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[Mine] core curric - 2016 > Ch 14: Overview of PN > Flashcards

Ch 14: Overview of PN Flashcards

1
Q

If administered inappropriately, PN can result in:

A
  • Venous thrombosis (blood clots; e.g., DVT)
  • Suppurative thrombophlebitis (presence of venous thrombosis, inflammation, and bacteremia)
  • Extravasation (leakage of fluid in the tissues around the IV site – PN fluid is a vesicant (a fluid that irritates tissue))
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2
Q

mOsm/to calculate osmolarity:

Dex, AA, lytes

A
  • Dextrose: 5 mOsm/g
  • AA: 10 mOsm/g
  • Electrolytes: 1 mOsm/mEq of individual electrolyte additive
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3
Q

TPN characteristics

A
  • Glucose content: 150-600g per day
  • Hyperosmolar solution → delivered into a large-diameter vein (superior vena cava) via CVC
  • Rate of blood flow rapidly dilutes hypertonic PN to body fluids
  • Preferred in patients requiring a fluid restriction as it can be concentrated
  • Long term indefinite duration
  • Preferred in patients requiring > 7-14 days of PN
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4
Q

Max osmolarity of PPN

A

900 mOsm/L

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5
Q

Content of PPN:

A
  • Dextrose: 150-300 g/day (5-10% concentration)
  • AA: 50-100 g/day (3% concentration)
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6
Q

Why is PPN Used for short periods?
How long a time?

A
  • Up to 2 weeks
  • Due to few suitable peripheral veins and limited patient tolerance
  • May be limited by venous access
    *
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7
Q

PPN Contraindications

A
  • Significant malnutrition
  • Severe metabolic stress
  • Large nutrient or electrolyte needs (K is a strong vascular irritant)
  • Fluid restriction
  • Need for prolonged PN (>2 weeks)
  • Renal or liver compromise
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8
Q

Midline catheters recommended for PPN

A

Midline catheters recommended for PPN >6 days d/t catheter length and lower probability of dislodging vs other peripheral cannulas

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9
Q

Do Midlines reduce the risk of thrombophlebitis?

A

does not reduce the risk of thrombophlebitis

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10
Q

Permissive underfeeding

A

Provide 80% of EEN until pt’s condition improves
* Minimizes complications of PN delivery
* Critical illness

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11
Q

Hypocaloric feeding

A

Meet protein requirements, provide less energy
* Used in EN/PN for obese patients
* Minimizes metabolic complications of PN while improving nitrogen balance
* Used with BMI >30
* Critically ill or other hospitalized patients

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12
Q

Supplemental PN

A

Purpose to avoid energy deficits during no nutrition or undernutrition
* Used when EN is insufficient to meet energy needs

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13
Q

Indications for PN

A
  • Contraindication to EN or access
  • Impaired absorption or loss of nutrients
  • Mechanical bowel obstruction
  • Need for bowel rest
  • Motility disorders
  • Inability to achieve or maintain enteral access
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14
Q

Criteria for PN

A

Delay in those with severe metabolic instability
* Address electrolyte abnormalities
* Address hypovolemia, shock, hypoxia

Is CVC available?

Duration of therapy exceeds 5-7 days

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15
Q

Criteria for PN in:
Well nourished stable adult

A

Wait 7 days

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16
Q

Criteria for PN in:
Nutritionally-at-risk

A

Wait 3-5 days

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17
Q

Criteria for PN in:
Baseline moderate or severe malnutrition

A

as soon as feasible

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18
Q

Conditions where PN should be used with caution:

A
  • Hyperglycemia (>300 mg/dL)
  • Azotemia (BUN >100 mg/dL)
  • Hyperosmolality (serum osmo >350 mOsm/kg)
  • Hypernatremia (>150 mEq/L)
  • Hypokalemia (K <3 mEq/L)
  • Hyperchloremic metabolic acidosis (Cl >115 mEq/L)
  • Hypophosphatemia (Phos <2 mg/dL)
  • Hypochloremic metabolic acidosis (Cl <85 mEq/L)
19
Q

PN & IBD

A

PN has not been shown to improve outcomes as primary management
* Bowel rest not necessary to achieve remission in Crohn’s

20
Q

PN & SB fistulas

A

PN noted improvement in mortality rates and spontaneous surgical closures
* Exception: when fistula arises from bowel with active Crohn’s

21
Q

PN & pancreatitis

A

Unlikely to benefit mild, acute, or chronic relapsing pancreatitis when <1 week

22
Q

PN & pancreatitis
Recommendations

A
  • 25-35 kcal/kg
  • Adequate glycemic control
  • Glutamine administration (0.3g/kg alanyl-glutamine dipeptide) to minimize effects of NPO status on gut integrity
23
Q

Why is GI/bowel rest + PN no longer indicated in pancreatitis? Why should PN be avoided (unless EN is not feasible)?

A

d/t ileus, SBO, inability to place feeding tube

24
Q

What baseline state have studies shown have the highest risk of adverse postsurgical outcomes?

A

low visceral protein stores (specifically Alb) at baseline

25
Q

Perioperative PN reserved for severe malnutrition at baseline where risk > benefits of surgery 2/2

A

high risk for post-op complications

Max benefits seen in >7-10 days

26
Q

2011 evidence - cancer/surgical patients

A

EN comparable to PN in malnourished cancer patients undergoing surgery

27
Q

Does ASPEN/SCCM recommend EN or PN as preferential feeding route?

A

ASPEN/SCCM recommend EN > PN as preferential route
* Greatest benefit seen in first 24-48 hours after admission to ICU

28
Q

When should PN should be a last resort in patients with normal nutrition status?

A

cannot initiate EN > 7 days

29
Q

PN indications in critical illness

A
  • hemodynamically stable patients
  • paralytic ileus
  • acute GI bleed
  • complete bowel obstruction
30
Q

PN & GI malignancies

A

Review of PN literature has reported improved outcomes in patients with upper GI malignancies when PN is initiated 7 days before surgery

31
Q

PN during chemo/XRT associated with:

A
  • increased infection complications
  • no improvement in clinical response, survival, or toxicity to chemo
32
Q

ASPEN guidelines: PN & cancer

A
  1. thorough nutrition assessment
  2. use PN only in malnourished patients unable to ingest/absorb adequate nutrients for >7-14 days
33
Q

Is EN or PN preferred in hematopoietic cell transplant and why?

A

EN preferred in hematopoietic cell transplant 2/2 better glycemic control vs PN

34
Q

Is standard formula immune-enhancing formula appropriate in cancer patients?

A

Data supports use of immune-enhancing EN

35
Q

Home PN considerations

A
  • Patient/caregiver capabilities
  • Safety of home environment for PN
36
Q

Medicare & home PN requirements for reimbursement:

A
  • Document GI tract is non-functional (“artificial gut”)
  • Condition is permanent (>/= 90 days therapy needed)
  • Documented evidence of inability to tolerate EN
37
Q

Medical conditions requiring caution with home PN initiation:

A
  • DM
  • CHF
  • Pulmonary disease
  • Severe malnutrition
  • Hyperemesis gravidarum
38
Q

Electrolyte d/o requiring caution with home PN initiation:

A
  • Hypernatremia
  • Hypokalemia
  • Hyperchloremic metabolic acidosis
  • Hypophosphatemia
  • Hypochloremic metabolic alkalosis
39
Q

PN associated with complications and patient harm include:

A
  • Infections related to introduction of IV catheter and their manipulations
  • Administration of viable growth medium
  • Metabolic complications from overfeeding or refeeding
  • Problems caused by other errors during prescription, transcription, or preparation
40
Q

Successful use of PN requires:

A

adequate system to order, transcribe, prepare (compound), dispense, and administer

41
Q

PN should only be advanced when the following criteria are met:

A
  • Stable blood pressure, pulse, respiration rates – can be adversely affected by PN
  • Normal K, Phos, BG
42
Q

Prevent rebound hypoglycemia with d/c of PN

A

taper over 1-2 hours

43
Q

What to do if PN needs to be emergently stopped

A

replace with D10W at same rate, or at least 50 ml/hr

44
Q

Current water-soluble vitamin daily parenteral doses are 2 to 2.5 times greater than the Recommended Dietary Allowance (RDA) or Adequate Intake (AI) because of

ASPEN self assessment - PN

A

increased requirements due to
* malnutrition
* baseline vitamin deficiencies
* increased urinary excretion of water-soluble vitamins when used intravenously.

[Mine] core curric - 2016 (22 decks)

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