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Therapeutics II > Block 2: Parenteral Nutrition > Flashcards

Block 2: Parenteral Nutrition Flashcards

1
Q

What are the types of PN?

A

CPN and PPN

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2
Q

PN is classified as a ___ medication

A

High alert

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3
Q

2-in-1 PN

A

Dextrose, amino acids, electrolytes, vitamins, and minerals in one PN bag, ILE administered separately

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4
Q

3-in-1 PN

A

Total nutrient admixture (TNA) and all-in-one: all PN macronutrients (amino acids, dextrose, and ILE) as well as other PN ingredients in same PN bag

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5
Q

Continuous PN?

A

PN infused over 24 hr

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6
Q

Cyclic PN

A

PN infused over < 24 hours (usually 8–18 h)

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7
Q

MCB

A

Multichambered bags

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8
Q

What are the indications for PN?

A
  1. Impaired absorption, loss of nutrients via the GIT, EN can worsen infection
  2. Mechanical bowel obstruction
  3. Restrict PO intake or EN for bowel rest
  4. Motility disorders
  5. Inability to achieve or maintain enteral access or EN
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9
Q

What patients would used PN?

A
  1. Patient with GI problems
  2. Pancreatitis
  3. Cancer
  4. Critical patients with malnutrition
  5. Hyperemesis gravidarum
  6. Eating disorders
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10
Q

What is the goal of TPN?

A
  1. Provide 100% of nutritional needs
  2. Avoid complications
  3. Facilitate transition to PO/enteral
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11
Q

What is come of the points when prescibing PN?

A
  1. If the gut works, use it via EN
  2. Individualize therapy and don’t overfeed leading to FLS, hypertriglyceridemia, hyperglycemia
  3. Titrate
  4. Trasition to PO to prevent GI decay, nutrient def, FLS
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12
Q

When should you initiate PN

A
  1. After 7 days in patients who are weel nourished and stable
  2. After 3-5 days in those who are nutritionally at risk
  3. As soon as feasible in patients with baseline moderate- severe malnutrition
  4. After 7-10 days if unable to meet > 60% of energy
  5. after 7-10 days if unable to meet > 60% of energy
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13
Q

What are the most common nutritional screening?

A

NRS and NUTRIC

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14
Q

What are the main principles of Nutritional screening?

A
  1. What is the condition now: BMI
  2. Is the condition stable: assess rectent weight loss (>5% in 3 months is significant)
  3. Will the condition worsen – has food intake decreased; bowel obstruction
  4. Will the disease process accelerate nutritional deterioration?
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15
Q

When do you initiate NUTRIC screening?

A

If “Yes” to any”
1. BMI < 20.5 kg/m2
2. Weight loss within 3 months
3. Reduced dietary intake in the last week
4. ICU patient

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16
Q

When do you use the NUTRIC score?

A
  1. Critically ill

Score of 0-5 indicates low risk
Score of 6-10 indicates high risk

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17
Q

What is pharmacist job in regards the PN?

A
  1. Nutrition support team
  2. Evaluate the PN prescription
  3. Clinical review
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18
Q

What are the types of macronutrients?

A
  1. AA
  2. Carbs
  3. Lipids
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19
Q

Who manny kcal does 1 g aa provide?

A

4 kcal

10-20% total kcal

20
Q

Who manny kcal does 1 g lipid provide?

A

9kcal

10% IVFE: 1.1 kcal/mL
20% IVFE: 2 kcal/mL
30% IVFE: 3 kcal/mL
Should provide 15-30% of total non-protein kcal

21
Q

Who manny kcal does 1 g carb provide?

A

3.4 kcal

Should provide 45-60% total kcal

22
Q

What are the drugs that contain lipids?

A
  1. Propofol: 1.1 kcal/mL
  2. Clevidipine: 2 kcal/mL
  3. Amphotericin B

take them into account of fat calories if patient is on it

23
Q

What are the micronutrients?

A
  1. Vitamins
  2. Trace elements
  3. Electrolytes
24
Q

What are you multivitmins? Volume?

A

10mL:
1. Vitamins A, B1, B2, B6, B7, B9, B12, C, K, niacinamide, dexpanthenol

25
Q

What are trace elements? Volume?

A

1 mL
1. Zince sulfate
2. Copper
3. Sulfate
4. Manganese
5. Chromium
6. Chloride
7. Selenium

26
Q

What are your electrolyte the additives?

A
  1. NaCl
  2. Soidum acetate
  3. Sodium phosphate
  4. KCl
  5. Potassium acetate
  6. Potassium phosphate
  7. Calcium gluconate
  8. Mg sulfate
27
Q

Daily requirement for Ca, Mg, P, Na, K?

A

Ca: 10-15 mEq
Mg: 8-20 mEq
P: 20-40 mmol
Na: 1-2 mEq/kg
K: 1-2 mEq/kg

28
Q

What is the difference between chloride and acetate salts?

A

Chloride: acidifier for metabolic alkalosis
Acetate: alkalinizer for metabolic acidosis

29
Q

What the indications of PPN?

A
  1. Lower risk of infections, metabolic, and tech complications
  2. Mild-moderate stressed patients from whom central access is unavailbale or undesirable
30
Q

What is the indication of CPN?

A
  1. Risks associated with catheter insertion and care of the site, greater potential for infection and catheter-induced trauma
  2. Larger blood vessels with higher blood flow rates quickly dilute hypertonic solutions
31
Q

What is the max of PPN?

A

900 mOsm/L

32
Q

With osmolarity is too high in PN how should you lower macronutrients?

A

Amino Acid: 10 X grams of amino acid/liter
Dextrose: 5 X grams of dextrose/liter
Lipid emulsion (20%): 1.3 mOsm x g

33
Q

What are the benefits and limitations of P IV?

A

Benefits: Fast access, can be started by nurses and phlebotomist
Limitations: Infiltration, phlebitis, or catheter obstruction can interrupt therapy
* Osmolarity > 900 mOsm/L must be given via central line

34
Q

What are examples of long term Central IV therapies?

A
  1. Peripheral Inserted Central Catheter (PICC)
  2. Tunneled cantral venous catheter
  3. Non tunneled
  4. Ports central venous cath (oncology)
35
Q

What are the steps to calculate TPN?

A
  1. Calculate TEE
  2. Calculate protein needs
  3. Calculate lipid needs
  4. Calculate carbs need
  5. Calculate sterile water
36
Q

What is the distribution of total calories?

A
37
Q

How do you calculate lipid needs?

A
  1. 10-30% of non-protein calories = in kcal
  2. Lipid in gram = total mL x % (the strength of AA you use)

Lipid do not need to be given daily esp. in high TG:
* Lipid infusion
* If lipid given alone: hang over 12 hours,
* If 3 in one: 24 hours
* With 1.2-micron filter

38
Q

How do you calculate carb needs?

A
  1. Total carb cal=total calories-protein calories - lipid calories
  2. Calculate total g dx:
    * Dextrose monohydrate: 3.4 kcal/g
    * Complex: 4 kcal/g
    * Dextrose in PN: 70%, 50%, 30%, 20%
  3. Calculate total of DX:
    * Total g dx x %
39
Q

How do you calculate PN fluid needs?

A
  1. Total fluid needs (when weight > 20 kg) =1500 mL + (20 mL) x (weight in Kg – 20)
  2. Sterile water (mL) = total fluid needs (mL) – protein (mL) – lipid (mL) – DX (mL)
40
Q

What are the steps to calculate TPN?

A
  1. Calculate total kcal/day
  2. Calculate protein dose in grams, kcal and mL
  3. Determine fat dose in grams, kcal and mL
  4. Subtract protein and fat kcal from total kcal to get carbohydrate kcal [total kcal – protein kcal – fat kcal = CHO kcal]
    * Convert CHO kcal to grams, get mL
  5. Sterile water volume:
    * Determine total fluid volume
    * Sterile water added = total fluid volume - the volume from (protein + lipid + CHO)
41
Q

Describe the interaction between ca and P?

A
  1. Add potassium or sodium phosphate early and calcium gluconate nearly last
  2. Use calcium gluconate (NOT chloride)
  3. When both values are high, risk of precipitation occurs
    Cal (mEq/L) x Phosphate (mEq/L) > 55-60 results in precipitation and deposition of complexes in the vasculature
42
Q
A
42
Q

What are the complications of PN?

A

GI: GI atrophy, cut bacterial overgrowth
Metabolic/nutritional: FLD, HTG, HPG, refeeding
Mechanical: pump failure, problems with tubing, clogging
Infectious: Line infection

43
Q

What is refeeding syndrome?

A
  1. Starvation/malnutrition – catabolism
    * [glucagon] increases and [Insulin] decrease
    * rapid conversion of glycogen stores to glucose, gluconeogenesis, fat metabolism
  2. Refeeding (switch to anabolism)
    * (When feeding) Shift from fat to carbohydrate metabolism
    * insulin release -> increased cellular uptake of glucose, phosphate, potassium, magnesium, and water
44
Q

What are the risk facotrs of reffeding syndrome?

A
  1. not been fed for 7-10 days with evidence of stress and depletion
  2. Prolonged fasting and massive weight loss in obese patients
  3. Anorexia
  4. Oncology patients
45
Q

How do we start and stop TPN?

A
  1. Start at 1/2 the goal rate -> increase as tolerated
  2. Decrease by 1/2 current rate -> discontinue no sooner than 4 hours later
46
Q

What monitoring parameters are we looking at in PN?

A
  1. Body weigh
  2. Inputs and outputs
  3. Vitals
  4. Blood glucose
  5. Serum electrolytes
  6. TG
  7. Kidney: BUN/SCr
    Liver function tests

Nutrition status:
Albumin, prealbumin

Therapeutics II (30 decks)

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