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Advanced MNT 2 > Parenteral Nutrition Part 3 > Flashcards

Parenteral Nutrition Part 3 Flashcards

1
Q

Hyperglycemia from parenteral nutrition
RBG > _____ mg/dL
the target BG range is _______ mg/dL

A

180

140-180

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2
Q

hyperglycemia is caused by

A

metabolic stress
medications
DM
excess CHO administration
overfeeding

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3
Q

complications of hyperglycemia

A

dehydration
increased CO2 production
hepatic steatosis

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4
Q

TO PREVENT HYPERGLYCEMIA

Administer dextrose in amounts _____ mg/kg/min

________ solution
Avoid _______

At risk patients, limit dextrose to _______ g/day on Day 1

Capillary glucose monitoring every ___ hrs

A

<4-5

Mixed substrate
overfeeding

100-150

6-8

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5
Q

Hyperglycemia Treatment

reduce dextrose content in PN to _____

addition of regular _____ to PN
____ unit for every gram of dextrose

A

≤ 4 mg/kg/min

insulin
0.1

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6
Q

Refeeding Syndrome (RS) is ________ that occur within the 1st few days after refeeding a starved patient

A

Metabolic alterations

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7
Q

Refeeding Syndrome (RS)

Rapid shift of electrolytes from _______ to _____ due to _______

electrolyte abnormalities include ________, __________, and ________

A

bloodstream
cells
insulin

hypophosphatemia*
hypokalemia
hypomagnesemia

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8
Q

_______ deficiency may manifest as a result of RS

Refeeding Syndrome (RS) Can cause=>
_________, ______, ______, ________, _______

Can be life-threatening

A

Thiamin

Respiratory failure
parethesias
muscle weakness
cardiac arrhythmias
hemolysis

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9
Q

Individuals at Risk for RS

A

Anorexia nervosa
Alcohol & substance use disorders
Cancer
Mental health disorders
Malabsorption
Starvation
Critical illness
AIDS

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10
Q

individuals are at SIGNIFICANT risk for refeeding syndrome if they have any ____ of the following

BMI?
Wt loss?
Caloric intake?
Low levels of _______ before feeding

evidence of ____________
evidence of _____________

A

1

<16

7.5% in 3 month OR
>10% in 6 months

none for >7 days OR
<50% of EER for >5 days during acute illness or injury OR
<50% of EER for >1 month

K+, Phos, Mg

severe subcutaneous fat loss
severe muscle loss

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11
Q

individuals are at MODERATE risk for refeeding syndrome if they have any ____ of the following

BMI?
Wt loss?
Caloric intake?
Low levels of _______ before feeding

evidence of ____________
evidence of _____________

A

2

16-18.5

5% in 1 month

none for 5-6 days OR
<75% of EER for >7 days during acute illness or injury OR
<75% of EER for >1 month

K+, Phos, Mg

severe subcutaneous fat loss
severe muscle loss

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12
Q

REFEEDING SYNDROME PREVENTION AND TREATMENT

Identify patients at _____
Replete __________ levels

Include adequate amounts of __________ in initial PN solutions

Supplement with ______ before initiating feeding

Continue with _______ for _______ or longer in patients with _________, ____________, or if signs of deficiency

A

risk
low serum electrolyte

K+, Mg, Phos & vitamins

100 mg thiamin

100 mg/d
5–7 days
severe starvation
alcohol use disorder

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13
Q

REFEEDING SYNDROME PREVENTION AND TREATMENT

Initiate kcal at _______ kcal/kg for the 1st _____

Limit initial CHO to _______ g/d on Day 1
_______ g/kg protein

Increase PN gradually by increasing by ______ kcal every ____ days as tolerated

Monitor serum electrolytes & fluid status as PN is advanced

A

10-20
24 hrs

100-150
1.2-1.5

100-300
1-3

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14
Q

OVERFEEDING
Results in=>________, _______, _______

Particularly a concern for _________ patients

Consider other sources of kcal (e.g., TF, propofol, dextrose from IVF, PD, CRRT)

A

hyperglycemia
hypercapnia
lipogenesis

critically ill

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15
Q

Hypertriglyceridemia is caused by

A

Excessive administration of ILE (total amount or rapid rate)

Hyperlipidemia

Dextrose overfeeding

Medications

Carnitine deficiency

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16
Q

Hypertriglyceridemia Treatment

A

Increase infusion time: >10 hrs/d

Decrease lipid administration:
Provide <30% of kcal from fat or <1 g/kg/d

If chronic, EFAD replacement only

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17
Q

EFAD is caused by

A

Inadequate fat administration

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18
Q

To prevent EFAD
Provide a minimum of ____% of energy as _______ or ____% of energy from lipid

Minimum: _____ ml of ____% lipid ___/wk or _____ ml of ____% lipid once per week

A

2-4%
linoleic acid
10%

250
20%
2x
500
20%

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19
Q

Prerenal Azotemia is

A

build up of nitrogenous waste

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20
Q

Prerenal Azotemia is caused by

A

excessive protein administration

dehydration

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21
Q

treatment for Prerenal Azotemia

A

decrease protein content of PN
increase fluid intake
monitor BUN

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22
Q

complication from long term PN

A

metabolic bone disease

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23
Q

can also do this to hopefullly get enough EFA

A

2 tbs safflower oil on skin every day

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24
Q

metabolic bone disease come with ______ and ___________

A

bone pain
pathological fractures

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25
Q

causes of metabolic bone disease

A

limited Ca intake
hypercalciuria
metabolic acidosis
aluminum toxicity
corticosteroids
prolonged immobilization

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26
Q

METABOLIC BONE DISEASE
Recommendations for prevention=>

Provide adequate ____, _____, and ____

avoid _________ and ______ loads

Rx ____________

A

Ca (10-15 mEq/d)
Phos (20-40 mmol/d)
Mg

metabolic acidosis
high protein

weight-bearing exercise

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27
Q

Risk for GI for PN

A

atrophy
bacterial translocation
PNALD

28
Q

GIT Atrophy & Bacterial Translocation etiology

A

Lack of intestinal stimulation by enteral nutrients

29
Q

GIT Atrophy & Bacterial Translocation symptoms

A

enteric bacteremia
sepsis

30
Q

GIT Atrophy & Bacterial Translocation prevention

A

early use of GIT

31
Q

GIT Atrophy & Bacterial Translocation treatment

A

Transition to enteral/oral feedings as tolerated

32
Q

PN-Associated Liver Disease (PNALD) possible etiology

A

Overfeeding
Dextrose-based PN with minimal ILE
Excessive ILE
EFAD

33
Q

PN-Associated Liver Disease (PNALD) symptoms

A

Elevation of LFTs

34
Q

PN-Associated Liver Disease (PNALD) prevention and management

A

Cyclic PN
Avoid overfeeding
Avoid dextrose infusion >5 mg/kg/min
Use mixed substrate solution
Decrease ILE to <1g/kg/d
Rule out other causes

35
Q

Catheter-Related complications

A

Catheter-Related Infections
pneumothorax
phlebitis
catheter occlusion

36
Q

Catheter-Related Infections possible etiology

A

Inappropriate technique in line placement
Poor catheter care
Contaminated solution

37
Q

Catheter-Related Infections symptoms

A

Elevated WBC
fever
red
hardened area around catheter site

38
Q

Catheter-Related Infections prevention

A

Development of strict protocols for line placement and catheter care

39
Q

Catheter-Related Infections treatment

A

IV antibiotics

Remove catheter and place at another site (last resort)

40
Q

pneumothorax possible etiology

A

Catheter placement by inexperienced personnel

41
Q

pneumothorax symptoms

A

Dyspnea
tachycardia

42
Q

pneumothorax prevention

A

Catheter placement by experienced personnel

43
Q

pneumothorax treatment

A

A large pneumothorax may require chest tube placement

44
Q

Phlebitis possible etiology

A

Peripheral administration of hypertonic solution (>900 mOsm/L)

Line infiltration

45
Q

Phlebitis symptoms

A

Redness
swelling & pain at peripheral site

46
Q

Phlebitis prevention

A

Minimize osmolarity of solution
use of a mixed substrate solution

47
Q

Phlebitis treatment

A

Change peripheral line site
Consider TPN

48
Q

Catheter Occlusion possible etiology

A

Venous thrombosis
Fibrin sheath
Solution precipitates

49
Q

Catheter Occlusion symptoms

A

Inability to infuse fluid
swelling or pain in the arm & neck

50
Q

Catheter Occlusion prevention

A

Routine catheter flushing
Prophylactic anticoagulation therapy

Monitor solution for precipitation.
Calculate the Ca-Phos precipitation check

51
Q

Catheter Occlusion treatment

A

Anti-coagulation therapy with urokinase or streptokinase

52
Q

What is the result of Calcium & Phosphorus Precipitation?

This can cause ?

A

Forms an insoluble calcium-phosphate salt

catheter occlusion & respiratory distress

53
Q

Calcium & Phosphorus Precipitation Risk factors

A

Excessive Ca &/or Phos in PN
Increased temperature
Increased pH
Order of mixing

54
Q

Calcium & Phosphorus Precipitation Prevention

A

Avoid excessive Ca & Phos in PN solution
[2 x Phos] + Ca must be <45 per liter of PN

Provide additional Phos or Ca via a separate IV line

55
Q

Example Ca-Phos Precipitation Calculation

Patient is receiving 1.8 L of a 3-in-1 PN order which contains 15 mEq Ca and 35 mmol Phos.
- How much per liter?
- Assessment?

A

[2 x 35 mmol Phos] + 15 mEq Ca = 85
85/1.8 L = 47 per L

Increased risk for Ca-Phos precipitation

56
Q

Nutritional Needs for Patients on PN

Energy: _____ kcal/kg
Patients with obesity: _____ kcal/kg IBW

Protein:
Stable patients: ________ g/kg
Critically ill patients: _______ g/kg
Patients with obesity: ________ g/kg IBW

A

20-30
22-25

0.8–1.5
1.2-2.5
2.0-2.5

57
Q

Volume guidelines for day 1 PN

Based on estimated fluid needs and ________

A

patient tolerance

58
Q

CHO guidelines for PN day 1

Begin with ______ grams

For individuals with DM, hyperglycemia, or refeeding syndrome risk begin with ______ grams

A

150-200

100-150

59
Q

Protein for day one PN

__________________

A

Goal amount can usually be given

60
Q

Lipid guidelines for PN DAY 1

Provide ILE if _________ is adequate

A

TG clearance

61
Q

Standard Electrolytes for PN day 1

A

Recommend adjustments as needed

62
Q

Standard vitamins & trace elements for PN day 1

A

Consider need for additions or restriction

63
Q

Guidelines for Advancing PN

If tolerating=> Increase to goal on day _____

_______ acceptable
Glucose: ______ mg/dL
TG ________ mg/dL
Electrolytes=> adjust as needed based on serum levels

A

2

Fluid status
≤180
<400

64
Q

Cyclic PN

Begin with a ________________ and then ____________ provided daily (while _________) until goal hours achieved

Achieved over ______ days

Stable patients can tolerate _____ hours/day cycle

A

24-hr continuous infusion
decrease hours
increasing infusion rate

3-4

8-12

65
Q

Cyclic PN—Glucose

Fluctuations when _________________

Rebound _____________

Taper rate to ______ the goal infusion rate for _____________

Monitor glucose __________, __________, and _____________ and also monitor until ____________ is established

A

beginning & ending TPN
hypoglycemia

half
first and last hour

2 hrs after initiation
mid cycle
2 hrs after cycle completed
tolerance

66
Q

Discontinuing PN Therapy

Do not abruptly stop TPN=> ______________

Taper TPN=>Reduce infusion rate by ____% for the ____ _______ and ____% in the _____ before discontinuation

Or can hang an __________
Monitor serum _______

A

rebound hypoglycemia

50
1st hour
50
2nd hour

IV solution of D10
glucose

67
Q
A

Advanced MNT 2 (17 decks)

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