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345 final > Total Parenteral Nutrition > Flashcards

Total Parenteral Nutrition Flashcards

1
Q

Malnutrition

even looked at obese pts

A

• Includes both the deficiency and excess (or
imbalance) of energy, protein and other nutrients
• Undernutrition affects body tissues, functional
ability and overall health
• Undernutrition is made worse by:
– Acute conditions (e.g. a trauma)
– Infections
– Inflammation

Make it more challenging to
correct due to:
• Extensive physiological changes
• Increased nutritional needs

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2
Q

review

A

Order for PN

  • Review of indication for PN
  • Complete standard bloodwork

Dietitian: • Complete nutritional assessment
• Assess for route and type of PN (in
consultation with team)
• Complete PN prescription

Pharmacy:
• Review and verify PN prescription
• Compounding and labeling of PN

Nursing: • Review and verification of order
• Administration
Monitor and reassess the patient

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3
Q

Parenteral Nutrition

A

• Intravenous administration of nutrients (amino acids,
dextrose, lipids, fluid, electrolytes, vitamins and minerals)
• 2 categories based on site of administration:
– Peripheral PN
– Total (Central) PN (given via the superior vena cava)
• Standard solutions (Pre-Mixed) or patient specific
(Compounded) depending on the institution
– 2 in 1 or 3 in 1 solutions available for each

white is lipid and yellow sltn is amino acid, dextrose sltn

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4
Q

Indications for PN

A

• Failure of Enteral Nutrition despite proper tube
placement
• When Enteral Nutrition is contraindicated or there is
underlying intestinal tract disease, for example:
– Small bowel obstruction
– Massive small bowel resection (cant absorb nutrient)
– Intractable diarrhea &/or vomiting
– Persistent signs of gut dysmotility
• Persistent gastrointestinal hemorrhage

cannot feed the gut

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5
Q

Adjunct to Enteral Nutrition

when?

A

in hypercatabolic state until adequate Enteral Nutrition can be established
– Gastrointe stinal tract is not accessible or enteral access has been lost or cannot beobtained, such as in:
• Facial injuries/ head and neck cancer
• Upper Gastrointestinal tract obstruction
• Severe esophageal varices

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6
Q

PN MAY be Indicated

50-50
depend on pt

A 
Inflammatory Bowel Disease not
responding to medical therapy
– Intensive chemo/ severe mucositis
– Major surgery/stress when Enteral
Nutrition is not expected to resume within
7-10 days
– Trauma requiring repeated surgeries
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7
Q

Contraindications to PN

A

• Functional gastrointestinal tract (GIT)
• Previously well nourished adult, minimal stress,
recovery of GI tract expected in < 7 days
• Sole dependence on PN expected < 7 days
• Prognosis does not warrant aggressive therapy
• Risks > benefits
• No venous access

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8
Q

• Determine appropriate access

A

– Peripheral or central
• If central access:
– CXR (Chest X-Ray) post line insertion to ensure
appropriate position of the catheter
• PN is infused through a venous catheter or
cannula
• Start with a continuous infusion of the nutrient
mixture (24 h/day thru central catheter instead of feeding tube)

Femoral not great place to run TPM infusion , higher risk of infection

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9
Q

Central Access Devices
4 types
• PICC (Peripherally Inserted Central Catheter)
• Short Term Non Tunneled

A

• PICC (Peripherally Inserted Central Catheter)
– Inserted into a peripheral vein & wired into the central venous system into the superior vena cava
– Stay in place for up to 1 year for extended therapies

• Short Term Non Tunneled
– Triple or double lumen placed into jugular, subclavian, or femoral vessel
– For multiple access needs in acute care
– 4-6 weeks only; high complication risk

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10
Q

Central Access Devices
4 types
• Long Term Tunneled
• Implanted Catheter

A

• Long Term Tunneled
– E.g.: Broviac
– Long term/ recurring therapies (chemo, home TPN)
– Single & multilumen, decreased risk of cathet infection
– Possible decreased risk of catheter infection
– Easier to care for & repair; decreased risk of dislodgement

• Implanted Catheter
– Catheter is attached to a disk w/ a self sealing port
– Advantages include minimal changes to body image, do not require routine site care when not in use, ideal for infrequent but chronic IV therapies, done every few months (rare)

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11
Q

Factors to consider when choosing type of central

access:

A

– Duration & type of therapy (daily vs intermittent)
– Past medical history (previous central line insertions,
head & neck surgeries, thrombosis –> pt with lots of IV lines it might be difficult to get peripheral access on them)
– Resources required to care for device
– Age & mental status of patient
– Acuity level of patient
– Diagnosis
– Risk of infection

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12
Q

Peripheral PN

when is it used

A

we just need to bridge them for a few days or for you know less than a week they’re high nutritional risk, but until we can get longer term central access
• Require low concentrations of macronutrients in large
fluid volumes
• Osmolarity of < 900 mOsm/L (might not meed nutrient needs due to low conc of macronutrient)
• Undesirable for fluid restricted patients
• Typically used for short periods of time
• Patients must have good peripheral access
• High risk of line thrombosis

central line has more risks of comp
In patients that are obese often it’s hard to get really good peripheral lines, just like in patients that are really skinny and malnourished often their veins aren’t that great either

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13
Q

Standardized/Premixed

PN

A

• Industry compounded multichamber bags available with and without lipid injectable solution
and electrolytes
• Cost effective & improved patient safety (reduce infection risk, only 1 IV port and line)
• Not appropriate for all patients & requires full assessment to determine suitability

chamber bag w/ lipid, aa, dextrose

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14
Q

Compounded PN

A

Amino acids, dextrose,electrolytes, vitamins, minerals
(w/ or w/out lipid)
• PN to meet individual nutrient requirements of specific patients
• 3 L bags (2 diff bags or all in one bag)
• Lipids
– Different lipid emulsions available
– NOT INTERCHANGEABLE (diff types of fat w/ diff eefects on body systems)

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15
Q

PN Composition

A 
• Macronutrients
– Carbohydrate in the form of dextrose
– Amino Acids (AA)
– Lipid
– Water
• Micronutrients
– Electrolytes
– Vitamin & trace elements
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16
Q

carbohydrates

A

• Caloric density of dextrose is 3.4 kcals/gram
• 2.5% to 70% dextrose solutions available
(70 g dextrose/ 100 mls)
• Higher dextrose concentrations are for central
PN
• Acidic solutions (pH 3.5-6.5)

17
Q

protein

A

• Crystalline amino acids provide 4 kcals/gram
• 2.5%-20% amino acids solutions available
(20 g/ 100 mls)
• May also contain combinations of electrolytes
&/or buffers (e.g.: acetate) keep things from becoming acid
• Generally balanced between essential, semiessential, & non-essential amino acids

18
Q

lipid

possible complication

A

Non-carbohydrate energy source
• Provide Essential Fatty Acids
• Energy dense (some calories for pt)
• Egg yolk phospholipid as an emulsifier &
glycerin to provide isotonicity
• Contain small amounts of vitamin E and K• Ph range of 6-9

• Available in various concentrations:
• ­ potential for microbial growth due to pH
• High infusion rates associated w/
hypertryglyceridemia & infectious complications
• Composed of different fats to alter immune &
inflammatory response

19
Q

Micronutrients

• Electrolytes

A

– Pre-added in specific amounts to stock
formulations or individually added according
to patient needs (diff med needs eg. lasix, add extra K+)
– Sodium, potassium, magnesium, phosphorus,
& calcium
– Acetate & chloride added/adjusted to maintain
acid-base balance
– Available in different salt forms
–> Important to know especially in times of product shortages

20
Q

Multivitamin

A 
Multivitamin combinations & some single
vitamins available
– Fat soluble & water soluble
– No vitamin K contained in multivitamin sltn (add
separately if indicated due to possible
contraindications)
21
Q

Trace elements

A

– Common formulations include zinc, copper,
chromium, selenium, manganese
– Also available in singular form
– Different combinations & concentrations for
pediatrics & adults
– Iron dextran available for addition if required
(not commonly added to PN- given as a
separate infusion)

22
Q

Other Additions to PN

A

• Schedule 1 Medication Additions to PN
• Other Medication Additions to PN (NonSchedule-1)
• Specific Medication Interactions and PN
consult pharm, physician, nursing

• Any additions to PN must be done in pharmacy under
sterile conditions to prevent contamination
• Prior to addition of any of the following medications to
parenteral nutrition, discussion with the medical team
and verification of dosing is required
Medical Team:
MD/Pharmacist
Dietitian/Nursing

23
Q

The decision to add any of the following medications to the

parenteral nutrition mixture should be based on:

A

• an expected therapeutic action of the medication
• only if there is compelling evidence to support its
physiochemical compatibility and stability within the
parenteral nutrition admixture (if not guaranteed, won’t add it)
• no other reasonable alternative route of administration
exists

need all 3 checks

24
Q

When adding a medication to a PN admixture

consider the effect of the following:

A

– discontinuation of PN
– interruption of PN
– loss of IV access
– duplication of therapy

25
Q

Schedule 1 Medication Addition

H2RA
Vit K
insulin

A

• H2-Receptor Antagonists
– Can add to PN for stress ulcer prophylaxis
– Do not add if already receiving a PPI via IV or
orally
– Prior to addition to PN discussion between
MD, Pharmacy, RD

• Vitamin K (Phytonadione)
– Standard weekly dose: 10 mg
– Additional dosing can be given if vitamin K deficient
– Potential contraindications to giving vitamin K:
• History of DVT/clots/pulmonary emboli
• Warfarin use
– Remember that lipid infusions contain small amounts of inherent vitamin K

Insulin
– Only regular insulin can be added to PN
– Can be done in consultation with the Dietitian,
Pharmacist, and Physician/ Nurse Practitioner
– Addition to PN solution:
• Allows for easier management of Blood Glucose outside of the critical care setting
• If also receiving oral/enteral nutrition, addition of insulin to PN should be used with caution and should only account for the dextrose provided by the PN

26
Q

Specific Medication Interactions

warfarin
propofol

A

• Warfarin
– Addition of vitamin K for patients with a history of
warfarin use should only be under the direction of
the Physician/Pharmacist
– The amount of vitamin K in lipid emulsions does not
have a significant impact on the anticoagulation
effect of warfarin (when lipids are administered
according to guidelines)

• Propofol
– formulated with a 10% soybean based ILE
– Solution provides 1.1 kcals/mL
– PN lipid emulsions will require adjustment if Propofol
to be infused greater than or equal to 24 hours (dont want to overfeed)

27
Q

– Drug/PN incompatibilities

A

• Changes in solution clarity, color, or pH
• Some drugs may chelate with divalent cations &
form a precipitate
• Nursing must ensure compatibilities with PN if
infusing through the same catheter
• For all medication compatibility with PN checks refer to the AHS Parenteral Drug Manual

28
Q

Ordering PN

pn in Alberta is prescribed by the registered dietitian and macro and micro nutrient composition is also determined and infusion rates are then calculated, once we have figured all of that out.

A

• High Alert Medication
– medications that bear a heightened risk of causing
significant patient harm when used in error

• Writing PN prescription requires knowledge of:
– Micro/macro nutrients
– Nutrient interactions
– Implications of disease and organ dysfunction on nutrient metabolism

• PN prescribed by the Registered Dietitian
• Macro & micronutrient composition determined and
infusion rates are calculated

29
Q

how is PN ordered>

A
  • Orders entered into the CPOE
  • Computerized Provider Order Entry
  • In place of paper order forms
  • Improves safety of ordering PN
  • Eliminates transcription errors
  • Provides compatibility reports at the time of order entry
  • Pharmacist performs clinical review and verification:
  • Calcium/phosphorus solubility
  • PN limits/alerts
  • Allergies and clinical review
30
Q

Once orders are ready for compounding:

A

– PN is prepared under sterile conditions by the
pharmacy technicians
– Patient specific label is attached to the PN bag
– Solution is refrigerated until delivery to unit and/or use (sometimes take out of fridge 20-30 mins before to warm up)

31
Q

PN Shelf Life

A

– All PN bags have a Best Used by Date on the label
– Compounded PN BUD is shorter than PreMixed
solution with no additional additives
– Once any PN is hung the expiry is 24 hours
(exception: lipids have a hang time of 12 hours, increased infection risk)

32
Q

PN Administration

contiinous vs cycled

A

• Continuous PN
– PN infused over 24 hours (lipids 12 hours if run
separately)
– Typically for PN initiation and metabolically unstable
patients

• Cycled PN
– PN administration over less than 24 h
– Typically 12 h infusion
– Patient must be hemodynamically stable
– Advantages:
• Improved liver clearance, gives liver a break 
• Assists with patient mobilization
33
Q

ON monitoring

A 
weight
meds
physl signs of malnutrieton 
GI symptoms
reassess nutrient requrires
signs of infection
34
Q

Complications

• Divided into 3 categories

A 
– Mechanical
– Metabolic
– Infectious
• Risk of complications can be reduced by
proper line care techniques & close
monitoring of physiologic & metabolic
parameters
35
Q 
explain 
– Mechanical
– Metabolic
– Infectious
complications
A

• Mechanical:
– Placement related events
– Thrombosis
– Thrombophlebitis

• Metabolic (involves dietician and pharm)
– short term and long term complications including:
• Electrolyte imbalances
• Hyper/hypoglycemia
• Fluid imbalances
• Cholestatic liver disease
• metabolic bone disease

• Infectious (Catheter related)
• Attributed mortality of 12-25%
• All central venous catheters are at risk of
developing nosocomial bloodstream infections
• Infections originate from various sources
– Endogenous skin flora
– Contamination of catheter hub
– Seeding of the device from another site
– Contamination of IV fluid/PN
• Dextrose & lipid serve as ideal mediums for bugs

36
Q

Pharmacy role:

A

Regular monitoring of infectious complications
– Development of tools to assist practitioners in
identifying Catheter Related Blood Stream Infections
(CRBSI)
– Providing recommendations for targeting therapy of
CRBSI

345 final (24 decks)

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