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Children's Pulm > TPN > Flashcards

TPN Flashcards

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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
Q

ASPEN carbohydrate recommendations for adults

A

Glucose/kg/min
• Initial: N/A
• Advancement: N/A
• Goal: <7 mg

26
Q

Fat calories

A

10 Kcal/g

27
Q

Ordering fat in TPN

A

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
Q

Too much fat can lead to

A

hypertriglyceridemia

PN associated liver disease

29
Q

What may delay progression of PN associated liver disease

A 
SMOF
soybean
MCT (medium-chain triglyceride)
Olive oil
Fish oil

Carnitine aids lipid metabolism: 10-30 mg/Kg/day dose

30
Q

ASPEN fat recommendations premature infants

A

G/kg/min
• Initial: 0.5-1
• Advancement: 0.5-1
• Goal: 3

31
Q

ASPEN fat recommendations term infants <1yr

A

G/kg/min
• Initial: 0.5-1
• Advancement: 0.5-1
• Goal: 2.5-3

32
Q

ASPEN fat recommendations children 1-10yr

A

G/kg/min
• Initial: 1-2
• Advancement: 0.5-1
• Goal: 2-2.5

33
Q

ASPEN fat recommendations adolescents

A

G/kg/min
• Initial: 1
• Goal: 1-2

34
Q

adults

A

G/kg/min
• Initial: N/A
• Advancement: N/A
• Goal: 1

35
Q

Micronutrients in TPN include

A

Electrolytes
Vitamins
Minerals
Trace elements

36
Q

TPN electrolyte ordering limitations

A

• 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
Q

What is utilized at times if chloride levels are too high

A

acetate

38
Q

Vitamin dosing and contents

A

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
Q

Trace elements contents and ordering considerations

A

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
Q

Additives in TPN

A
  • 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
Q

TPN monitoring parameters

A

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
Q

Peripheral parenteral nutrition osmolarity

A

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
Q

Peripheral parenteral nutrition limitations

A

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
Q

TPN like fluids used when

A

pts on TPN are admitted later in the day

45
Q

Complications of TPN

A

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
Q

Signs of refeeding syndrome

A

severe hypophosphatemia
hypokalemia
hypomagnesemia

47
Q

TPN pharmacy ordering tips

A
  • 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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