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TPN Flashcards

1
Q

TPN Indications

A

Inability to meet nutritional needs through enteral nutrition due to:

  • inc metabolic needs
  • impaired ability to tolerate oral/enteral feeds
  • inadequate intake
  • *anticipated use of at least 7 days**
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2
Q

Typical conditions that may require TPN

A 
prematurity 
severe lung disease
GI d/o (NEC, short gut syndrome, bowel obstruction, intractable diarrhea, pancreatitis)
multi-organ failure
sepsis
CF
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3
Q

Timing ot initationing TPN

A

infants: within 3 days of being NPO

children >1yr: within 5-7 days or within 3 days if malnourished

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4
Q

Steps to initiate TPN

A
    1. CONSULT A DIETICIAN
    1. ASSESS NUTRITIONAL STATUS
    1. DETERMINE WEIGHT TO USE
  • 4.VERIFY TYPE OF ACCESS
    1. DETERMINE FLUID REQUIREMENTS, ENERGY NEEDS, MACRONUTRIENT GOALS, AND DURATION using ASPEN guidelines (american society for parenteral and enteral nutrition)
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5
Q

Dietician consult when ordering TPN

A
  • DIETICIANS PROVIDE RECOMMENDATIONS INCLUDING WHAT WEIGHT TO USE, AND ENERGY, GLUCOSE, FAT, AND PROTEIN GOALS.
  • AS A PROVIDER, IMPORTANT TO COMMUNICATE ANY SPECIAL NEEDS OF PATIENT
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6
Q

Assess nutritional status

A

DIET HISTORY

ANTHROPOMETRICS
• HEIGHT/LENGTH
• WEIGHT: current vs dosing; don’t weight adjust unless instructed by dietician
• BMI- GOOD MEASURE OF ADIPOSITY

LAB VALUES

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7
Q

Method used to calculate fluid requirements

A

Holliday-Segar method

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8
Q

Conditions that increase fluid needs

A 
fever
V/D
insensible losses
ostomy output
polyuria
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9
Q

Conditions that decrease fluid needs

A

heart disease
BPD
renal insufficiency

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10
Q

ASPEN energy needs recommendations

A 
KCAL/KG/DAY
• PRETERM INFANTS: 90-120
• < 6 MONTHS: 85-105
• 6-12 MONTHS: 80-100
• >1-7 YEARS: 75-90
• >7-12 YEARS: 50-75
• >12-18 YEARS: 30-50
• ADULTS: 25-30
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11
Q

TPN macronutrients ranges

A 
% of total parenteral energy intake 
Protein: 10-20% 
Carbs: 40-60%
Fat:
• <12m: up to 55%
• >1yr: 25-30%
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12
Q

Conditions which increase protein requiremets

A 
sepsis
burns
wounds
surgery
trauma
stomal losses
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13
Q

Conditions which decrease protein requirements

A

liver failure
renal disease
errors of metabolism

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14
Q

Protein calories

A

4 Kcal/g both essential and non-essential aminoacids

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15
Q

TPN protein brands

A

Trophamine amino acid solution-> default
Aminosyn-> delivers high amount of protein in low volume
Heptamine-> for liver failure
Nephramine-> renal failure not on dialysis

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16
Q

ASPEN protein recommendations

A 
G/Kg/day
• Preterm: 3-4
• Term <1yr: 2.5-3
• Children 1-10yr: 1.5-2.5
• Adolescents: 0.8-2
• Adults: 0.8-1
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17
Q

Glucose calories

A

3.4 KCal/G

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18
Q

Too much glucose can lead to

A

hyperglycemia
hyperosmolarity
osmotic diuresis
increase risk of hepatic steatosis

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19
Q

Order carbohydrate for TPN

A

% dextrose or glucose infusion rate (GIR = glucose/Kg/min)

20
Q

How to calculate glucose infusion rate

A
  1. CALCULATE GRAMS OF GLUCOSE IN PN -> ENERGY (KCALS) FROM CARBS DIVIDED BY 3.4KCAL/G = GRAMS GLUCOSE
  2. CONVERT TO MILLIGRAMS GLUCOSE -> GRAMS GLUCOSE DIVIDED BY 1000 = MG GLUCOSE
  3. CALCULATE MILLIGRAMS GLUCOSE PER KILOGRAM -> MG GLUCOSE DIVIDED BY BODY WEIGHT = MG GLUCOSE/KG
  4. CALCULATE MILLIGRAMS OF GLUCOSE PER KG PER MINUTE -> MG GLUCOSE/KG DIVIDED BY MINUTES OF INFUSION = MG
    GLUCOSE/KG/MINUTE (MINUTES OF INFUSION = 1440 IF DELIVERED OVER 24 HR)
21
Q

ASPEN carbohydrate recommendations for premature infant

A

Glucose/kg/min
• Initial: 6-8 mg
• Advancement: 1.4-1.7 mg
• Goal: 10-14 mg (max 15mg)

22
Q

ASPEN carbohydrate recommendations for term infant <1yr

A

Glucose/kg/min
• Initial: 6-8 mg
• Advancement: 3.5 mg
• Goal: 10-14 mg (max 14-18 mg)

23
Q

ASPEN carbohydrate recommendations for childrens 1-10yrs

A

Glucose/kg/min
• Initial: 3-6 mg
• Advancement:n 2-3 mg
• Goal: 8-10 mg

24
Q

ASPEN carbohydrate recommendations for adolescents

A

Glucose/kg/min
• Initial: 2.5-3 mg
• Advancement: 1-2 mg
• Goal: 5-6 mg

25
ASPEN carbohydrate recommendations for adults
Glucose/kg/min • Initial: N/A • Advancement: N/A • Goal: <7 mg
26
Fat calories
10 Kcal/g
27
Ordering fat in TPN
defaults to intralipid 20% contains egg-> use caution in egg allergy; discuss if vegan Must give at least 0.5 G lipid/kg/day to meet essential fatty acid needs Limiting infusion to 0.5-1 G/Kg/day can help prevent PN associated liver disease
28
Too much fat can lead to
hypertriglyceridemia | PN associated liver disease
29
What may delay progression of PN associated liver disease
``` SMOF soybean MCT (medium-chain triglyceride) Olive oil Fish oil ``` Carnitine aids lipid metabolism: 10-30 mg/Kg/day dose
30
ASPEN fat recommendations premature infants
G/kg/min • Initial: 0.5-1 • Advancement: 0.5-1 • Goal: 3
31
ASPEN fat recommendations term infants <1yr
G/kg/min • Initial: 0.5-1 • Advancement: 0.5-1 • Goal: 2.5-3
32
ASPEN fat recommendations children 1-10yr
G/kg/min • Initial: 1-2 • Advancement: 0.5-1 • Goal: 2-2.5
33
ASPEN fat recommendations adolescents
G/kg/min • Initial: 1 • Goal: 1-2
34
adults
G/kg/min • Initial: N/A • Advancement: N/A • Goal: 1
35
Micronutrients in TPN include
Electrolytes Vitamins Minerals Trace elements
36
TPN electrolyte ordering limitations
• calcium/phosphate must be within certain parameters to avoid precipitation • sodium concentrations may not exceed 154 MEQ/L • Potassium mat not exceed 6 MEQ/100ml -rate calculated by pharmacist; cannot exceed 1 MEQ/KG/HR - If >0.5MEQ/KG/HR must monitor cardiac function
37
What is utilized at times if chloride levels are too high
acetate
38
Vitamin dosing and contents
Children >3kg and <11y/o: use MVI pediatric dosage = 5ml Adolescents >/=11 y/o: use AMI adult dosage = 10ml ``` Contains: vitamins ADEK B1,2,3,6,12 vitamin C dexpanthenol folic acid biotin ```
39
Trace elements contents and ordering considerations
Contains: zinc, copper, manganese, chromium, selenium • Decrease concentration of copper in half and do not give manganese to children what have PN associated cholestasis (direct bili >2) • Zinc supplementation used in pts w/ excess GI losses from diarrhea or ostomy output
40
Additives in TPN
* HEPARIN: USUAL DOSAGE 1 UNIT/ML, HELPS MAINTAIN LINE PATENCY * CYSTEINE : HELPS IMPROVE CALCIUM/PHOSPHOROUS SOLUBILITY IN INFANTS UP TO 1 YR BY DECREASING PH OF SOLUTION. * L-CARNITINE: AIDS IN METABOLIZING LIPIDS; 10-30 MG/KG/DAY * RANITIDINE: PPX ULCERS, 2-3 MG/KG/DAY, RENAL DOSING 1MG/KG/DAY
41
TPN monitoring parameters
MUST MONITOR ANTHROPOMETRICS AND LABS AT BASELINE AND OFTEN UNTIL STABLE • INITIALLY: WEIGHT, HEIGHT/LENGTH, FOC, FLUID BALANCE, ELECTROLYTES, CALCIUM, MG, PHOS, GLUCOSE, BUN/CR, TRIGLYCERIDES, LFTS, AND CBC. • DAILY: WEIGHT, FLUID BALANCE • DAILY UNTIL STABLE: ELECTROLYTES, CALCIUM, MG, PHOS, GLUCOSE, BUN/CR, TRIGLYCERIDES • WEEKLY: ELECTROLYTES, CALCIUM, MG, PHOS, GLUCOSE, BUN/CR, TRIGLYCERIDES, LFTS, AND CBC. • MONTHLY: HEIGHT, LENGTH, FOC
42
Peripheral parenteral nutrition osmolarity
limited to = 900 MOSM/L calculated by: (% dextrose X 50 MOSM/L) + (% protein concentration X 100 MOSM/L) + ~200 MOSM/L (estimation of electrolytes, minerals and elements)
43
Peripheral parenteral nutrition limitations
dextrose limited to 10% usually used for a short period of time can require large amount of fluid to meet nutritional needs, cannot use if fluid restriction required
44
TPN like fluids used when
pts on TPN are admitted later in the day
45
Complications of TPN
Mechanical: thrombosis, air embolus Infection Metabolic: •electrolyte abnormalities; refeeding syndrome (potentially fatal) •abnormal glucose levels •cholestasis: prolonged use; excess amounts of macronutrients •metabolic bone disease due to insufficient amounts of calcium and phosphorous
46
Signs of refeeding syndrome
severe hypophosphatemia hypokalemia hypomagnesemia
47
TPN pharmacy ordering tips
* enter order in pediatric assistant by 1400, must be ordered daily * pay attention to total electrolyte amounts, especially in large children and ensure total daily dose is appropriate

Children's Pulm (4 decks)

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