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Fall 2024 > Therapeutics Exam 3 (Parenteral and Enteral Nutrition) > Flashcards

Therapeutics Exam 3 (Parenteral and Enteral Nutrition) Flashcards

1
Q

What is the equation for ideal body weight?

A

Male= 50 kg + (2.3 x inches over 60’’)

Female= 45.5 kg + (2.3 x inches over 60”)

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2
Q

What is the equation for Nutrition Body Weight (NBW)?

A

NBW= IBW + 0.25(wt - IBW)

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3
Q

When do you use NBW?

A

If actual body weight is 130% or more of IBW

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4
Q

When conducting a nutritional assessment, what do we take into consideration?

A

-Risk factors for malnutrition
-History
-Anthropometrics
-Classifications of malnutrition
-Nitrogen balance

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5
Q

UBW (Under Body Weight) is considered what?

A

20% below IBW

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6
Q

***What are the risk factors for malnutrition?

A

UBW (under body weight) =20% below IBW

Involuntary weight loss >10% in 6 months

NPO > 10 days*
(clinically use > 7 days)

Gut malfunction*

Mechanical Ventilation*

Increased Metabolic Needs (trauma/burn, high dose steroids)

Alcohol/substance abuse (empty calories)

Protracted nutrient losses (chronic disease)
.
.
.
** refers to ICU patients

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7
Q

When a patient is expected to be NPO, what amount of days of NPO would we want to start nutrition?

A

Start nutrition if patient is expected to be NPO for >7 days

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8
Q

All hospitalized patients should receive nutrition within how long after hospitalization?

A

48 hours

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9
Q

What are the 2 main screening tools used for nutritional risk screening?

A

NUTRIC

Nutritional Risk Score (NRS-2002)

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10
Q

What NUTRIC score indicates that a patient is at high nutritional risk?

A

6-10

(5-9 without IL-6)

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11
Q

What NUTRIC score indicates that a patient is at low nutritional risk?

A

0-5

(0-4 without IL-6)

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12
Q

Which part of supplemental nutrition is the most important?

A

Protein, most patients do not get enough

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13
Q

When doing a nutritional assessment, what does anthropometrics refer to?

A

Somatic (muscle) protein status

*most patients do not receive enough protein
*look at trends

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14
Q

Why is albumin not used as a nutritional marker?

A

It has a long half-life and most patients are in the hospital for only a few days

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15
Q

What nutritional monitoring parameters do we use to assess visceral protein status?

A

Transthyretin (prealbumin)
**but never used alone

C-Reactive Protein (CRP)

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16
Q

***What is the normal serum concentration of prealbumin?

A

15-40 mg/dL

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17
Q

What does an increased CRP mean?

A

The body is in an inflammatory state

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18
Q

When CRP goes up, what does prealbumin do?

A

Goes down

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19
Q

What is a normal CRP?

A

< 1 mg/dL

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20
Q

If prealbumin decreases as CRP increases, what does this mean?

A

Inflammation

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21
Q

If prealbumin decreases as CRP is normal, what does this mean?

A

Malnutrition

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22
Q

What are the 3 classifications of malnutrition?

A

Marasmus

Kwashiorkor

Mixed

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23
Q

What is Marasmus?

A

Protein-Calorie malnutrition

(both protein and calories are low)

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24
Q

What is Kwashiorkor?

A

Protein malnutrition

(only protein is low)

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25
Q

Regarding nitrogen balance, what does high urea in the urine indicate and why?

A

High urea= High protein breakdown

When protein is broken down (catabolized) it is converted to nitrogen which gets converted to urea and excreted in the urine

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26
Q

What does UUN stand for?

A

Urinary Urea Nitrogen

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27
Q

Over how long do we measure Urinary Urea Nitrogen?

A

24-hour urine collection

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28
Q

Urinary Urea Nitrogen (UUN) represents what % of total nitrogen excretion?

A

85-90%

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29
Q

What is a nitrogen balance study used to assess?

A

The adequacy of protein repletion

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30
Q

What is the ideal goal nitrogen balance?

A

+3 to +5 grams

*want more protein going in than going out, do not want a balance of 0

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31
Q

What is the formula for nitrogen balance?

A

Nitrogen Balance= (N in) - (N out)

N in= (24-hr protein intake [g])/ 6.25

N out= 24-hour UUN (g) + 4 g

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32
Q

How do we give someone nitrogen if they are not receiving enough?

A

Cannot give someone nitrogen alone, have to give it in the form of amino acids/protein

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33
Q

When estimating caloric needs, what does the Harris-Benedict Equation give you?

A

Basal Energy Expenditure (BEE)
or
Resting Energy Expenditure (REE)

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34
Q

What is Basal Energy Expenditure (BEE)?

A

Bare minimum amount of energy/calories to maintain life
(if you are laying there doing nothing)

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35
Q

What is Resting Energy Expenditure (REE)?

A

Energy being spent by a person at rest

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36
Q

1 inch= how many cm?

A

2.54 cm

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37
Q

What is the equation for Total Energy Expenditure (TEE)?

A

TEE= REE x stress or activity factors

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38
Q

What is the recommended amount of calories per day for a Non-stressed, Non-depleted patient?

A

20-25 kcal/kg/day

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39
Q

What is the recommended amount of calories per day for a Stressed/Hospitalized patient?

A

25-30 kcal/kg/day

*note that this applies to trauma/stress/surgery patients, critically ill, and major burns

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40
Q

What is the most specific method to calculate caloric requirements?

A

Indirect Calorimetry

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41
Q

When would we use indirect calorimetry to estimate calorie requirements?

A

For critically ill patients

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42
Q

What two pieces of data does indirect calorimetry give you?

A

REE (resting energy expenditure)
RQ (respiratory quotient)

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43
Q

What is an RQ?

A

Respiratory quotient

(How much CO2 is produced vs how much oxygen is consumed)

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44
Q

*****What is the equation for TEE?

A

TEE= REE x 1.2

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45
Q

What is the goal range for the RQ?

A

0.85-0.95

(Above this is overfeeding)
(Below this is underfeeding)

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46
Q

How often do we monitor RQ?

A

Once weekly

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47
Q

What is the recommended amount of protein per day for a mild to moderate stress patient (floor patients)?

A

1-1.5 gm/kg/day

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48
Q

What is the recommended amount of protein per day for a moderate to severe stress patient (ICU, trauma, surgery, burn)?

A

1.5-2 gm/kg/day

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49
Q

How do calories affect protein utilization?

A

Adequate calories must be present for appropriate protein utilization

*ensure patient is receiving enough non-protein calories

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50
Q

True or False: We usually include protein in calculation of total calories

A

True

*we subtract protein for Non-Protein Calories (NPC)

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51
Q

What is the standard distribution of dextrose to fat in non-protein calorie distribution?

A

70% dextrose
30% fat

(70/30)

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52
Q

During sepsis or bloodstream infections, what is the standard calorie distribution of dextrose and fat?

A

100% dextrose
0% fat

-Used in blood stream infections/fungal infections
(putting fat in the blood stream would feed the infection)

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53
Q

What is parenteral nutrition (PN)?

A

The process of supplying nutrients via an IV delivery system

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54
Q

What are the synonyms for parenteral nutrition (PN)?

A

TPN
PN
TNA (total nutrient admixture)
3-in-1

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55
Q

**What are the indications for parenteral nutrition?

A

Anticipated prolonged NPO course >7 days

Inability to absorb nutrients via the gut
-Ileus
-Small bowel resection
-Malabsorptive states
-Intractable vomiting/diarrhea

Enterocutaneous fistulas

Inflammatory Bowel Disease

Hyperemesis Gravidum

Bone Marrow Transplantation (mucositis)

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56
Q

What total osmolarity should you restrict peripheral PN to?

A

< 900 mOsm/L

(because if it is super concentrated then it will not be accepted by the body)

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57
Q

What are some limitations to using peripheral PN?

A

-Requires large volumes of liquid (may not be good for HF or AKI/CKD patients)

-Limited in calories

-Short-Term Access (<7-10 days) *put a central line in ASAP

**Many hospitals do not do the peripheral route

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58
Q

What are the advantages of central PN?

A

-Allows for administration of hypertonic solutions
-More calories can be delivered

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59
Q

What are the disadvantages of central PN?

A

Infection risk

Not a benign procedure (risky)

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60
Q

What are the insertion sites for a central venous catheter?

A

Subclavian (SC) [Chest]
Internal Jugular (IJ) [Neck]
Femoral [Groin]

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61
Q

What are the long-term central venous access options?

A

PICC (peripherally inserted central catheter)
Tunneled
Implanted Port

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62
Q

What are the 3 main components of nutrition?

A

Protein
Carbohydrates (Dextrose)
Fat

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63
Q

**One gram protein= how many kcal?

A

One gram protein = 4 kcal

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64
Q

What is the maximum concentration of dextrose available?

A

D70% (D70W)

*we dilute this, do not put it directly into a vein

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65
Q

One gram of dextrose= how many kcal?

A

3.4 kcal

66
Q

What is the maximum carbohydrate rate that can be utilized?

A

4-5 mg/kg/min

*do not exceed this rate because the liver can only process so many carbs

67
Q

1 gram of lipids = how many kcal?

A

10 kcal

68
Q

What are the 2 IV fat lipid emulsions used to prevent essential fatty acid deficiency?

A

Intralipid

SMOFlipid

69
Q

Intralipid contains what?

A

Soybean oil
Water for injection
Egg yolk phospholipid*
Glycerin*

70
Q

SMOFlipid contains what?

A

Soybean oil
Medium-chain triglycerides
Olive oil
Fish oil*

71
Q

Which IV fat emulsion is more commonly used and why?

A

SMOFlipid

-improved liver function
-less increase in triglycerides from baseline

72
Q

What is the maximum amount of lipids a patient can receive per day?

A

60% of caloric intake

Max of 2.5 g/kg/day *

73
Q

Which drug can contribute to a patient’s lipids they are receiving?

A

Propofol
(sedative)

**need to subtract the dose from this drug from the total amount of lipids the patient needs

74
Q

How many lipids does propofol provide?

A

1.1 kcal/mL

75
Q

Which media is a good growth environment for bacteria?

A

Lipids/Fat

76
Q

What are the limitations on how long a lipid bag can hang for?

A

IV fat emulsion by itself: 12 hours

Added as a TNA (3-in-1): 24 hours

77
Q

What is a Total Nutrient Admixture?

A

“Custom TPN”

3-in-1

Dextrose, Amino Acids, and Lipids in one bag

78
Q

What is a Conventional Administration TPN?

A

“Custom TPN”

Dextrose and Amino Acids in one bag

Lipids 2-3 times per week separately

79
Q

What is a Premix Solution For Injection?

A

“Standard TPN”

Available with or without electrolytes

*NO LIPIDS (not stable enough)

80
Q

Who would we administer Clinimix E to?

A

CrCl > or = 50

**do not give electrolytes to patients with CrCl < 50

81
Q

How do we initiate PN titration?

A

Start at 25% of goal

Increase rate to final goal rate within 24 hrs

**only titrate the first bag, not every day

82
Q

When initiating or discontinuing PN what lab value must we check?

A

Blood glucose

83
Q

How often do we check blood glucose levels when initiating or discontinuing PN?

A

q 4-6 hours

Before each increase in rate

If BG > 200, continue at same rate for 4 hours and recheck

84
Q

When would we consider starting insulin in a patient receiving PN?

A

If we check their BG and it is >200, then recheck it 4 hours later and it is still >200

85
Q

How do we titrate a patient off of PN?

A

Decrease rate by half every 2 hours until rate is < 50 mL/min, then discontinue

86
Q

When doing Cycling PN (infusion over 12-18hrs per day) what is the maximum rate that can be used?

A

No specific guidelines

Max= 200 mL/hr

87
Q

What are the additives that can be put in PN?

A

Electrolytes
Vitamins
Trace Elements
Medications?

88
Q

Which electrolytes should be used with caution in patients with renal disease?

A

Potassium
Phosphate
Magnesium

89
Q

Which two electrolytes maintain acid-base balance?

A

Acetate
Chloride

90
Q

Which two electrolytes can precipitate together?

A

Phosphorus
Calcium

91
Q

To avoid Ca + Phos precipitation, what dose should be avoided?

A

> 150

92
Q

When would you consider giving a patient zinc?

A

If they have large wounds

93
Q

In which condition do we not want to give trace elements?

A

Livery dysfunction

94
Q

Which two trace elements do we supplement individually with liver dysfunction?

A

Zinc
Selenium

95
Q

True or False: The addition of iron to PN is not recommended

A

TRUE

-destabilizes fat emulsion
-may contribute to infectious complications

96
Q

Which medication used for GERD or stress ulcer prophylaxis can go into PN?

A

Famotidine

97
Q

Which medications are not compatible with PN?

A

PPIs

(“zoles”)

98
Q

For patients requiring insulin, what type of insulin should be used?

A

Regular insulin only

99
Q

What is the range of fluids a person should receive?

A

30-40 mL/kg/day

100
Q

What units is phosphorus typically ordered in?

A

mMol

**need to convert to mEq

101
Q

How do we convert mMol of phos to mEq?

A

1mMol phos = 1.4 mEq phos

102
Q

What electrolyte functions as the acid in PN?

A

Chloride

103
Q

What fraction of acid to base should be in PN?

A

2/3 Acid (chloride)

1/3 Base (acetate)

104
Q

Why do we use acetate as a base?

A

You cannot put bicarb in a TPN because it would convert to chalk with calcium

We use acetate because it is converted to bicarb in the body

105
Q

Which electrolytes are considered “positive” and need to be balanced?

A

Sodium
Potassium

106
Q

Which electrolytes are considered “negative” and need to be balanced?

A

Phos

*Also Chloride and Acetate but these are done at the end

107
Q

What is bacterial translocation and how is it caused?

A

Time-dependent passage of bacteria or endotoxins from the GI tract to extra-intestinal sites

When you stop feeding the gut, you stop making normal acid in the stomach
-This allows bacteria to grow
-They may then travel from below the diaphragm to above it

**You are less likely to see this complication if you are feeding the gut
**These bacteria can cause systemic infection

108
Q

What are the baseline monitoring parameters we want to have before starting PN?

A

-Complete metabolic panel (including Ca, Mg, and Phos)

-Hepatic function panel

-Prealbumin/CRP

-PT/INR (bleeding risk)

-Glucose finger sticks q4-6 hrs

109
Q

How often do we check a prealbumin/CRP?

A

Twice weekly

(half-life is 2-3 days)

110
Q

How often do we check Triglyceride and Respiratory Quotient (RQ)/Indirect Calorimetry levels?

A

Weekly

111
Q

What is refeeding syndrome?

A

Fluid, micronutrient, electrolyte, and vitamin imbalances

-Occurs within first few days of feeding a starved patient

*Could be life-threatening

112
Q

***What are the 3 common electrolyte issues with refeeding syndrome?

A

Hypophosphatemia (first) [<2.4]
Hypomagnesemia [<1.7]
Hypokalemia [<3.5]

113
Q

How do we prevent refeeding syndrome when starting nutrition?

A

-Replete electrolytes before initiating feeds

-Calculate everything like normal for a patient and then cut the nutrition in half

Limit:
Carbs (dextrose) to 100-150g
Fluids to 800 mL/day

-Increase calories/dextrose by 20-33% of goal every 1-2 days

-Give thiamine 100mg daily for 5-7 days

114
Q

What percent of daily calories should be made of essential fatty acids?

A

4-10% of daily calories

115
Q

What causes Essential Fatty Acid Deficiency (EFAD)?

A

Several weeks on a fat-free PN regimen
(10-14 days)

116
Q

How many days do you have before you need to add fat to a TPN?

A

10 days

117
Q

How do we prevent Essential Fatty Acid Deficiency (EFAD)?

A

-Provide 4% of caloric intake as lipids

Provide at least 500mL of 10% fat emulsion over 3-5 hours TWICE WEEKLY
or
Provide at least 250mL of 20% fat emulsion over 5-9 hours TWICE WEEKLY

118
Q

When is enteral nutrition indicated?

A

Oral consumption is inadequate

Oral consumption is contraindicated (but not EN):
-Esophageal obstruction
-Head and neck surgery
-Dysphagia
-Trauma
-Cerebrovascular accident
-Dementia

119
Q

What are the contraindications to enteral nutrition (EN)?

A

-Mechanical obstruction (hernia, tumors, adhesions, scar tissue)

-Non-mechanical obstruction (ileus-gut not moving)

-Intractable vomiting

-Severe malabsorption

-Severe GI hemorrhage

-Fistulas

120
Q

What are the routes of administration for EN?

A

Nasogastric (NG)
Nasojejunal (NJ)
Orogastric (OG)
Orojejunal (OJ)

N= start in nose
O= start in mouth
G= end in stomach
J= end in small bowel (jejunum)

Gastrostomy (PEG) -long-term

Jejunostomy (PEG/PEJ)

121
Q

Which tube is longer, thinner, and more bendy? Jejunal or Gastric

A

Jejunal

122
Q

What is an advantage of using a gastric tube?

A

Meds can get put down the tube

*This tube is wider and has less risk of clogging

123
Q

What patient factors make a jejunal tube a better choice to use?

A

High risk of aspirating
Vomiting
Gastric residuals

*if tube is in the stomach it will get vomited out, best to go straight to jejunum

124
Q

What tubes can be used for long term access?

A

PEG or PEJ

125
Q

What are the 4 methods of administration for EN?

A

Bolus
Intermittent
Continuous Infusion
Trickle or Trophic

126
Q

When administering bolus EN< what rate do we use?

A

> 200mL formula over 5-10 minutes

127
Q

What is the maximum volume of bolus EN that can be administered?

A

300-400mL

128
Q

Bolus EN is primarily used for which patients?

A

Those with a feeding tube

129
Q

What method of administration of EN is preferred for jejunal feedings?

A

Continuous Infusion

130
Q

When initiating a tube feed, what is sometimes done to make sure that the patient is digesting properly?

A

Check for residuals every 4-6 hours
(stop feed of period of time, withdraw contents of tube and see if any feed is left in the stomach)

131
Q

Having residuals of what volume may prompt us to stop EN?

A

> 500mL

(this mean that 5 hours of tube feed is sitting in the stomach)

132
Q

What percent of goal calories are we trying to achieve with EN in the first week?

A

> 50-60% of goal calories

*if we cannot reach this, consider PN

133
Q

True or False: Bowel sounds/flatus is required to start EN

A

FALSE
-EN will promote gut motility

134
Q

Why do we not want to initiate EN in hemodynamically unstable patients?

A

Concern for intestinal ischemia

135
Q

What is the main EN formula used in the ICU?

A

Impact 1.5

-has immune support
-use in: major elective surgery, trauma, burn, head/neck cancer, and mechanical ventilation

136
Q

What is the standard EN formula?

A

Jevity

137
Q

When should the EN formula Impact 1.5 be used with caution?

A

Sepsis

138
Q

What are the components of EN?

A

Protein (either intact or partially digested/elemental)

Fat (either long-chain or medium-chain* fatty acids)

Carbohydrates

139
Q

Which patients may be better off receiving elemental protein?

A

Patients with malabsorption or diarrhea

140
Q

What is Pro-Stat?

A

A modular supplement of protein used in EN

Provides:
-15 g protein
-72 kcal
-3 g CHO

141
Q

When should we give patients glutamine?

A

Reduces mortality in burn patients

**Do not supplement if patient is already receiving glutamine via an immune-modulating formula (Impact 1.5) *burn patients are an exception

142
Q

When should we give patients probiotics?

A

Mixed data

Normally considered in diarrhea but new data shows it could cause diarrhea

*Just don’t give these

143
Q

What are the possible GI complications of EN?

A

-High gastric residuals
-Aspiration
-Nausea/Vomiting
-Abdominal distention
-Diarrhea and Constipation **check meds

144
Q

What are ways we can reduce the risk of aspiration?

A

*Elevate head of bed to 30-45 degrees

Administer as continuous infusion

Change to post-pyloric delivery

Prokinetic drugs or narcotic antagonists

145
Q

What are the 4 prokinetic agents that can increase gut motility?

A

Metoclopramide

Erythromycin (QTc prolongation)

Naloxone (when opioids are causing constipation, can block receptors in the gut)

Methylnaltrexone (one time dose, last line)

146
Q

If a patient develops diarrhea while on EN, what do we do?

A

Change to fiber-containing formula

Suspect Clostridium difficile (especially if antibiotic use)

Evaluate medications

147
Q

Which medications may make a patient more likely to experience diarrhea?

A

Hyperosmolar meds

Liquid formulations with sorbitol*

Bowel regimen (but do not completely stop this)

Broad spectrum antibiotics

148
Q

What are some common metabolic side effects of EN?

A

Hyper/Hypo glycemia

Overhydration/Dehydration

Electrolyte Imbalance (**hyponatremia)

149
Q

What is the goal blood sugar level in the ICU?

A

< or = 180 mg/dL

150
Q

What are the mechanical complications of EN?

A

Clogging of feeding tube

Tube malposition (assess with abdominal x-ray “KUB”)

Rhinitis + Sinusitis (from bacteria growing on nasal tube, need to reposition daily, can use a thinner tube or change to OG)

151
Q

What are the possible medication-related complications associated with EN?

A

Clogged feeding tube
Drug-tube interaction

152
Q

**What are the guidelines for medication delivery via enteral feeding tubes?

A

Liquid meds are preferred

Crush tablets to a fine powder or empty capsule contents, and mix with water

Do not crush SR or enteric coated medications

*Administer each med separately

*Adequately flush with water between each med and at end

Dilute hypertonic/irritating meds in 30 mL of water before administration

153
Q

How much water should be used to flush a feeding tube before/after medication administration?

A

15-30 mL sterile water

Use 5-10mL between each med

154
Q

What medications interact with tube feeds?

A

Antibiotics (Fluoroquinolones, Itraconazole, Tetracyclines, Penicillin)

Anti-Retrovirals (Didanosine, Dolutegravir, Indinavir)

Other: Levothyroxine, Warfarin, Phenytoin, Theophylline

155
Q

If a patient is receiving a medication that interacts with their tube feed, how do we adjust the tube feed?

A

Hold, Wait 1 hr, Give med, Wait 2 hours, Resume tube feed

(off tube feed for a total of 3 hours per medication administration)

156
Q

How often should we monitor serum electrolytes, glucose, BUN/SCr [CMP]?

A

Daily until stable

Then twice weekly

Then weekly

157
Q

What considerations do we need to make for acute renal failure patients?

A

*Have increased protein requirements to prevent nitrogen deficiency

Continuous Renal Replacement Therapy: Max: 2.5 g/kg/day

Hemodialysis: 0.8-1.2 g/kg/day

*Prealbumin is eliminated renally and therefore is falsely high

158
Q

What considerations do we need to make for pulmonary failure patients?

A

Fluid-restriction (need calorically dense formula)

Monitor phosphate closely

159
Q

True or False: we cannot orally feed patients with acute pancreatitis

A

False, oral intake normally recovers in 3-7 days, not requiring PN

160
Q

True or False: Parenteral nutrition does not affect pancreatic secretion and function

A

True

Fall 2024 (16 decks)

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