Test 2 Parenteral Nutrition Flashcards
Why don’t we start with the full % of dextrose that we want?
it will give the pt hyperglycemia because the endogenous insulin hasn’t been able to keep up yet
How do we reach the level of dextrose that we want?
increasing in increments of 2-2.5% as pt tolerates
Maximum dextrose %
- PIV: 12.5%
- Central: 25-30%
dextrose nutritional contribution
3.4kcal/gram
amino acids nutritional contribution
4kcal/gram
lipid nutritional contribution
- 10kcal/gram
- for 10%: 1.1kcal/mL
- for 20%: 2kcal/mL
- for 30%: 3kcal/mL
initiation of lipids
- 0.5-1 gram/kg/day
Distribution of calories with protein
- Dextrose: 40-60%
- Amino acids: 7-15%
- Lipidsi: 30-50%
Distribution of calories without protein
- Dextrose: 50-70%
- Lipids: 30-50%
Phosphorous amount in KPhos
0.68mmol phosphate
Phosphorous amount in NaPhos
0.75mmol phosphate
Problem with calcium / phosphorous stability
- precipitation can occur
- calcium gluconate more stable
- add phosphate salts early; add calcium at end
- limit amount of Ca/Phos due to osteopenia
formulations of sodium
- Sodium Chloride (NaCl)
- Sodium Acetate (NaAc)
- Sodium Phosphate (NaPhos)
formulations of potassium
- Potassium Chloride (KCl)
- Potassium Acetate (KAc)
- Potassium Phosphate (KPhos)
formulations of calcium
Calcium Gluconate
formulations of magnesium
Magnesium Sulfate
osmolarity limits in PIV
900-1100 mOsm/L
potassium limits in PIV
40 mEq/L
advantages of PIV
- rapid access
- less invasive: not meant to be there for a long period of time (7 days or shorter)
disadvantages of PIV
- cannot meet caloric needs (due to osmolarity limitations)
- Hypertonic formulations can cause phlebitis
- Extravasation of PN: results in damage to tissue, scarring
osmolarity limits in central line
no limits
potassium limits in central line
120mEq/L
advantages of central line
- suited for longer duration use
- can meet nutritional requirements
- decreased risk of phlebitis or extravasation
disadvantages of central line
- Risk of infection with line
- Catheter-induced trauma
What are the types of complications that can occur with PN?
- mechanical and technical
- infection
- metabolic and nutritional
mechanical and technical complications with PN
- infusion pump failure
- catheter-related complications
infection complications with PN
- catheter-related infections
- typically gram + infections
metabolic and nutritional complications with PN
- PNALD: Parenteral nutrition associated liver disease
- Hypertriglyceridemia
- Hyperglycemia
- Refeeding syndrome
PNALD
- Increase in total bilirubin, direct bilirubin, AST, ALT, Alkaline phosphatase
- Characterized by direct bilirubin > 2 mg/dL
- MANAGEMENT: cycle TPN, supplement with omega-3 fatty acids, start trophic feeds if possible
Hypertriglyceridemia
- Adults > 400 mg/dL
- Infants and children > 200-250 mg/dL
- MANAGEMENT: Hold or decrease lipid infusion, Consider decreasing rate of glucose infusion if excessive
Hyperglycemia
- Adults > 180 mg/dL
- Infants and children > 150 mg/dL
- MANAGEMENT: Decrease rate of dextrose infusion, Use intermittent or continuous infusion insulin
Refeeding syndrome
- occurs in malnourished pts when started on aggressive nutrition treatment
- rapid decrease in serum phos, K, Mg
- MANAGEMENT / prevention: identify high risk pts, start slow, advance slowly, increase amount of phos, K, and Mg in PN
