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CNSC Exam > PN Complications > Flashcards

PN Complications Flashcards

1
Q

the most common complication of PN

A

hyperglycemia

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2
Q

____ associated hyperglycemia occurs in acutely ill and septic patients from insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion

A

stress hyperglycemia

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3
Q

common causes of hyperglycemia in health care and PN

A

extra provision of glucose, hepatic steatosis, increased CO2 production

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4
Q

what is ASPEN’s target BG in adult hospitalized patients getting nutrition support

A

140-180 mg/dL

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5
Q

what is the SCCM target range for BG for the ICU population

A

150-180 mg/dL

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6
Q

what are some methods in the treatment of PN associated hyperglycemia

A
  1. start PN at 1/2 of energy needs
  2. start with 150-200 g dextrose in 1st 24 hours or <100 g if poor glucose control
  3. <4-5 mg/kg/min GIR
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7
Q

how often should blood glucose be monitored with short acting subcutaneous insulin

A

every 6-8 hours

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8
Q

how often should blood glucose be monitored in critically ill with insulin infusion therapy

A

every 4 hours

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9
Q

provide __ to __ units of insulin per gram of dextrose or ___ to ____ in the PN bag for those who are already hyperglycemia

A

0.5 to 1 or 0.15-0.2 units/gram of dextrose

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10
Q

when a patient on PN is hyperglycemic supplement ___ insulin

A

short or rapid acting insulin

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11
Q

when adding insulin to PN, add ____ of of the patients total insulin needs required over 24 hours added to the next day’s PN

A

2/3

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12
Q

only ____ insulin should be added to PN formulation to account for the duration of insulin therapy

A

regular

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13
Q

increase proportional amounts of ___ in the PN to increase energy when patients are hyperglycemic

A

fat/lipids

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14
Q

in rare cases ___ deficiency can make insulin less effective and would require supplementation in PN

A

chromium

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15
Q

what are the consequences of hyperglycemia

A

poor wound healing
increased infection risk
dehydration, coma, death

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16
Q

hypoglycemia often occurs because of excess ____ provision in PN

A

insulin

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17
Q

when a patient is hypoglycemic while on PN provide a___% dextrose infusion or ampule of ___% dextrose /stop insulin provision

A

10% or 50% ampule

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18
Q

rebound hypoglycemia often occurs when abruptly stopping

A

IV/PN infusion of dextrose

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19
Q

to avoid rebound hypoglycemia, how should TPN be tapered

A

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

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20
Q

If a patient is NPO and PN is stopped, when should a blood glucose be checked

A

30 mins to 1 hour after PN discontinuation

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21
Q

_____ and ____ cannot be produced by the body and therefore can lead to the development of essential fatty acid deficiency if not provided in PN

A

omega 3 and omega 6 fatty acids

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22
Q

what are the clinical symptoms of essential fatty acid deficiency

A

scaly dermatitis, alopecia, hepatomegaly, fatty liver anemia

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23
Q

the ___ test with a ratio over 0.2 indicates EFAD

A

triene to tetraene ratio

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24
Q

EFAD can develop within ___ to ___ weeks with lipid free PN

A

1-3 weeks

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25
Q

__ 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

A

1-2 % total energy from linoleic
0.5% total energy from alpha linolenic acid
500mL or 500mL 20% IL2x/week

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26
Q

Provision of ____% Intravenous Lipid Emulsion 2x/week at a dose of 500mL can prevent the development of EFAD

A

20%

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27
Q

___ based ILEs can suppress the immune system from reticuloendothelial dysfunction, an exaggerated inflammatory response and the activation of the arachidonic pathway

A

Soy based

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28
Q

____ can occur with overfeeding of dextrose or rapid ILE administration > 0.11`g/kg/hour

A

hypertriglyceridemia

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29
Q

what are the implications of hypertriglyceridemia

A

impaired immunity
altered pulmonary hemodynamics
increased risk of pancreatits

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30
Q

what are some methods to manage PN associated hypergtriclyderidemia

A

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

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31
Q

if a blood triglyceride level over ____mg/dL occurs, stop ILE provision or decrease the amount

A

400 mg/dL

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32
Q

____ can develop due to ILE induced hypertriglyceridemia when TCG’s exceed 1000mg/dL

A

pancreatitis

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33
Q

patients with a(n) ____ allergy can develop a reaction due to the composition of ILE’s

A

eggs

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34
Q

symptoms of an egg allergic reaction results in

A

cyanosis, dyspnea, flushing, sweating, dizziness, headache, nausea, vomiting

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35
Q

which vitamin is likely to suffer extensive photodegradation if the PN bag is exposed to light

A

vitamin A

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36
Q

In a hypoalbuminemic patient, the use of albumin within PN solutions has consistently demonstrated

A

improved serum albumin concentrations

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37
Q

what is most likely to contribute to PN associated alterations in renal tubular function

A

bactermenia/fungemia

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38
Q

which vitamin may be restricted in end stage renal disease patients requiring PN

A

vitamin A

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39
Q

TNA PN preparations have a higher risk of this PN preparation issue than 2 in 1

A

precipitation of calcium salts

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40
Q

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

A

creaming

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41
Q

is PN still safe to use in the first stages of creaming (when the emulsion starts to breakdown)

A

yes, other individual droplets are generally preserved

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42
Q

_____ is an inherent contamination of PN solutions

A

aluminum

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43
Q

which disease states are at highest risk for developing an aluminum toxicity while on PN

A

renal dysfunction (limited ability to excrete)

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44
Q

contamination of aluminum in PN is usually from introduction of

A

raw materials during MANUFACTURING

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45
Q

____ deficiency from PN use can cause hepatic steatosis

A

choline

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46
Q

the most common hepatic complication of PN is

A

steatosis

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47
Q

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

A 
cycled
enteral feedings (small)
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48
Q

____ and ____ should NOT be added to PN in hepatobiliary disease to prevent toxicity

A

copper & manganese

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49
Q

with prolonged hyperbilirubinemia, a prudent step is to avoid routine administration of

A

copper & manganese

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50
Q

what are 2 methods to prevent PN induced cholestasis

A

early start of oral/EN feeds to stimulate cholecystokinin release for bowel motility and gallbladder emptying

starting Ursodiol, a medication that improves biliary flow

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51
Q

a medication (given orally) that is used to improve bile flow

A

Ursodiol

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52
Q

in cholestasis or biliary obstruction which labs are elevated

A

alkaline phosphorus and total bilirubin

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53
Q

what are the 2 main proposed causes of PNALD

A

overfeeding dextrose and lipids, or providing manganese/coper

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54
Q

Often patients who develop PNALD will see elevated liver function tests within

A

1-4 weeks

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55
Q

_____ is a result of decreased calcium intake or increase calcium excretion

A

hypocalcemia

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56
Q

what are possible causes of hypercalciuria

A 
excessive calcium provision
inadequate phosphorous supplementation
amino acids in PN
cycling PN
chronic metabolic acidosis
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57
Q

what are interventions when a patient has hypercalciuria

A

reduce amino acid concentration in PN, correct metabolic acidosis by adding more acetate

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58
Q

what poses the greatest risk of developing metabolic bone disease while on PN

A

long term PN /corticosteroid use

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59
Q

what is the most accurate way to diagnose metabolic bone disease

A

bone mass asessment

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60
Q

in a home PN patient displaying signs of metabolic bone disease, the following adjustment would be the most appropriate

A

decrease protein because it causes more calcium losses

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61
Q

what is the max glucose utilization rate in PN for adults

A

5 mg/kg/min

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62
Q

what is an adverse effect of excessive IV lipid emulsion

A

thrombocytopenia (too much vitamin K)

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63
Q

in a patient getting PN with MVI containing vitamin K and warfarin, the most appropriate course of action would be to

A

maintain consistent vitamin K provision even after PN is discontinued, and adjust anticoagulation therapy as needed

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64
Q

the deficiency of this vitamin can result in abnormal prothrombin time

A

vitamin K

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65
Q

what is the max hang time for lipid emulsions when they are infused alone

A

12 hours

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66
Q

when lipids are a part of a TNA, what is the max hang time

A

24 hours (TNA’s have a lower pH, making it less likely for microorganisms to grow)

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67
Q

compounding PN with manual or automated devices, adding multiple injections, detachments and nutrients are considered ___ risk

A

medium

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68
Q

Transferring, measuring, and mixing PN in sealed packages when preformed promptly is considered ____ risk

A

low

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69
Q

addition of non sterile ingredients or devices are at _____ risk

A

high

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70
Q

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

A

DOES NOT

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71
Q

amino acid concentration, calcium concentration, calcium salt formation, dextrose/phosphate concentration, pH/temperature, presence of additives and order of mixing all influence

A

solubility of calcium phosphate precipitation

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72
Q

what items are mandatory on the PN Order Form

A 
general statement of warning for incompatibilities
contact # of the prescriber
hang time
location of venous access
height, weight, dosing weight
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73
Q

what items are mandatory on the PN Label

A

amount of micronutrients/day
dosing weight
route of administration

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74
Q

PN prescribing errors occur when ______

A

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

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75
Q

what biochemical evidence indicates essential fatty acid deficiency

A

triene to tetraene ration >2 (holman index)

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76
Q

in a patient in the ICU receiving concurrent infusions of lipid injectable emulsion and propofol, these concurrent infusions could potentially cause

A

hypertriglyceridemia

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77
Q

Propofol is a ____% emulsion

A

10%

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78
Q

which component of PN is most likely to impact anticoagulation in a patient on warfarin

A

ILE’s as they contain vitamin K

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79
Q

when a patient is on coumadin/warfarin and on PN with ILE,s what should be monitored

A

vitamin K and INR to make sure they are in therapeutic range

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80
Q

when initiating PN that contains regular insulin, how often should capillary blood glucose levels be monitored

A

every 6 hours (once stable they can be monitored less often)

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81
Q

what risk is associated with abrupt cessation of a PN solution

A

rebound hypoglycemia

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82
Q

which patients are at the highest risk of rebound hypoglycemia when terminating a PN solution

A

patients on high doses of insulin and not on an EN or PO diet

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83
Q

how long should PN be tapered down when stopping PN to prevent rebound hypoglycemia

A

1-2 hour taper down in rate

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84
Q

in adult PN patients, IVLE use should be limited when serum TCGs rise above

A

400 mg/dL

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85
Q

the FDA currently recommends that daily intake of parental aluminum should not exceed

A

5 mcg/kg/day

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86
Q

PN products that are a concern for aluminum contamination are

A

calcium/phosphate salts
heparin
albumin

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87
Q

aluminum toxicity can cause

A

altered bone formation
altered PTH secretion
altered urinary calcium excretion

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88
Q

populations at risk for aluminum toxicity are

A

infants
children
renal insufficient
chronic PN

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89
Q

when is cycling PN recommended

A

patients at risk for liver dysfunction

long term PN patients

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90
Q

patients on a continuous rate of PN develop _______ that causes hepatic fat deposition causing a rise in LFT’s

A

hyperinsulinemia

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91
Q

what is most likely to contribute to metabolic bone disease in PN dependent patients

A

aluminum toxicity

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92
Q

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

A
  1. calcium and bone fixation
  2. 25 hydroxyvitamin d to active 1,25 dihydroxyvit D
  3. parathyroid hormone
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93
Q

the upper limit for aluminum is ___ mcg/kg/day

A

5

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94
Q

what is a risk factor for the development of PN associated liver complications in PN dependent patients

A

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

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95
Q

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

A
  1. omega 6 fatty acids
  2. pro inflammatory
  3. toxic phytosterols
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96
Q

what are some methods to reduce the risk of developing liver complications when using ILE’s in PN

A
  1. cycle PN
  2. supplement with EN
  3. consider adding ursodiol
  4. increase the omega 3 to 6 ratio with different ILEs
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97
Q

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

A

hepatic steatosis (overfeeding from hyperinsulinemia which leads to fat deposition)

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98
Q

what are the 3 types of hepatobiliary disorders associated with long term PN

A

steatosis (overfeeding)
cholestasis (primarily in children 2/2 impaired biliary secretion)
gallbladder stones/sludge from lack of GI stimulation

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99
Q

Hepatic steatosis is a complication of PN associated liver disease which causes mild elevations in ____,____ and ____ and is caused by ________

A

alk phos, ALT, bilirubin

OVERFEEDING

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100
Q

Cholestasis is a complication of PN associated liver disease which causes an elevation of _____ and primarily occurs in children due to __________

A

conjugated bilirubin

impaired biliary secretion

101
Q

Gallbladder stones/sludge are complications of PN associated liver disease which is due to ________

A

the lack of EN/GI stimulation from long term PN use

102
Q

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?

A

thiamine

103
Q

hyperglycemia in a patient receiving PN, is associated primarily with what type of sodium/fluid imbalance

A

Hypertonic, hyponatremia

104
Q

hypertonic hyponatremia can result from _____ or ______ free solutions

A

hyperglycemia

sodium free hypertonic solutions

105
Q

in hypertonic, hyponatremia; an increase in blood glucose causes a shift of water ____ of the cells and into the extracellular space which decreases serum ________

A

OUT of the cells

decreased serum sodium

106
Q

for every 100 mg/dL increase in blood sugar greater than 100mg/dL , serum sodium will increase by ____ mE/qL

A

1.6 mEq/L

107
Q

how is pseudohyponatremia (hyponatremia from high dextrose concentration) treated

A

treat the hyperglycemia, don’t use fluids as it is NOT a true sodium or water imbalance

108
Q

A long term PN patient presents with involuntary movements, tremor, and ridgitiy. What etiology may explain this

A

manganese toxicity

109
Q

____ deficiency is associated with Keshan Disease (cardiomyopathy) and increased oxidative damage

A

selenium

110
Q

selenium toxicity can cause

A

hair/nail loss, tooth decay, peripheral neuropathy

111
Q

in order to prevent rebound hypoglycemia upon discontinuing PN, it is recommended the PN infusion rate to be decreased over what time span

A

1-2 hours

112
Q

in what timeframe should a blood glucose be taken upon the cessation of PN

A

30-60 minutes after

113
Q

what would be the most serious complication of hypertriglyceridemia in a patient getting PN

A

pancreatitis

114
Q

what are some potential causes of hyperglycemia in a patient receiving PN?

A

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

115
Q

what are some risk factors for the development of rebound hypoglycemia after cessation of PN (things that effect glucose regulation)

A

malnutrition
hepatic dysfunction
renal insufficiency

116
Q

rebound hypoglycemia occurs when elevated endogenous insulin levels don’t adjust to the reduced ___ infusion

A

dextrose

117
Q

the preferred site for placement of a central venous access device is

A

subclavian

118
Q

the density of skin flora at the _______ is a major contributing factor for catheter related bloodstream infections

A

catheter site

119
Q

catheter related thrombosis caused by fibrin buildup with blood vessels adhering to a central venous catheter is called

A

mural thrombosis

120
Q

the layer of fibrin that develops around the outside of a central venous catheter due to aggregation

A

fibrin sheath

121
Q

the use of 0.1N hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of

A

calcium-phosphate salts. this crystalloid solution are acidic which will help Ca-Phos solubility

122
Q

direct infusion of 0.1N hydrochloric acid can cause

A

fever, phlebitis, sepsis

123
Q

for catheter occlusions due to precipitates associated with medications with a high pH such as tobramycin or phenytoin ______ is used to treat them

A

1 mEq/L NaBicarb

124
Q

70% ethanol is the effective solvent to dissolve

A

lipid residue

125
Q

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

A

decreased amino acid content

126
Q

the most important contributor of metabolic bone disease is

A

a negative calcium balance which can be due to protein in long term PN patients

127
Q

long term PN patients should typically not exceed _____g/kg/day protein to avoid negative calcium balance and MBD

A

1.5g/kg/day

128
Q

causes of hypocalcemia

A

low calcium intake

increased urinary calcium excretion (hypercalciuria)

129
Q

causes of hypercalcemia

A 
excessive calcium provision
inadequate phosphorous supplementation
excessive protein in PN
cyclic PN infusion
chronic metabolic acidosis
130
Q

the best approach to prevent PN induced cholelithiasis is the administration of _________ to stimulate ______ secretion, bowel ________ and ______ emtpying

A
  1. oral or enteral feeding
  2. cholecystokinin
  3. motility
  4. gallbladder
131
Q

Ursodiol is NOT the best approach for treating PN induced cholelithiasis because

A

it can only be given orally and has mixed results in studies

132
Q

what are some short term complications of home PN

A

dehydration
refeeding syndrome
catheter malposition
electrolyte abnormalities

133
Q

what is most likely to cause elevated serum bicarb levels in a home PN patient?

A

excess acetate salts in PN

134
Q

excess chloride salts, significant diarrhea and acute renal failure are all causes of metabolic _______

A

acidosis

135
Q

what are clinical signs and symptoms of refeeding syndrome

A 
sodium retention
hypo K phos and mag
pulmonary hypertension
fluid overload
cardiac decompensation
136
Q

severe hypophosphatemia can lead to

A

respiratory failure/seizures

137
Q

hypokalemia and hypomagnesemia can lead to

A

cardiac arrhythmias, neuromuscular adverse effects including weakness and muscle cramps

138
Q

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

A

fluid overload as 125mL/hr x 24 hours is 3000mL of water which provides 60mL/kg. TPN should only provide 30-40mL/kg.

139
Q

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

A

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)

140
Q

PPN should be administered for at last _____ days with no more than _____ weeks total

A

5 days minimum

2 weeks maximum

141
Q

Patients who get PPN must have good _________, the ability to tolerate large ______, and contraindication to _______

A

peripheral access
large volumes
central access

142
Q

contraindications to starting PPN are

A 
significant malnutrition
severe metabolic stress
large nutrient or electrolyte needs
fluid restriction
>2 week need for PN
renal/liver compromise
143
Q

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

A

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

144
Q

what feature of a Groshong central venous catheter reduces the risk of catheter occlusion

A

pressure sensitive 3 way valve

145
Q

a Groshong CVC has a pressure sensitive 3 way valve restricts ______ and _____ by remaining closed when not in use

A

blood backflow

air embolism

146
Q

what are pros of a Groshong CVC’s

A

no need for clamping
no need for heparin flushes for cath. patency
should flush w/ NS after meds/blood aspiration

147
Q

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

A

alteplase 2mg/mL

148
Q

conventional therapy for an occluded central venous access device due to an intraluminal clot or fibrin sheath is _________in a single or repeated bolus

A

local thrombolytic therapy

149
Q

_________ is the only FDA approved thrombolytic agent for CVAD occlusions

A

cathflow altepase

150
Q

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?

A

initiate systemic antimicrobial therapy

a. blood cultures are negative (not bacteremia)
b. has temp, increased heart rate

151
Q

erythema, tenderness or purulence within 2 cm of the catheter exit site is called a

A

an exit site infection

152
Q

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

A

increase fluid and increase sodium

153
Q

Patients with an ileostomy or small bowel fistula output are at risk for loss of _____, _____ and ____

A

water, sodium and electrolytes

154
Q

Sodium content from high output ileostomy can be up to ____mEq/L

A

100mEq/L

155
Q

a high BUN: Cr ratio over 20:1 indicates

A

volume depletion

156
Q

___occurs when fluid replacement doesn’t contain adequate sodium to account for ileostomy losses

A

hyponatremia

157
Q

the use of 70% ethyl alcohol is most effective for clearing catheter occlusions 2/2 the precipitation of

A

lipid residue

158
Q

the most common route of infection for a tunneled central venous access device is

A

contamination of the catheter hub/intraluminal contamination

159
Q

pathogenesis of a non tunneled CVAD is known as

A

extraluminal colonization

160
Q

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

A

pinch off syndrome

161
Q

_______ occurs when a central catheter is being compressed between the first rib and the clavicle, causing intermittent compression and pinching. This causes intermittent occlusion.

A

Pinch off syndrome

162
Q

the hallmark sign of pinch off syndrome is

A

occlusion being resolved when the patient raises then lowers their arm

163
Q

treatment of pinch off syndrome includes

A

removing the catheter and replacing in in a more lateral position in the subclavian or IJ vein

164
Q

what types of conditions predispose a patient to refeeding syndrome

A

chronic alcoholism
malabsorption syndromes/ gastric bypass
weight loss
prolonged fasting >7 days

165
Q

A patient with refractory hypokalemia should be assessed for what electrolyte disorder

A

hypomagnesemia

166
Q

____ is an important regulator of intracellular potassium. Hypomagnesemia can cause refractory hypokalemia 2/2 accelerated renal potassium loss.

A

magnesium

167
Q

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

A

the brain causing Parkinson’s like symptoms

168
Q

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

A
  1. decrease calorie content as he is being overfed at 45cal/kg
  2. 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
169
Q

the most accurate method of diagnosing PN associated metabolic bone disease is to measure

A

bone mineral density

170
Q

what are some co morbidities that are risk factors for the development of MBD for a patient on LTPN

A
  1. Malabsorption disorders (Chron’s)
  2. Cancer (decreased food intake, altered vit D metabolism, decr. absorption 2/2 chemoradiation
  3. Steroid use from Chron’s, short bowel syndrome
171
Q

a rise in which lab values would most likely indicate cholestasis

A

conjugated bilirubin, increased gamma glutamyltranserase and increased alk phos

172
Q

during LTPN administration, hepatobiliary complications can best be prevented by ______ which allows the body to oxidize fat and decreases insulin levels.

A

cycling PN

173
Q

carnitine is ____ present in any PN formula but can be added if there is a measured deficiency

A

not

174
Q

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

A

superior vena cava syndrome

175
Q

swelling, erythema, and induration along the subcutaneous tract of a tunneled catheter is known as

A

a tunnel infection

176
Q

chest pain, earache, jaw pain, arm swelling, and leaking at an exit or insertion site are the symptoms of

A

thrombosis

177
Q

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 __________

A

sentinel event

178
Q

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

A

sentinel vent

179
Q

what is an etiology of a thrombotic catheter occlusion

A

fibrin sheath/sleeve

180
Q

non-thrombotic catheter occlusions include

A

mechanical obstruction
drug/mineral precipitates or lipid deposits
catheter migration/malposition

181
Q

the most effective strategy to decrease the risk of catheter associated sepsis is the use of

A

full barrier precautions during catheter insertion (mask, cap, sterile gloves, long sleeve gowns, sheet drapes)

182
Q

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?

A

training of nursing staff to maintain CVAD and cleanse insertion sites with 2% chlorexide prep

183
Q

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

A

catheter related bloodstream infection (CRBSI)

184
Q

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

A

CRBSI

185
Q

a critically ill patient has been receiving PN providing 45 kcal/kg. The consequences of providing excess calories to a critically ill patient are

A

fatty liver, vent weaning failure and increased blood sugar

186
Q

a patient presents to the clinic with a suspected catheter occlusion. What should your initial actions be

A
  1. obtain history of signs/sx of cath malfunction
  2. double check catheter function for patency & blood aspiration
  3. check for mechanical causes of kinking, clamps, sutures
  4. assess if the occlusion is relieved from postural changes
  5. obtain history of flushing techniques, med infusion and blood aspiration
  6. assess physical symptoms (edema, redness, pain)
187
Q

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

A

hyperglycemia, the PN provides a GIR of 6 and >7g/kg dextrose

188
Q

discontinuation of lipid injectable emulsion is recommended treatment for catheter related bloodstream infections related to ______

A

malasezia furfur

189
Q

______ 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

A

malassezia furfur

190
Q

treatment of malassezia furfur is

A

administration of anti fungal therapy

191
Q

excess carbohydrate administration in PN has been associated with

A

hepatic steatosis

192
Q

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

A

catheter related infections

193
Q

A diabetic patient when starting on PN should start at ________ g/dex/day to avoid hyperglycemia and refeeding syndrome

A

100-150 g dex/day

194
Q

Add ___ to ___ units of insulin/gram of dextrose to PN and increase the next day by __ of the previous day sliding scale insulin

A

0.5-1 unit per gram of dextrose

2/3 of sliding scale days previous

195
Q

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

A

increase chloride to acetate ratio
pH is elevated = alkalosis
pCO2: WNL
Bicarb elevated: = metabolic acidosis

196
Q

A home PN dependent patient with a peripherally inserted central catheter presents with arm, shoulder and neck swelling. What is the most likely cause

A

catheter related central venous thrombosis

197
Q

arm, shoulder, neck swelling, limb, jaw or ear pain and dilated collateral veins of the arm, neck or chest are all sx of

A

catheter related central venous thrombosis as CVCs cause endothelial trauma and inflammation

198
Q

vitamin ____ can become toxic in renal failure

A

vitamin A

199
Q

how much folic acid should be provided for TPN patients for the initial 5-7 days of PN

A

1mg/day

200
Q

some vitamins are severely degraded in the PN making process which is an issue for ______ Pn patients

A

long term PN

201
Q

what steps should be taken during IV vitamin shortage

A

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

202
Q

if all IV MVI’s are out after a shortage, which IV medications should be given separately to TPN patients

A

thiamine, ascorbic acid, pyridine and folic acid daily

203
Q

trace element toxicity is common in TPN patients with ____ disease

A

hepatobiliary disease

204
Q

which minerals are of concern with patients on TPN and who have hepatobiliary diseases

A 
zinc
copper
manganese
chromium
selenium
aluminum
205
Q

consider decreasing __ and ___ in hepatobiliary patients on TPN

A

manganese and copper

206
Q

in an IV trace element shortage, do not give newly initiated adult patients starting on PN who are not _____ and with no ______

A

critically ill or no pre existing deficits

207
Q

____ is not a part of PN due to compatibility issues warranting separate IV infusion or oral supplementation

A

iron

208
Q

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

A

2-5 days

209
Q

When a patient is at high risk for re-feeding syndrome, provide ____ of energy needs on the first day of PN (about ____ kcal)

A

1/2 of energy needs (about 1000 kcal)

210
Q

patients at risk for re-feeding syndrome should only receive ____g of dextrose and fat a day in the beginning

A

200

211
Q

when advancing nutrition support for patients with or at risk for re-feeding syndrome, how should calories be advanced

A

increase gradually over 2-5 days based on patient’s tolerance

212
Q

hepatic dysfunction due to intestinal failure on patients on parenteral nutrition is called

A

PN associated liver disease (PNALD)

213
Q

hepatic fat accumulation resulted from patients on parenteral nutrition due to overfeeding is called

A

steatosis

214
Q

patients with hepatic steatosis are likely to have an elevation in this liver enzyme

A

AST

215
Q

a condition of impaired secretion of bile or frank biliary obstruction (primarily in children) is called

A

cholestasis (PN associated cholestasis)

216
Q

PNAC or cholestasis will likely result in the elevation of these lab values

A

elevated ALK Phos, GTT, conjugated bilirubin

217
Q

If untreated PNAC or cholestasis can lead to the development of

A

liver cirrhosis or fibrosis

218
Q

_____ can cause cholecystitis due to the lack of enteral stimulation when on sole PN

A

gallbladder sludge/stones

219
Q

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 ______

A 
lack of enteral stimulation
cholecystokinin
bile
gallbladder
cholecystitis
acalculous cholecystitis
220
Q

risk factors for developing hepatic steatosis on PN are

A

overfeeding (promotes hepatic fat deposition, stimulation of insulin prompting lipogenesis)

221
Q

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

A

fat

essential fatty acids

222
Q

to decrease the risk of developing cholestasis make sure to provide less than ______ g/kg/day of ILE

A

< 1 g/kg/day

223
Q

_____ plays a role in fat metabolism by mobilizing hepatic fat stores (infants)

A

carnitine

224
Q

Carninte still needs to have its role in preventing PNALD in TPN established before being available for PN

A

true

225
Q

_____ 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

A

choline

choline

226
Q

per ASPEN recommendations state “commercially available PN choline products should be developed for routine addition to adult PN formulas” true or false

A

true

227
Q

what are ways to manage PNALD

A 
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
228
Q

____ is characterized by low bone mass, compromised bone strength, deterioration of bone tissue and leads to bone fractures

A

osteoporosis

229
Q

Osteoporosis is diagnosed based on >______ standard deviations below the mean age for bone density

A

2.5 standard deviations

230
Q

_______ is characterized by The Who criteria of having a bone density t-score of -1 to 2.5 standard deviations below mean bone density

A

osteopenia

231
Q

the softening of bones due to decreased calcified tissue is called

A

osteomalacia

232
Q

what are the major risk factors for developing metabolic bone disease

A

long term PN , hyperparathyroid disease, malabsorption, malignancy, corticosteroids, ETOH use, Roux en y gastric bypass

233
Q

patients on TPN are at a high risk of hypocalcemia because supplementing calcium is limited by the incompatibility of ____

A

phosphorous

234
Q

ASPEN recommends ___to ___ mEq of calcium gluconate a day from PN to prevent bone disease

A

10-15 mEq ca gluconate

235
Q

ASPEN recommends ___ to ___ mol of phosphorous in PN to prevent bone disease

A

20-40 mmol/day of phos

236
Q

Hypocalcemia can be caused by high ___ sources over 2 g/kg/day as it increases urinary losses

A

high protein sources or cycled PN (increase urinary calcium losses)

237
Q

excess vitamin D can cause ___ deficiency because it can suppress PTH secretion and promote bone resportion

A

calcium

238
Q

parenteral ergocalciferol is or is not available in the US to supplement vitamin D deficiency

A

is not

239
Q

Aluminum can contribute to bone disease because

A

decreases bone formation

240
Q

Patients on long term PN should have a _______ at baseline and then once a year to assess bone density

A

DEXA scan

241
Q

these lab values should be routinely monitored to evaluate for metabolic bone disease

A

magnesium,phosphorous,calcium
PTH, TSH
25-dihydroxyvitamin D
24 hour urine calcium

242
Q

other non medical prevention therapies to avoid MBD could be

A

low intensity resistance exercise

243
Q

medications used to treat metabolic bone disease to decrease bone resorption are

A

bisphosphonates, calcitonin,

244
Q

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

A 
protein doses
sodium 
10-15 mEq/Day
20-40 mol/day
acidosis
aluminum
245
Q

Lifestyle modifications to help mitigate MBD are

A

weight bearing exercise
smoking cessation
decreased caffeine/alcohol intake

246
Q

high phosphorous content limits the ability of this type of calcium salt to TPN

A

calcium gluconate

247
Q

when infusing medications and TPN at the same time, it increases the risk of

A

precipitation

248
Q

calcium ____ is known to cause precipitate in the VAD

A

chloride

249
Q

what is used to clear calcium phosphate occlusions in VADs

A

0.1 N Hydrochloric acid

CNSC Exam (32 decks)

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