PN Overview Flashcards
for a pregnant patient with hyperemesis gravidarium presenting with fluid/electrolyte imbalances, ketonuria and dehydration, what would be the first line of therapy
IV fluid, additional B vitamins such as B12 and B6 as well as thiamine
for a patient with severe hyperemesis gravidarum with little to no po intake, what should be supplemented to prevent Wernicke’s encephalopathy and neural tube defects
Thiamine
Folic Acid
what is the second line of therapy for hyperemesis gravidarum
hold oral intake, start antiemetic
if a patient with hyperemesis gravidarum is unable to take oral feedings after 24-48 hours of supportive therapy (IV fluid, anti emetic, vitamins) what should be started as far as nutrition support
enteral feedings
when should PN be considered for hyperemesis gravidarum
if a patient fails EN due to exacerbated nausea, vomiting, diarrhea, significant gastric residuals or tube displacement, and clinically significant weight loss >5% of body weight
Rapid IV infusion of potassium phosphate can cause
thrombophlebitis
infusion rates of IV phosphate should not exceed ___mmol/hr because it can cause ________ and metastatic ___ deposition/organ dysfunction
7 mmol/hr
thrombophlebitis
calcium phosphate deposition
the most common complication associated with PN
hyperglycemia
hyperglycemia is the most common complication associated with PN due to
stress associated hyperglycemia in sepsis/acutely ill causing insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion
what is the glycemic BG target for the majority of critically ill patients
140-180mg/dL (American Association of Clinical Endocrinologists and American Diabetes Association)
a target BG below ____ is not recommended in the ICU due to the adverse effects of hypoglycemia
<110mg/dL
What is the preferred approach for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus
basal, bolus insulin.
(basal insulin is given for hepatic glucose output and bolus insulin regularly scheduled is used for meal times) as well as correctional insulin
what form of glutamine supplementation improves physical compatibility and stability for admix in PN solutions
glutamine dipeptide (L-alanyl, Lglutamine, Glycl L glutamine)
___glutamine supplementation is more beneficial than enteral supplementation
parenteral
IV glutamine supplements are _____ available in the U.S.
not
free ____ is unstable in PN solutions
glutamine
a critically ill obese patient with a BMI of 33.4
should be recommended for this range of calories/body weight/day per SCCM and ASPEN
11-14 kg/ABW/day
for all classes of obesity where BMI >30 kg/m2, the goal PN regiment shouldn’t exceed ___ to ___ total energy requirements as measured by indirect calorimetry
65-70%
If indirect calorimetry isn’t available, the weight based equation of _______ should be used for patients with a BMI of 30-50 kg/m2 to predict energy needs
11-14 kcal/kg/ABW
If IC isn’t available, the weight based equation of ___ should be used for patients with a BMI >50 kg/m2 to predict energy needs
22-25 IBW
protein should be provided in a range > or equal to ____ g/kg _____ a day for patients with a BMI of 30-40 kg/m2
2.0 g/kg IBW day
protein should be provided in a range up to ____g/kg ____ a day for patients with a BMI greater than or equal to 40
2.5 g/kg IBW /day
the majority of PN complications that increase PN Prescription errors happen when
inadequate knowledge of PN therapy, certain pt characteristics related to PN such as renal function, calculation of PN doses are incorrect, specialized PN dosage formulation characteristics and lack of knowledge of prescribing nomenclature
According to ASPEN , what is the best way to express dextrose content on the PN label to avoid misinterpretation
total grams within 24 hours (ie 255 grams/day)
On the PN label, PN ingredients are ordered in ____ for adults and ______ for pediatrics and neonates
amounts per day for adults
amounts per kg for neonates/peds
On the PN label, macronutrients should be expressed in
grams per day
On the PN label, micronutrients should be measured in
mEq,mmol,mcg,mg per day (units)
Mandatory items on a PN ORDER FORM per ASPEN
patient identifiers (birthdate or age) patient allergies Height, Weight Diagnosis (es)/ indication for PN Administration route/venous access device (periph vs. central) Prescriber contact info order date/time administration date/time volume infusion rate infusion schedule (continuous vs cyclic) type of formulation (TNA vs 2 in1 + ILE) PN ingredients (amt per day or per kg) electrolytes in complete salt form full generic name for each ingredient joint commission approved abbreviations dose of vitamins, trace elements, on nutrients medication
electrolytes on the PN order form and label should be expressed in
complete salt form
Mandatory inpatient PN label should contain
electrolytes in complete salt forms 2 patient identifiers patient location dosing weight in kg administration date and time route of administration prescribed volume overfill volume infusion rate in mL/hr duration of infusion (continuous or cycled) size of the in line filer all ingredients with barcode same sequence as PN order name of institution or pharmacy contact info for above
if ILE is hung separately, the mandatory PN label should also contain
2 patient identifiers patient location patient dosing weight in kg administration time/date route of administration prescribed amount of ILE volume of ILE infusion rate duration of infusion complete name of the ILE beyond use date and time, name of the institution/pharmacy with contact#
A patient’s PN order is 2400mL, 300 grams of dextrose, 90 grams of protein and 225mL of IL20%. How many total kcals and grams of fat are provided
1830 kcal and 45 grams of fat 300 g dextrose x 3.4 kcal = 1020 kcal 90g protein x 4 kcal = 360 kcal 225mL IL20% x 2kcal/mL = 450 kcal 450kcal of lipid /10 kcal = 45 grams 1020 + 360 +450 = 1830
A patient who weighs 75 kg is getting 2: in 1 PN with piggy back ILE 20% at 65mL/hr. with 117 grams of protein, 273 grams of dextrose. What is the total daily caloric content per kg of body weight
117 g protein x 4 kcal = 468 kcal
273 g dextrose x 3.4 kcal = 928 kcal
250mL x 2kcal= 500 kcal
468+928+500 kcal = 1896 kcal/75 kg = 25.3 g/kg
A critically ill obese patient has a BMI >33.4 kg/m2, how much protein is recommended per SCCM and ASPEN
greater than or equal to 2.0 g/kg IBW
Which of the following is an indication to start PN
high output fistula, Chron’s disease, pancreatitis, hyperemesis gravidarum
high output fistula
When is PN indicated in severe burn patients
when EN is contraindicated or unlikely to meet nutritional needs. Studies have found that use of PN in burn patients has been associated with increased mortality
The routine use of preoperative PN is indicated for patients with a non functioning GI tract who are ____ to decrease perioperative complications
severely malnourished when used for >7 days pre op
An adult patient with an abdominal tumor resulting in an unresolved SBO for over 7 days is a candidate for PN true or false
true
Any adult with a GI obstruction that precludes oral intake for at least 1 week is a candidate for PN true or false
true
Palliative use of nutrition support in terminal ill patients is ______ indicated
rarely
patients who are scheduled for surgery and are _______ are recommended for PN if PN can continue for 7-10 days
severely malnourished
When should PN be used in Chron’s
only after failure to tolerate EN (studies have found no advantage of PN over the use of EN)
EN should only be used in patients with Chron’s requiring
nutrition support therapy
peri operative specialized nutrition support is indicated in patients with IBD who are ___ and surgery can be safely postponed
severely malnourished
In a TNA ILE is stable at room temperature for ______ and stable refrigerated for ________
24 hours (room temp) 9 days (refrigerated)
Prolonged exposure to light of an ILE can cause
degradation
ILE is most stable at a pH of ____ and adding _____ can cause instability
6-9 pH
acidic dextrose
ILE administration via Piggy Back separate from dextrose and protein has a max hang time of
12 hours
ILE administration via piggy back separate from dextrose and protein tubing/filters should be changed
with each new infusion
_____ micron filters should be used to stop fat emboli, air emboli, microorganisms, or particulate matter from the patient
1.2 micron
what is the most appropriate distal catheter tip placement at a peripherally inserted central catheter
superior vena cava
a catheter inserted via peripheral vein (cephalic or basilic) whose distal tip lies in the vena cava
PICC line
central or peripheral access is defined by
position of the distal tip
disadvantages of PICC lines
limited self care ability
limited mobility
high rate of malposition or coiling
long lines increase risk of occlusion
advantages of PICC lines
NO risk of pneumothorax of puncture of carotid/subclavian arteries
NO repeated skin punctures
comes in single, double or triple lumens
When is it most appropriate to start a PN infusion in a patient with a new central venous catheter inserted at the bedside without fluoroscopy
AFTER chest x-ray confirms correct cath tip placement
one of the most common complication(s) of central venous catheters inserted at the bedside
misplacement/pneumothorax
fluoroscopy for central line insertion allows
immediate repositioning of catheter tip
The CDC recommends to ______ routinely replace CVC’s, PICCs, HD catheters or pulmonary artery catheters to prevent catheter related infections
NOT
DON’T Recommend to routinely replace
The CDC recommends ______ remove the CVC/PICC based on fever alone
DON’T remove the line based on fever alone
______ should be used to determine appropriateness of catheter removal if infection is evidenced from another site or non infectious cause
clinical judgement
Catheter insertion over a guidewire during bacteremia should ______ due to a source of infection/colonization of the skin to the insertion site
SHOULD NOT BE DONE
Which of the following additives has the greatest risk of destabilizing a lipid injectable emulsion in a total nutrient admixture (TNA) (sodium chloride, calcium acetate, iron dextran or potassium phosphate)
iron dextran
Phase separation and liberation from free oil from the destabilization of TNAs can result over time with an excess of ____ added to a formula
cations
The ____ the cation valence, the greater the destabilizing power of a TNA with oil (ILE)
greater the valence, the more disruptive
A PICC line should only be removed if
it is suspected or known to be the source of infection
the LEAST favorable place for a PN catheter is
femoral
Evidenced based interventions for patients with IV catheters that should be implemented together for the best outcomes is known as
the institute for health care improvement central line bundle
what are the two principles of the central line bundle
- optimal cath selection
2. avoid of CV access in places at high risk for infection (femoral catheters, when alternative access is available
what are the max percentages of dextrose and amino acids appropriate for peripheral PN
10% dextrose
3% amino acids
osmolarity up to _______ mOsm/L can be safely infused peripherally
900 mOsm/L
high concentrations of ____ increases calcium phosphorous precipitation in PN
amino acids
the increase of temperature of PN bags increases the dissociation of ____ salts
calcium
storage of PN in the refrigerator decreases the risk of _____ precipitation
calcium phosphate
when compounding PN, always add _____ first then ______
PHOS FIRST
then calcium
what type of parenteral amino acids should be used in a hospitalized adult with acute kidney injury requiring PN (standard, branched chain , essential amino acids, or renal specialty amino acids
standard
patients with acute renal insufficiency have a decreased ability to synthesize ____ amino acids, no research has proven the benefit of branched chain amino acids or renal specialty formulas to be more beneficial than the standard
non essential amino acids
Branched Chain Amino Acid PN formulations are the most appropriate for
a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources, despite optimal pharmacotherapy
APSEN recommends the use of _______ amino acid formulas for critically ill patients with acute and chronic liver disease
standard amino acid formulations
Failure to provide linoleic and alpha linolenic acids with PN will most likely result in
essential fatty acid deficiency
to prevent EFAD in adults, provide at least ___ to____ total calories as linoleic and ____ to _____ of alpha linoleic acid. In infants provide at least ___ to ___ g/kg/day of lipids to prevent EFAD
2-4% total calories linoleic acid
- 25-0.5% total calories alpha linoleic acid
- 5 to 1 gram/kg/day
what is a lipid injectable emulsion produced by the transesterification of fatty acids to form a composite triglyceride molecule?
a structured lipid
what is the purpose of using a structured lipid for an injectable lipid emulsion
to slow the rate or release and utilization of medium chain fatty acids
in a patient with hepatobiliary disease, which trace elements should be withheld or require a dose reduction when prescribing PN
manganese and copper due to impaired excretion in liver disease
what parts of PN are a major source of aluminum exposure 2/2 contamination of raw materials and byproducts
calcium salts, phosphate salts, calcium gluconate and potassium phosphate
The FDA mandates all manufacturers to measure and report the maximum content of ______ in their products
aluminum
per the FDA, large volume PN products should contain less than _____ mcg/L of aluminum
25 mcg/L
per the FDA, small volume PN products should label the amount of aluminum________
at the time of product expiration
a long term PN patient begins to experience Parkinson’s like symptoms; which trace element toxicity is most likely to present these symptoms
manganese
excess manganese accumulates in the _____ when not excreted through bile appropriately
the brain
What are the Parkinson’s like symptoms from hypermagnesemia
rigidity
involuntary movement
tremors
what patients are at risk for manganese toxicity
patients who are on TPN and have liver failure and elevated LFT’s because bile excretion is limited
patients with chronic liver disease should get ____ free TPN
manganese free
when compared to the DRIs for fat soluble vitamins given orally, the DRIs for parenterally administered fat soluble vitamins are ____ even though the amounts in PN are higher than PO. Fat soluble vitamin needs increase 2/2 malnutrition & metabolic changes from chronic illness. No toxicities have been reported
equal
when compared to the DRIs for water soluble vitamins given orally, the DRI’s for parenterally administered water soluble vitamins are
higher
PN water soluble doses are 2-2.5x____ than the RDA or AI 2/2 increased requirements from malnutrition, baseline vitamin deficiencies, increased urinary excretion of water soluble vitamins when used IV (rare toxicity)
greater than
according to the United States Pharmacopeia (USP) chapter 797, a PN solution prepared from 8.5% amino acid with electrolytes, 70% dextrose with MVI, trace elements and famotidine added would be classified as ____ risk
medium (Compounding of PN using manual or automated devices during which there are multiple injections, detachments, and attachments of nutrient source products to the device or machine to deliver all nutritional components to a final sterile container)
according to the United States Pharmacopeia (USP) chapter 797, PN solutions are categorized as low, medium and high risk corresponding with the probability of
microbial contamination, chemical or physical contamination
according to the United States Pharmacopeia (USP) chapter 797, PN high risk solutions involve
NONSTERILEE ingredients and devices
Automated Computed Devices for compound TPN are _____ error free
NOT ERROR FREE, errors can still occur
Error rates of ACD devices compared to manual compounding are ____% and ___% respectively
22% ACD
39% Manual
There should be established ____ limit warnings and _____ based limits in the pharmacy and ACD systems
dose limit warnings
weight based limits
_____ should develop monitoring and surveillance plans for PN compounding
pharmacies
when is manual compounding appropriate to use over ACD’s when preparing PN
- when the volume of PN are less than the ACD can accurately provide
- when chemical interactions between PN components cannot be mitigated by sequencing
- conservation during drug shortages
_______ all healthcare providers should have the ability to override soft and hard limit alerts from ACDs
NOT ALL
the preparation of compounded sterile preparations (CSPs) for all patient populations should be _____ for each population, with ________ strategies
separate, separate
a translucent band at the surface of the emulsion separate from the remaining TNA dispersion is called
creaming
when TNA has creaming, this is the ____ phase of an emulsion and the lipid droplets are preserved. Light creaming is a _____ occurrence and _____ spose a significant risk unless in extreme cases
Initial phase
common occurrences
Doesn’t (little clinical risk)
when a TNA develops yellow/brown oil droplets near or at the TNA surface, marbling/streaking of oil all throughout the TNA or a continuous layer of yellow brown liquid at the surface of TNA this is known as
Cracking (terminal state of emulsion destabilization)
Cracking of a TNA solution is the _____ phase of emulsion destabilization and can cause a ____ risk of clinical danger
terminal phase of emulsion destabilization
high risk of clinical danger
what complication is most likely to occur when transitioning a critically ill patient from PN to EN and why. how can this be limited?
hyperglycemia because there may be an overlap in excess nutrients given when transitioning. This can be limited by keeping GIR < 4 mg/kg/min
rapid infusion of IV Na or KPhos may result in ____ from an abrupt decrease in ________
tetany from abrupt decrease in serum calcium
potassium phosphate in PN is _____ in nature, acid base wise
acidic/acidifying
while getting PN, your patient develops metabolic acidosis. What serum electrolyte level needs to be monitored most closely
potassium
during metabolic acidosis and tissue catabolism, there is an extracellular shift in ____ to maintain electroneutrality. Correcting metabolic acidosis will treat this.
potassium
what is considered the most serious complication of significant hyperphosphatemia?
soft tissue and vascular complications 2/2 calcification when serum calcium multiplied by serum phos exceeds >55mg/DL
