MNT

Question 1

In H&N cancer pts undergoing surgery, use of _ _ _ supplementation has been associated with fewer infections and shorter LOS

Answer 1

Arginine

Question 2

ASPEN recs re: immune modulating enteral formulas containing arginine, nucleic acids, essential fatty acids

Answer 2

Recommends use as it may be beneficial in malnourished cancer patients undergoing major operations

Question 3

Where should the catheter tip be positioned when providing PN through central venous access?

Answer 3

Superior vena cava or adjacent to the right atrium

Question 4

Home PN patients with recurrent CRBSI despite adherence to aseptic technique should be considered for use of prophylactic:

Answer 4

Antimicrobial or ethanol lock solutions

Question 5

Which form of calcium is preferred when compounding PN?

Answer 5

Calcium gluconate

Question 6

Should calcium and phosphorous be added in close sequence or consecutively when compounding PN?

Answer 6

No

If mixed in too high a concentration, calcium and phosphorus may form an insoluble precipitate of calcium phosphate. Pulmonary emboli secondary to calcium phosphate precipitates have been the cause of at least two deaths.

Question 7

What type of filter should be used for PN formulations?

Answer 7

1.2 micron filter may be used for all PN formulations

A 0.22 micron filter was recommended for a 2-in-1, whereas a 1.2 micron filter was recommended for TNA

Question 8

PN labeling should include:

Answer 8

• rate and duration of infusion
• components of formulation
• beyond use date in compliance with USP <797>, ASPEN

Question 9

Home PN labeling should be consistent with USP general chapter <17>:

Answer 9

• pt name
• drug name (spell out full generic and brand name)
• strength/dose
• purpose for use of PN should be clear “for nutrition supplementation” or “to provide nutrition”
• limit auxiliary info

Question 10

What is the only form of iron that can be added to PN? What can the PN NOT contain if adding iron?

Answer 10

Iron dextran - required a test dose prior to initial infusion

Iron can be added when PN does not continue ILE

Question 11

When should PN MVIs be added to the bag?

Answer 11

Immediately before starting PN infusion

Question 12

How many mL should you flush an enteral tube with between medications?

Answer 12

15 mL water before and after each medication

Question 13

Home blenderized or reconstituted powdered EN formulas should be discarded after:

Answer 13

24 hours

Or per manufacturer guidelines

Question 14

How long should ILE - as a separate infusion - run before being discarded?

Answer 14

12 hours

Question 15

How long can TNA hang before being discarded?

Answer 15

24 hours. Lipids added = altered pH which prevents microbial growth, thus allowing longer hang time

Question 16

Why should amino acids not be exposed to light?

Answer 16

To maintain stability up to the expiration date

Question 17

Adult AA solutions do not typically contain which amino acids?

Answer 17

Cysteine
Taurine
Glutamine

Cysteine and taurine are non-essential in adults. Cysteine can complex with copper. Copper-cysteine complexes are likely to precipitate.

Glutamine is still considered non-essential (but we know its role). The FDA has not approved glutamine in TPN, and it’s contraindicated in renal and liver disease. (Not sure what extent of disease or if dysfunction would also count)

Historically, glutamine was not added to commercial parenteral nutrition solutions due to instability.

No glutamine in AA solutions because of rapid degradation to toxic by products upon heat sterilization

Question 18

The functions of glutamine are many and include:

Answer 18

• Regulates GI cell growth, function, and regeneration in SBS
• Conditionally essential AA during metabolic stress and injury
• Crucial for energy metabolism and proliferation of hepatocytes in the liver
• Substrate for protein synthesis
• Anabolic precursor for muscle growth
• Acid-base balance in the kidney
• Substrate for ureogenesis in the liver
• Substrate for hepatic and renal gluconeogenesis
• Oxidative fuel for intestine and cells of the immune system
• Inter-organ nitrogen transport
• Precursor for neurotransmitter synthesis
• Precursor for nucleotide and nucleic acid synthesis
• Precursor for glutathione production

Question 19

Why is glutamine supplementation contraindicated in liver disease?

Answer 19

Conversion of glutamine to glutamate and ammonia may worsen hepatic encephalopathy

Glutamine may also diminish the therapeutic effect of lactulose

Question 20

Is the aluminum contamination greater in KPhos or NaPhos?

Answer 20

Potassium phosphate

Question 21

What two MN have the ability to reduce selenite to the poorly soluble elemental selenium?

Answer 21

Copper
Vitamin C

Question 22

What pH value reduces risk of folic acid precipitation?

Answer 22

pH >5.0

Question 23

What b-vitamins are are unstable in sunlight (direct or indirect)?

Answer 23

Thiamin
Pyridoxine
Riboflavin

Question 24

What are the main determinants of thiamin degradation

Answer 24

Sunlight
Sulfites