase and increased alk phos
during LTPN administration, hepatobiliary complications can best be prevented by ______ which allows the body to oxidize fat and decreases insulin levels.
cycling PN
carnitine is ____ present in any PN formula but can be added if there is a measured deficiency
not
A patient has been receiving PN through a central venous catheter for the past week while in the hospital. They now present with SOB, cough and cyanosis of the face, neck ,shoulder and arms. What type of device complication is characterized by the patient’s symptoms
superior vena cava syndrome
swelling, erythema, and induration along the subcutaneous tract of a tunneled catheter is known as
a tunnel infection
chest pain, earache, jaw pain, arm swelling, and leaking at an exit or insertion site are the symptoms of
thrombosis
Your patient develops sudden chest pain and shortness of breath following a placement of a central line for PN support. A pneumothorax is suspected and radiographically confirmed. This situation should be viewed as a __________
sentinel event
a patient safety event of an unexpected occurrence involving death or serious physical or psychological injury or the risk there of. Serious injury specifically includes loss of limb or function. They signal the need for immediate investigation and response. Also includes med errors, wrong site surgery, and blood transfusion errors. This event is known as
sentinel vent
what is an etiology of a thrombotic catheter occlusion
fibrin sheath/sleeve
non-thrombotic catheter occlusions include
mechanical obstruction
drug/mineral precipitates or lipid deposits
catheter migration/malposition
the most effective strategy to decrease the risk of catheter associated sepsis is the use of
full barrier precautions during catheter insertion (mask, cap, sterile gloves, long sleeve gowns, sheet drapes)
A patient is getting PN through a tunneled IJ catheter. He has a low grade fever, mild tachycardia, elevated heart rate of 110 degrees, but blood cultures are negative. There is mild redness & tenderness, but no purulence at the catheter site. How is this exit site infection best managed?
training of nursing staff to maintain CVAD and cleanse insertion sites with 2% chlorexide prep
A patient receiving PN that has chills, fever and positive blood cultures, but no redness or purulence at the catheter exit site probably has which of the following types of catheter infections
catheter related bloodstream infection (CRBSI)
bacteremia/fungemia with at least 1 positive blood culture, with clinical manifestations of fever and no apparent source except at the catheter site is called
CRBSI
a critically ill patient has been receiving PN providing 45 kcal/kg. The consequences of providing excess calories to a critically ill patient are
fatty liver, vent weaning failure and increased blood sugar
a patient presents to the clinic with a suspected catheter occlusion. What should your initial actions be
- obtain history of signs/sx of cath malfunction
- double check catheter function for patency & blood aspiration
- check for mechanical causes of kinking, clamps, sutures
- assess if the occlusion is relieved from postural changes
- obtain history of flushing techniques, med infusion and blood aspiration
- assess physical symptoms (edema, redness, pain)
A 60 year old female, height of 152 cm, wt of 45 kg is receiving PN for a rectovaginal fistula. The PN formula consists of 70 grams protein, 400 grams dextrose, 25 grams of fat in a total volume of 1.5 L, including all electrolytes and additives which is infused continuously over 24 hours a day. Which complications is she at the greatest risk of developing
hyperglycemia, the PN provides a GIR of 6 and >7g/kg dextrose
discontinuation of lipid injectable emulsion is recommended treatment for catheter related bloodstream infections related to ______
malasezia furfur
______ are superficial infections of the skin and associated structures that an be a cause of catheter related blood stream infections . This occurs most commonly in premature infants getting PN containing ILE. the ILE presumably provides growth factors required of the organism
malassezia furfur
treatment of malassezia furfur is
administration of anti fungal therapy
excess carbohydrate administration in PN has been associated with
hepatic steatosis
patients with diabetes who are receiving PN have an increased risk of developing _________, Increased BG increases infection from counter regulatory hormones’ and the cytokine response
catheter related infections
A diabetic patient when starting on PN should start at ________ g/dex/day to avoid hyperglycemia and refeeding syndrome
100-150 g dex/day
Add ___ to ___ units of insulin/gram of dextrose to PN and increase the next day by __ of the previous day sliding scale insulin
0.5-1 unit per gram of dextrose
2/3 of sliding scale days previous
A critically ill 42yoM status post small bowel resection for Chron’s disease is receiving PN for severe post op ileus with NGT output of 2.5-3L/day . He has the following ABG results: pH of 7.49, pCO2 of 45 mmHg and a serum bicarb of 34mEq/L. What should be done with is PN
increase chloride to acetate ratio
pH is elevated = alkalosis
pCO2: WNL
Bicarb elevated: = metabolic acidosis
A home PN dependent patient with a peripherally inserted central catheter presents with arm, shoulder and neck swelling. What is the most likely cause
catheter related central venous thrombosis
arm, shoulder, neck swelling, limb, jaw or ear pain and dilated collateral veins of the arm, neck or chest are all sx of
catheter related central venous thrombosis as CVCs cause endothelial trauma and inflammation
vitamin ____ can become toxic in renal failure
vitamin A
how much folic acid should be provided for TPN patients for the initial 5-7 days of PN
1mg/day
some vitamins are severely degraded in the PN making process which is an issue for ______ Pn patients
long term PN
what steps should be taken during IV vitamin shortage
Reserve IV MVI for patients Mosley on PN
Use oral/EN MVI when able
don’t use pediatric IV for adults
reduce dose by 50% or 1-3x a week
if all IV MVI’s are out after a shortage, which IV medications should be given separately to TPN patients
thiamine, ascorbic acid, pyridine and folic acid daily
trace element toxicity is common in TPN patients with ____ disease
hepatobiliary disease
which minerals are of concern with patients on TPN and who have hepatobiliary diseases
zinc copper manganese chromium selenium aluminum
consider decreasing __ and ___ in hepatobiliary patients on TPN
manganese and copper
in an IV trace element shortage, do not give newly initiated adult patients starting on PN who are not _____ and with no ______
critically ill or no pre existing deficits
____ is not a part of PN due to compatibility issues warranting separate IV infusion or oral supplementation
iron
patients who are at risk for re-feeding syndrome are most likely to develop referring syndrome within __ to __ days after the start of nutrition support
2-5 days
When a patient is at high risk for re-feeding syndrome, provide ____ of energy needs on the first day of PN (about ____ kcal)
1/2 of energy needs (about 1000 kcal)
patients at risk for re-feeding syndrome should only receive ____g of dextrose and fat a day in the beginning
200
when advancing nutrition support for patients with or at risk for re-feeding syndrome, how should calories be advanced
increase gradually over 2-5 days based on patient’s tolerance
hepatic dysfunction due to intestinal failure on patients on parenteral nutrition is called
PN associated liver disease (PNALD)
hepatic fat accumulation resulted from patients on parenteral nutrition due to overfeeding is called
steatosis
patients with hepatic steatosis are likely to have an elevation in this liver enzyme
AST
a condition of impaired secretion of bile or frank biliary obstruction (primarily in children) is called
cholestasis (PN associated cholestasis)
PNAC or cholestasis will likely result in the elevation of these lab values
elevated ALK Phos, GTT, conjugated bilirubin
If untreated PNAC or cholestasis can lead to the development of
liver cirrhosis or fibrosis
_____ can cause cholecystitis due to the lack of enteral stimulation when on sole PN
gallbladder sludge/stones
gallbladder sludge/stones develop due to lack of ____ stimulation, from the decreased release of the hormone _____ leading to impaired ____ flow and decreased _____ contract-ability which can progress to _______ or ______
lack of enteral stimulation cholecystokinin bile gallbladder cholecystitis acalculous cholecystitis
risk factors for developing hepatic steatosis on PN are
overfeeding (promotes hepatic fat deposition, stimulation of insulin prompting lipogenesis)
overfeeding carbohydrates with patients at risk for PNALD will lead to excess ___ deposition in the liver, deficient of _____ which impairs lipoprotein formation and TCG secretion
fat
essential fatty acids
to decrease the risk of developing cholestasis make sure to provide less than ______ g/kg/day of ILE
< 1 g/kg/day
_____ plays a role in fat metabolism by mobilizing hepatic fat stores (infants)
carnitine
Carninte still needs to have its role in preventing PNALD in TPN established before being available for PN
true
_____ is essential for lipid transport and metabolism but is not a component of PN. ____ supplementation has show to improve eLFT’s in a small population of adults but isn’t commercially available
choline
choline
per ASPEN recommendations state “commercially available PN choline products should be developed for routine addition to adult PN formulas” true or false
true
what are ways to manage PNALD
decrease fat/dextrose content decrease ILE to <1g/kg/day cycle PN infusion maximize enteral intake if possible or slow TF rate treat SIBO with antibiotics try the medication Ursodiol only provide ILE 1-2x/week remove supplemental Mn and Cu
____ is characterized by low bone mass, compromised bone strength, deterioration of bone tissue and leads to bone fractures
osteoporosis
Osteoporosis is diagnosed based on >______ standard deviations below the mean age for bone density
2.5 standard deviations
_______ is characterized by The Who criteria of having a bone density t-score of -1 to 2.5 standard deviations below mean bone density
osteopenia
the softening of bones due to decreased calcified tissue is called
osteomalacia
what are the major risk factors for developing metabolic bone disease
long term PN , hyperparathyroid disease, malabsorption, malignancy, corticosteroids, ETOH use, Roux en y gastric bypass
patients on TPN are at a high risk of hypocalcemia because supplementing calcium is limited by the incompatibility of ____
phosphorous
ASPEN recommends ___to ___ mEq of calcium gluconate a day from PN to prevent bone disease
10-15 mEq ca gluconate
ASPEN recommends ___ to ___ mol of phosphorous in PN to prevent bone disease
20-40 mmol/day of phos
Hypocalcemia can be caused by high ___ sources over 2 g/kg/day as it increases urinary losses
high protein sources or cycled PN (increase urinary calcium losses)
excess vitamin D can cause ___ deficiency because it can suppress PTH secretion and promote bone resportion
calcium
parenteral ergocalciferol is or is not available in the US to supplement vitamin D deficiency
is not
Aluminum can contribute to bone disease because
decreases bone formation
Patients on long term PN should have a _______ at baseline and then once a year to assess bone density
DEXA scan
these lab values should be routinely monitored to evaluate for metabolic bone disease
magnesium,phosphorous,calcium
PTH, TSH
25-dihydroxyvitamin D
24 hour urine calcium
other non medical prevention therapies to avoid MBD could be
low intensity resistance exercise
medications used to treat metabolic bone disease to decrease bone resorption are
bisphosphonates, calcitonin,
PN modifications to avoid MBD are to avoid high ___ doses, avoid excess __ provision as it will increase renal calcium excretion, provide at least __ to __ mEq/day of ____ as _____, provide ___ to ___ mol of phos/day, treat metabolic _______, maintain adequate magnesium & copper, minimize ___ contamination
protein doses sodium 10-15 mEq/Day 20-40 mol/day acidosis aluminum
Lifestyle modifications to help mitigate MBD are
weight bearing exercise
smoking cessation
decreased caffeine/alcohol intake
high phosphorous content limits the ability of this type of calcium salt to TPN
calcium gluconate
when infusing medications and TPN at the same time, it increases the risk of
precipitation
calcium ____ is known to cause precipitate in the VAD
chloride
what is used to clear calcium phosphate occlusions in VADs
0.1 N Hydrochloric acid
