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ASPEN Clin 2 Readings > PN Practice Questions > Flashcards

PN Practice Questions Flashcards

1
Q 
What is the optimal nutrition support for a malnourished patient when EN is not feasible for a prolonged period?
A) Central Parenteral Nutrition 
B) Nasogastric enteral tube feedings
C) Postpyloric enteral tube feedings
D) Peripheral parenteral nutrition
A

A

The benefits of CPN are most closely related with patients with malnutrition

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2
Q

In which patient or condition treatment could PN elicit an improved patient outcome?
A) Cancer chemotherapy
B) Pre-op care of Sx patients with upper GI cancer
C) Allogenic bone marrow transplant
D) Critical illness

A

B

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3
Q

When does PN provide improved outcomes within the context of pre-op care of Sx patients with upper GI cancer?

A

When it is initiated 7-days before surgery

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4
Q 
CPN is contraindicated in which of the following conditions?
A) DNR status
B) Peritonitis
C) Intestinal Hemorrhage
D) High-output fistulas
A

A

Comfort measures only

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5
Q

PN should be discontinued when which of the following criteria are met?
A) A clear liquid diet is ordered
B) Tube feeding is initiated at 10% of goal rate
C) Solid food is tolerated by mouth
D) Advancement to regular diet is poorly tolerated

A

C

As the goal of PN therapy is to maintain the nutritional status of patient until some form of EN is tolerated.

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6
Q

When is PN tapered?

A

When EN can be used, where it will slowly increase in proportion to PN

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7
Q

When is PN discontinued?

A
  • Solid food tolerated orally

- DNR status

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8
Q

What are the three ways the PN can be prepared?

A

1) Lipid injectable emulsions (LIE)
2) TNA
3) 2 in 1 solution

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9
Q

What is the 2 in 1 solution?

A

Contains all the necessary IV macro and micronutrients, in the same container, without ILE which may be infused separately

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10
Q

PN is always ___ to body fluids

A

hypertonic

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11
Q

What is the osmolality of PN dependant on?

A
  • Dextrose
  • AA
  • Electrolyte content
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12
Q

What is TPN?

A

Total parenteral nutrition, usually associated with CPN as the entire needs of the patient may be delivered by this route

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13
Q

Where is TPN administered? Why?

A

Superior vena cava adjacent to the right atrium, as the rate of blood flow is the higher and will rapidly dilute the hypertonic PN

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14
Q

What has a higher concentration of nutrient components, PPN or TPN?

A

TPN

PPN must be lower for peripheral venous administration

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15
Q

Why is PPN usually an undesirable choice for those with fluid restrictions?

A

Concentrating the solution to meet their fluid req. will result in hyperosmolar solution, which is likely not suitable for peripheral administration

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16
Q

What are the criteria patients must meet in order for PPN to be indicated?

A

1) Good peripheral vein access

2) They should be able to tolerate large volumes of fluid (2.5 - 3L/days)

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17
Q

Time limit for PPN?

A

At least 5 days, but no longer than 12 days

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18
Q

How may the energy density of PPN be increased without increasing osmolality?

A

ILE’s, may also increase peripheral vein tolerance of PPN

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19
Q

Contraindications to PPN?(SSL-FNR)

A
  • Significant malnutrition
  • Severe metabolic stress
  • Large nutrient or electrolyte needs
  • Fluid restriction
  • Need for prolonged PN > 2 weeks
  • Renal or liver compromise
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20
Q

What is permissive underfeeding?

A

Used in the critically-ill patient, who do not tolerate PN well.
-Minimize complications of PN by feeding 80% of energy req. until patients condition has improved

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21
Q

What is hypocaloric feeding?

A
  • Used in both EN and PN for obese patients (BMI >30)
  • Meet pro req. but reduce energy
  • May also mitigate complications to PN while improving nitrogen balance
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22
Q

What is supplemental PN?

A

Minimize the energy deficit that accumulates during periods of no nutrition or undernutrition

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23
Q

Expert opinion suggests that wound healing will be impaired if PN is not started within _____ of post-op for indicated patients

A

5-10 days

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24
Q

How is PN indicated in pancreatitis?

A

It is not

-Important to maintain GI integrity with EN to improve outcomes

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25
Q

Patients at the highest risk of adverse post-surgical outcomes are those with low _____ at baseline

A

visceral proteins

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26
Q

What is critically illness characterized by?

A

A catabolic state that is generally the result of systemic inflammatory response to infectious or traumatic assault

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27
Q

Why is gut failure common in the critically ill?

A

Due to preferential blood supply to vital organs

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28
Q

Critically ill patients indicated for PN will meet what 3 criteria?

A

1) Are malnourished at baseline
2) Will not reliably ingest or absorb significant amounts of EN for a period greater than 7-10 days
3) Have been adequately resuscitated from any hemodynamic compromise

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29
Q

PN in cancer patients?

A

Associated with increased complications and infections if receiving chemo or radiotherapy

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30
Q

When is PN Ok to advance?

A
  • Stable BP,pulse and resp.rate

- Normal phosphorous, potassium and glucose concentrations

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31
Q

What is a best practice prior to advancing PN rate?

A

Control the patients blood glucose

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32
Q

Which of the following may increase the risk of phlebitis with peripherally administered PPN?
A) Osmolarity equal or less than 900 mOsm/L
B) Potassium 100 mEq/L
C) Calcium <5 mEq/L
D) Addition of heparin to the PPN

A

B

Potassium can be irritating in the veins, preferably less than 40 mEq/L should be administered, all other choices listed actually may decrease phlebitis risk

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33
Q

What is phlebitis?

A

Inflammation of the vein, can cause pain and swelling

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34
Q 
What is the smallest pore size of a filter recommended for TNA?
A) 0.22 um
B) 0.5 um
C) 1.2 um
D) 5 um
A

C

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35
Q

Is the 1.2 um filter a sterilizing filtre?

A

No, but will remove large micro-organisms and large particles which may otherwise lodge in the pulmonary capillaries if passed through

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36
Q

When is a 0.22 um filter used?

A

Often in 2-1 dextrose and amino acid PN, and it does qualify as a sterilizing filter

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37
Q

How big are fat particles? Which PN filters will occlude the use of ILE?

A
  • Fat particles between 0.1 and 1.0 um

- -0.22 and 0.5 um filters are occluded, or the emulsion may be destabilized if used with these filters

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38
Q 
Which of the following will increase the solubility of calcium and phosphate within a PN formulation?
A)  Use of calcium as  the chloride salt
B)  Use of phosphate as the sodium salt
C) Increased amino acid concentration
D) Increased temperature
A

C

The higher the concentration of AA, the less likely precipitation is to occur.

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39
Q

The higher the concentration of AA, the less likely precipitation is to occur. Explain how

A

Amino acids can form soluble complexes with calcium, which will reduce the effective concentrations of free calcium available to form insoluble precipitates with phosphorous ions.

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40
Q

Why is calcium gluconate preferable over calcium chloride?

A

Calcium chloride is more dissociated that calcium gluconate, making the risk of precipitation with phosphate higher.

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41
Q

What is more likely to occur at higher temperatures?

A

-Precipitation, as warmer temperatures will encourage the dissociation of of calcium salts, thus promoting the availability of ions to form insoluble complexes with phosphate

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42
Q

According to the ASPEN guidelines, the amount of dextrose used in the preparation of PN formula is required to appear on the label as:
A) The percentage of original concentration and volume (i.e. dextrose 50% water, 500 ml)
B) The percentage of final concentration after admixture (i.e. dextrose 25%)
C) Grams per liter of PN admixed (i.e. dextrose 250 g/L)
D) Grams per day (i.e dextrose, 250 g/day)

A

D

Most consistent and supports the 24-hour nutrient infusions, requires the least amount of calculations.

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43
Q

Most common CHO source in PN? kcal/g?

A
  • Dextrose
  • 3.4 kcal/g
  • Acidic and hyperosmolar
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44
Q

Most common protein source in PN? kcal/g?

A
  • Crystalline AA

- 4 kcal/g

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45
Q

Discuss the modified PN AA formulation for those with hepatic encephalopathy

A

-Increased branched chain amino acids
-Decreased aromatic amino acids
As their altered metabolism often results in higher serum amounts of AAA, which is taken up by the brain, act a neurotransmitters and may cause altered mental status

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46
Q

Modified PN for renal failure?

A

-Mostly essential AAs

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47
Q

ILE 20% formulation?

A

Provides 2kcal/ml

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48
Q

ILE 30% formulation?

A

Provides 2.9-3 kcal/ml

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49
Q

What is ILE 30% approved for?

A

Compounding of a 3-1 mixture, and not for direct IV administration

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50
Q

ILE products using a 50:50 mix of soybean and safflower oil will contain _____ as much omega-3 FA as an ILE using 100% soybean oil

A

half

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51
Q

What is Smoflipid?

A

ILE containing Soybean (S), MCT (M), Olive (O) and Fish (F) oils to be higher in omega-3 FA

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52
Q

When is Smoflipid contraindicated?

A

For patients with allergens or hypersensitivities to soy, egg, peanut or fish protein

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53
Q

What emulsifer is used in ILEs?

A

egg-phospholipid (caution with egg sensitivities and allergies)

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54
Q

What should the ILE infusion rate not exceed? What should the daily dose not exceed?

A
  • 0.11 g/kg/hr

- 60% of E requirements or 2.5 g/kg/day

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55
Q

What may exceeding the ILE infusion rate result in?

A
  • HyperTG
  • Infectious complications
  • Fat overload syndrome
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56
Q

What is fat overload syndrome?

A

Characterized by headaches, seizures, fevers, jaundice, abdominal pain, resp distress, pancytopenia and shock

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57
Q

What is the issue with Omega-3 and Omega-6 FA ration in PN?

A

We want to have enough Omega-3s to promote anti-inflammatory functions, but enough Omega-6s to avoid a EFA deficiency

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58
Q

Preferred form of calcium PN salt?

A

Calcium gluconate

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59
Q

Preferred form of magnesium PN salt?

A

Magnesium sulfate

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60
Q

Preferred form of iron in PN?

A

Iron dextran

-Should only be considered in dextrose-amino formulas because ILE formulas are disrupted by iron

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61
Q

Two nutrient with special consideration in PN?

A
  • Glutamine

- Carnitine

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62
Q

Glutamine in PN?

A

Has been considered for it’s role with intestinal integrity and protein synthesis during stress states, however no longer recommended for ICU as no benefit is shown

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63
Q

Carnitine in PN?

A

Carnitine is required for proper transport of LTC into the matrix of the mitochondria for B-oxidation. Sometimes added in IV formulations, but MCT oil may be preferable

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64
Q

What is the most appropriate strategy to provide calcium to a patient receiving PN in the event of a IV calcium gluconate shortage?

A
  • Evaluate for signs relating to low calcium concentrations (tetany, CNS, CVD issues)
  • Evaluate serum levels of calcium and ionized calcium, correct calcium with albumin levels
  • If calcium supplementation necessary, administer CaCl separately from PN formulation, using a different catheter.
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65
Q

What are the two ways to prepare for the administration of PN?

A

1) Traditional dextrose-AA formulation (2-in-1)

2) TNA system (3-in-1, or all-in-one)

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66
Q

What is the 2-in-one formulation?

A

Incorporates dextrose and AA alongside vitamins, minerals, electrolytes and trace elements. ILE will be administered separately

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67
Q

What is the TNA or the 3-in-1 formulation

A

incorporates ILE with AA, dextrose and all required micronutrients all at once

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68
Q

Considerations for osmolarity for PPN?

A

-<900 mOsm/L

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69
Q

Considerations for calcium and potassium in PPN?

A
  • Should be kept low
  • Calcium <5 mEq/L
  • Potassium <40 mEq/L
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70
Q

Considerations of ILE in PPN?

A

-Give daily to provide adequate energy and decrease osmolality

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71
Q

Considerations of TNA in PPN?

A

Deliver dextrose (10%) and AA (4%) at optimal concentrations to prevent lipid destabilization from divalent cations, but may have difficulties in adhering to the osmolarity restrictions in PPN

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72
Q

What may reduce risk of thrombophlebitis ?

A

Addition of heparin and/or small amounts of hydrocortisone to PPN

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73
Q

(T/F) all vitamins and minerals are found in SCAPN

A

False, must be injected because these micronutrients may destabilize the product if added prior to 24 hours of administration

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74
Q

What is stability with respect to PN?

A

Degradation of nutritional components which changes their original characteristics (i.e. maillard rxn)

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75
Q

What is compatibility with respect to PN?

A

Involved the formation of precipitates (crystalline matter or the seperation of oil and water)

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76
Q

What is the issue of administering ILE with iron dextran?

A

This trication will compromise compatibility of ILE, resulting in phase seperation
-Perhaps administer with 2-in-1

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77
Q

What may change the electric surface charge on the fat droplets in ILE, resulting in fat globules?

A
  • Changes in pH (stable between 6 and 9)

- Additions of electrolyte salts

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78
Q

When there is phase-seperation in ILE, how may the bag appear?

A

-Yellow oil streaks
-Amber oil layer on top of admixture bag
Unsafe for patient administration

79
Q

What is the most critical factor influencing the pH of a PN formulation?

A

-Crystalline amino acid solution used for compounding

80
Q

How should TNA be compounded?

A
  • Combine dextrose with the AA solution first, as the AA will buffer the acidity of the dextrose
  • Add this solution to the ILE
81
Q

When may TNA stability be compromised?

A 
When final concentrations are less than:
-4% AA
-10% dextrose
-2% ILE
This will cause the larger fat globules, which occurs before the 30-hour use before date assignment
82
Q

TNA should be used with ____ or ____ as PPN formulations

A
  • Extreme caution

- Not at all

83
Q

Which form of calcium phosphate is the greatest threat?

A

Dibasic calcium phosphate

-More likely to precipitate from a increase in pH

84
Q

How can we reduce the likelihood of dibasic calcium phosphate the precipitate? What is the consequence if in ILE?

A
  • lower the pH of the PN formulary, and lower the concentration of calcium and phosphate ions administered
  • Lowe pH is suboptimal in ILE, thus administer separately (i.e. 2-in-1)
85
Q

What filter is OK for removing calcium phosphorous precipitates?

A

-5 um

NOT a replacement for good compounding practices intended to prevent precipitation in the first place

86
Q

0.22 um filtres?

A
  • Can remove pathogenic microorganisms

- However, not compatible with ILE

87
Q

In stable formulas, what is often the size of normal fat droplets?

A

Often >5 um

88
Q

What is the recommendation of filter use with ILE?

A

-1.2 um

May remove some microorganisms, such as C. albicans

89
Q

What is the recommended filter for use with dextrose-AA PN?

A

-0.22 um

90
Q

CDC recommendations on ILE hang time when incorporated into dextrose-AA?

A

12 hours

91
Q

CDC recommendations on ILE hang time when incorporated into a TNA?

A

24 hours

92
Q

Which of the following is the most appropriate VAD strategy for a patient requiring long-term PN therapy?
A) Use a midclavicular catheter as a cost-effective measure
B) Place a percutaneous nontunneled catheter to initiate PN, then replace it with a implanted port
C) Place a single-lumen, tunnelled cuffed catheter
D) Place a triple-lumen, antibiotic coated catheter to ensure adequate access for future needs

A

C

93
Q

Which catheter was originally developed for patients with long-term PN needs?

A

Tunneled catheter

94
Q

Why would a midclavicular catheter not be appropriate for long-term access?

A

Does not provide central access, and long-terms means central

95
Q

When would percutaneous non-tunneled catheters with aditional features, such as coatings, or multiple lumens be indicated?

A

For acute, shorter term access

96
Q 
Thrombotic occlusions are most commonly treated with what?
A) Thrombolytics
B) Anticoagulants
C) 10% HCl
D) Sodium bicarbonate
A

A

Catheter occlusions are often due to a thrombotic problem, such as an intraluminal thrombus, extraluminal fibrin sleeve or vessel thrombosis.

97
Q

What are nonthrombogenic factors which may cause a catheter occlusion?

A

-Intraluminal drug and lipid precipitates

98
Q

Pharmacological agents that change ___ within the lumen will increase the solubility of the precipitate

A

the pH

99
Q

Which of the following practices have been shown to reduce the risk of catheter-related bloodstream infections?
A) Systemic use of antimicrobial prophylaxis at time of insertion/access
B) Routine placement of central venous access devices (CVADs)
C) Use of “central line bundle” of insertion and main tenance practices
D) Selection of an internal jugular site as opposed to subclavian site

A

C

100
Q

What does the central line bundle for insertion and maintenance consider? (5)

A

1) Hand hygiene
2) Maximal barrier precautions
3) Skin antisepsis with chlorhexidine gluconate
4) Optimal catheter site selection
5) Daily review of line necessity, with prompt removal of unnecessary lines

101
Q

What is the systemic use of antibiotic prophylaxis associated with?

A

May promote resistance of microbial populations associated with catheter infections

102
Q

What does blood flow rely on in the large central veins, such as the IVC and SVC?

A
  • Negative thoracic pressure
  • Abdominal and diaphragmatic muscle movement
  • NOT on valves
103
Q

Unlike arteries veins can _____

A

compensate for occlusions via rich collateral circulation

104
Q

What is the preferred vessel for central access ?

A
  • The SVC
  • Estimated blood flow of 2000 ml/min
  • Concentrated antibiotics, vesicants and PN can be infuse without causing damage to veins
105
Q

If the SVC becomes occluded or thrombosed, what may be an alternative site of access?

A

-the IVC

106
Q

What measures the outside diameter of a tube?

A
  • French

- 1 mm = 3 fr

107
Q

What measures the inside diameter of a tube?

A

mm

108
Q

What is gauge inversely proportional to?

A

Outside diameter

109
Q

What are multi-lumen catheters?

A

Provides for simultaneous infusion of multiple solutions or incompatible drugs

110
Q

Why are cuff often attached to CVCs?

A
  • Serve as subcutaneous anchors and mechanical barriers

- If they have silver irons, may exert short-term anti-microbial activity

111
Q

What are the 3 types of catheters indicated for peripheral access?

A
  • Peripheral (least risk fo catheter related infections)
  • Midline
  • Midclavicular
112
Q

In a peripheral catheter, where is the tip located?

A

located outside the central vessels

113
Q

In a central catheter, where is the tip located?

A

In the distal SVC, IVC or right atrium

114
Q

Infusion of PPN dextrose and osmolality limitations?

A
  • No more than 10% dextrose

- No more than 900 mOsm/L

115
Q

The leading complication fo peripheral access is peripheral venous thrombophlebitis, what are the hallmark signs and symptoms?

A
  • Pain
  • Eryhtema
  • Tenderness
  • Palpable cord
116
Q

CDC guidelines recommend close monitoring of the peripheral access, with the line being removed _____

A

no more than every 72 to 96 hours, unless clinically indicated

117
Q

When may a midline peripheral catheter be considered?

A

When treatment is considered for 2-6 weeks

118
Q

Which catheters are the most common in acute care setting for therapies of short duration?

A

Non-tunneled, non-cuffed CVADs (central)

119
Q

The subclavian vein is a common site of venipuncture when administering CPN, what is the risk of repeated use?

A
  • Stenosis
  • Serious risk for patients with renal concerns
  • The right internal jugular vein is the best approach for patients with CKD who may require dialysis
120
Q

What are the 3 categories of CVADs?

A
  • Tunneled
  • Non-tunneled
  • Implanted
121
Q

What is a PICC?

A
  • A non-tunneled CVAD

- A catheter inserted via a peripheral vein with the tip in the CVC

122
Q

What is the difference between tunneled and non-tunneled?

A

Tunneled associated with less infections, due to a seperation between venipuncture and exit site

123
Q

When may we use translumbar, transhepatic and transcollateral venous access?

A
  • Alternate vein sites if common vein sites are over-used

- These sites may be the only way to provide long-term access for PN and other medications

124
Q

What are TIVADs?

A
  • Totally Implanted Venous Access Devices (subcutaneous)

- Central access, and cosmetically more desirable

125
Q

What is the recommended 0.9% NaCl flushes for central access lines?

A
  • Flush before and after each use, or daily if not in use.

- Minimum flushing is equal to twice the internal volume of the VAD system + 20%

126
Q

What is a CRBSI?

A

Catheter related bloodstream infection

127
Q

What is the appropriate treatment for a catheter-related bloodstream infection in a patient with a tunneled cuffed vascular access catheter?

A
  • Gold-standard for CRBSI required catheter removal, but if long-term catheter salvage may be OK
  • Collect CV blood cultures, where those that becomes + 2 hours sooner than the peripheral culture are considered predictive for CRBSI’s
128
Q

What is the tx in the case of a CRSBI?

A
  • Systemic antibiotic therapy

- 70% ethanol catheter lock of 2ml daily with a 6 hr dwell time

129
Q

Signs and symptoms of CRSBI?

A
  • Elevated WBC (>10,500/mcL)
  • Fever, chills, malaise, N/V
  • Hypotension, tachycardia, headache, backache
130
Q

What causes a thrombotic occlusion?

A

-vessel wall damage
-blood flow changes
-a systemic alteration in circulation
All will arise from the catheter which disrupts blood flow, and can cause venous injury

131
Q

What are the leading causes of intraluminal occlusions?

A
  • Drug-heparin interactions
  • PN formulations with inappropriate calcium-phosphate ratio
  • Lipid residue
132
Q

What is catheter pinch-off syndrome?

A

Mechanical obstruction of the catheter related to postural changes caused by catheter compression between the clavicle and the first rib

133
Q

Which of the following is the most metabolic complication associated with PN?

A
  • Hyperglycemia
  • Associated with overfeeding
  • Can arise from insulin suppression and resistance as well as gluconeogenesis from stress and infection
134
Q

Non-diabetic hospitalized patients receiving IV dextrose infusion rates higher than ___ have ____ % chance of developing hyperglycemia

A
  • 4 mg/kg/min

- 50%

135
Q

What is azotemia associated with?

A
  • Renal or hepatic dysfunction

- Protein overfeeding

136
Q

Why does hyperammonemia rarely occur?

A

As PN solutions use crystalline amino acids

137
Q

One day after initiating PN in a critically-ill adult patients, the patient displays low potassium, low phosphorus and normal serum magnesium. The current PN regimen provides:

  • 90 g protein
  • 150 g dextrose
  • no lipid
  • minimum volume
  • K+ 80 mEq, P 40 mmol
  • Standard doses of sodium, magnesium, calcium, vitamins and trace elements. The patient weighs 60 kg and has a BMI of 18. What is the most appropriate response to the lab values?
A

Provide supplemental IV doses of potassium and phosphate today, but do not change the macronutrient doses with tonight’s PN bag

138
Q

Provide supplemental IV doses of potassium and phosphate today, but do not change the macronutrient doses with tonight’s PN bag –> Discuss why, what is the management and prevention of refeeding syndrome?

A

1) Identify patients at risk
2) Serum electrolyte monitoring and aggressive replacement
3) Slowly increasing E intake
- -> if this critcially-ill patient does not have proper K+ and P levels after the initiation of PN, the protocol is to be treated with IV infusion. Energy intake from PN should NOT be advanced until electrolytes are corrected.

139
Q

Which of the following measures would be considered beneficial in a patient who develops cholestasis while receiving long-term PN that is infused 12 hours nightly?
A) Stop all oral and enteral intake
B) Switch from cyclic to continuous method of PN administration
C) Decrease lipid injectable emulsion (ILE) dose from 1.5 g/kg/day to 1g/kg twice weekly
D) Increase protein dose from 1 g/kg/day to 2 g/kg/day

A

C

140
Q

What is cholestasis associated with?

A

ILE doses greater than 1g/kg/day in adult patients receiving long-term PN

141
Q

What has cyclic feeding been shown to do?

A

Reduce serum liver enzymes and conjugated bilirubin concentrations when compared to continuous infusions

142
Q

(T/F) Protein dosing in PN is associated with developing cholestasis in the adult

A

F

143
Q

Which of the following PN modifications is recommended to help prevent and/or treat osteoporosis in the long-term PN patient?
A) Maintain protein intake of at leas 2 g/kg/day
B) Provide more than 20 mEq calcium per day
C) Add injectable vitamin D to the PN formulation
D) Provide 20-40 mmol phosphorus per day

A

D

An inadequate phosphorous dose may increase urinary calcium excretion

144
Q

Why don’t we supplement more calcium with PN to prevent osteoporosis?

A

Limited by calciums compatibility with phosphorus (will form a precipitate) and higher calcium doses are offset by higher urinary losses.

145
Q

What is the preferable form of calcium supplementation?

A

Calcium gluconate of 10-15 mEq/day to be added to the PN formulation

146
Q

What have high protein doses (2g/kg/day) been associate with?

A

-Increase calcium excretion

147
Q

Why may excessive vitamin D be detrimental to the bone?

A
  • Suppress PTH and promote bone resorption

- PN formulations of ergocalciferol and cholecalciferol are not available

148
Q

What is stress-associated hyperglycemia?

A
  • Occurs in acutely ill and septic patients
  • Develops as a result of insulin resistance, increased gluconeogenesis, glycogenolysis and suppressed insulin secretion.
149
Q

What is excessive CHO administration associated with?

A
  • Hyperglycemia
  • Hepatic steatosis
  • Increased CO2
150
Q

PN should be administered at ___ the estimated E needs, or approx. ___ g of dextrose for the first 24 hours

A

50%

150-200

151
Q

When may the delivery of less dextrose (~100 g) be warranted?

A

-patient with low BMI or poor glucose control

152
Q

CHO administration rate should not exceed what?

A

4 to 5 mg/kg/min or 20-25 kcal/kg/day in acutely ill patients.

153
Q

The dextrose dose in the PN formulation should not be advanced until ____

A

the patients blood glucose concentrations are controlled

154
Q

In rare cases, what may hyperG be related to?

A
  • Chromium deficiency

- insulin is less effective during a chromium deficiency

155
Q

When may PN associated hypoG occur?

A
  • Excess insulin infusion via PN, IV or subcutaneous injection
  • Abrupt discontinuation of PN (rebound hypoglycemia)
156
Q

When is rebound hypoglycemia more common ?

A

In patients who require a large amount of insulin

157
Q

How can we avoid rebound hypoglycemia when discontinuing PN?

A

-Dextrose containing fluid should be infused for 1-2 hours following PN discontinuation

158
Q

Why is endogenous production of linoleic (omega-6) FA reduced in PN?

A

If hypertonic dextrose infused, insulin secretion increases, thus reducing lipolysis.
-Linoleic acid can be endogenously produce through lipolysis of adipose tissue

159
Q

ILE requirement to prevent EFAD?

A

250 ml of 20% administered over 8-10 hours, twice a week

160
Q

____ ILE’s have been associated with immune-suppressed effects through activating the ___

A

Soy-based
Arachidonic pathway
–> withhold soy based formula within the first week of PN in the critically ill

161
Q

When can hyperTG occur?

A

-Dextrose overfeeding or rapid administration rates of ILE (>0.11 g/kg/h)

162
Q

ILE intake should be restricted to less than _____ of total energy or ____

A

30%

1 g/kg/day

163
Q

Propofol is supplied as a ____

A

10% ILE

164
Q

What is a possible allergic rxn to ILE?

A

Egg-phospholipid

165
Q

What is azotemia?

A
  • Intolerance to protein load, cannot meet the demands od disposing the byproduct of protein metabolism (urea)
  • Prone to patients with renal or hepatic dysfunction
166
Q

What can azotemia arise from?

A
  • Excess protein
  • Dehydration
  • Inadequate energy prom non-protein sources
167
Q

Should we restrict protein in patients with liver failure, encephalopathy and hepatic failure?

A

Not recommended due to LBM loss

168
Q

What parameters should be monitored, and in what frequency to help identify and prevent metabolic consequences associated with TPN?

A
  • Normalize fluid and electrolyte status, replete if necessary and monitor daily until stable.
  • Administer PN slowly, and then titrate to reach goal to prevent hyperG
  • Monitor glucose every 6 hours until patient is euglycemic
  • Evaluate prealbumin: low levels may indicate inflammatory metabolism
169
Q

excessive amounts of which vitamins may be toxic?

A

Fat soluble

170
Q

(T/F) IV multivitamin therapy should be delayed until there are clinical signs of deficiency

A

F

-Should receive standard dose of parenteral multivitamins

171
Q

Monitoring in PN and warfarin therapy?

A

-Vit K

172
Q

Monitoring in PN and alcoholism?

A

Thiamine

173
Q

What is a key nutrient which may degrade in long-term TPN?

A

Vitamin A

-Degrades if added to mixture too soon

174
Q

In long-term TPN, which trace elements may be reduced or removed to avoid toxicity?

A

Manganese and copper

175
Q

___ is not included in the PN formulation

A

Iron

-Provided via PN on a “as needed” basis

176
Q

Define re-feeing syndrome

A

The adverse effects of metabolic and physiological shifts of electrolytes, vitamins and minerals that can occur as a result of aggressive nutrition support or nutrition repletion of a malnourished patient

177
Q

When is re-feeding syndrome at the greatest risk?

A

2-5 days after the start of nutrition support

178
Q

Explain the complications of re-feeding

A

In pro-longed starvation, our body will derive energy from ketones, decrease energy expenditure, reduce insulin signalling. When there is a reintroduction of CHO, we shift to glucose as the main fuel again. Insulin is released, and there is an enhanced uptake of glucose, electrolytes, minerals and water into the cells. There is a increased demand of P to synthesize ATP, as well as increased demands for thiamine, potassium and magnesium to oxidize glucose. Can cause neuromuscular, CVD and respiratory compromises. Fluid and sodium from the nutrient delivery worsens the situation, and can result in fluid overload and edema.

179
Q

How can the complications of RF syndrome be minimized when providing PN to a nutritionally depleted patient?

A
  • Hemodynamically stable and electrolyte and thiamine replenishment
  • Start nutriton slow at 50% of needs or 15 kcal/kg/day
  • Protein should remain the same, as it has less of an impact on glycolysis
  • The remaining kcals should comprise of dextrose and fat
  • Dextrose should never exceed 200 g/day
  • Increase to full goal rate over 2-5 days
  • Monitor electrolytes and weight daily
  • Administer vitamins and trace elements daily
180
Q

(T/F) re-feeding hyperphosphotamia has the same metabolic complications as refeeding syndrome

A

F

-however, concerning and replace with phosphate supplement

181
Q

What are the three kinds of heptobiliay disorders associate with PN?

A
  • Steatosis (Fat infiltration, due to overfeeding)
  • Cholestasis (impaired secretion of bile)
  • Gallbladder sludges/stones (Likely due to lack of EN stimulation)
182
Q

Macronutrient compostions of PN which may favour steatosis?

A

1) Excessive energy
2) Low-fat (more CHO)
3) Protein hydrosolates (we now use crystalline AA)

183
Q

What is high-soybean oil ILE associated with?

A
  • High omega-6 and phytosterols
  • Inflammatory and immuno-suppression
  • May contribute to biliary sludges and stones and other hepatoxic effects
184
Q

Liver complications are associated when both lipids are ____

A

high and low

  • -> Low due to EFAD
  • -> high to due inability to clear fatty acids in liver
185
Q

how is choline usually produced?

A

From methionine, which is included in the PN but is less effective

186
Q

Implications of low choline?

A

Elevated hepatic aminotransferase and steatosis

187
Q

Strategies to manage PN associated lover complications?

A
  • Decrease dextrose
  • Decrease ILE to <1 g/kg/day
  • Provide balance of dextrose and ILE
  • Cyclic PN infusion
188
Q

Why should oral and enteral nutrition be optimized whenever feasible for patients on long-term PN?

A

To promote the enterohepatic circulation of bile acids

189
Q

Consequence of continous PN feeds?

A

Can result in hyperinsulinemia and fat deposition in the liver, therefore potentially increasing the risk of liver diseases
–> May be indicated for cyclic PN

190
Q

What is the metabolic bone disease caused by vit D deficency?

A
  • Osteomalacia

- Bones contain oteoid tissue which fails to calcify

191
Q

____ have reported osteoporosis after at least 6-months of at home TPN

A

41-67%

192
Q

Paradox of vitamin D in bone health?

A

Both vitamin D deficiency and toxicity can result in bone disease

193
Q

Strategies to prevent and treat osteoporosis in patients receiving long-term PN?

A
  • Avoid high doses of protein
  • Avoid excessive doses of sodium
  • Calcium supplement of 10-15 mEq/d
  • Phosphorus: 20-40 mmol/d
  • Treat metabolic acidosis
  • Maintain adequate Mg, Cu, Al
  • Avoid heparin

ASPEN Clin 2 Readings (6 decks)

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