Ch: 17 Complications of Parenteral Nutrition

Question 1

What causes prerenal azotemia?

Answer 1

Dehydration, excess protein, and/or inadequate energy from other nonprotein sources

Question 2

To reduce risk of hypertriglyceridemia, how should ILE be given/infused

Answer 2

ILE should be restricted to <30% of total energy or 1 g/kg/d; also, if ILE is administered separately, it should provide slowly over at least 8-10 hours

Question 3

What is the most common complication of PN administration?

Answer 3

Hyperglycemia

Question 4

How much phosphorus does APSEN recommend be put in PN?

Answer 4

20-40 mmol/d

Question 5

The FDA establishes labeling requirements for ______ contamination or large volume, small volume, and pharmacy bulk packages used in PN compounding?

Answer 5

Aluminum

Question 6

To avoid metabolic acidosis, what should be added to TPN in adequate amounts?

Answer 6

Acetate

Question 7

When should patients/caregivers add MVI to their PN

Answer 7

just prior to administration of the PN

Question 8

How should PN be initiated?

Answer 8

At ½ of the estimated energy needs or approximately 150 to 200 g dextrose for the first 24 hours. Delivery of less dextrose (~100 g) may be warranted if pt has low BMI or poor glycemic control

Question 9

What generally causes osteomalacia?

Answer 9

Vit D deficiency

Question 10

How much vitamin K is included in the 13 vitamin preparation for PN?

Answer 10

150 mcg; this interacts with warfarin and can cause treatment failure

Question 11

How much calcium does ASPEN recommend in PN to offset higher ca urinary losses?

Answer 11

10-15 mEq calcium gluconate from PN formula

Question 12

In acutely ill patients, CHO administration should not exceed what?

Answer 12

Rate of 4-5 mg/kg/min or 20-25 kcal/kg/d in acutely ill patients

Question 13

How much vit D is contained in a PN adult MVI prep?

Answer 13

200 IU of vit D (ergocalciferol or cholecalciferol)

Question 14

What are the three types of hepatobiliary disorders?

Answer 14

Steatosis (more common in adults), cholestasis (more common in childern), and gallbladder sludge/stones

Question 15

How is risk of hypoglycemia in PN patients reducted

Answer 15

To reduce risk of hypoglycemia, 1-2 hour taper down of the infusion or half the infusion rate may be necessary

Question 16

What are some clinical manifestations of a EFAD?

Answer 16

Alopecia, hepatomegaly, thrombocytopenia, fatty liver, and anemia

Question 17

What kind of insulin should be added to PN

Answer 17

Regular insulin

Question 18

What insulin regimen is common in adding insulin to PN

Answer 18

In initial insulin regimen of 0.05-0.1 units per gram of dextrose in the PN is common, or 0.15 to 0.2 units per gram of dextrose may be used in patients who are already hyperglycemic

Question 19

Can ILE be given to a patient with pancreatitis?

Answer 19

ILE is considered safe for use in patients with pancreatitis without hypertriglyceridemia

Question 20

What is the primary factor that causes steatosis?

Answer 20

excessive energy intake

Question 21

In patients with hepatobiliary disease, which trace elements should clinicians consider reducing/removing?

Answer 21

manganese and copper

Question 22

What are some stratagies to manage PN related hepatobiliary complications?

Answer 22

Rule out non PN etiologies (hepatoxic meds), consider PN modifications (decreasing dex or ILE, cyclic infusion), maximize enteral intake, prevent/treat bacterial overgrowth, prescribe meds (ursodiol, cholestyramine)

Question 23

What is a prominent manifestation of a magnesium deficiency?

Answer 23

Hypocalcemia should be related with magnesium supplementation b/c it is often refractory to calcium therapy alone. Magnesium deficiency can also lead to hypophosphatemia b/c of increased phos excretion

Question 24

What is the prime indicator for diagnosing cholestasis?

Answer 24

An elevated serum conjugated bili (greater then 2 mg/dL is considered the prime indicator for cholestasis

Question 25

Aside from PN, what are some other risk factors for developing cholestasis?

Answer 25

include bacterial/fungal infections, sepsis, SIBO, massive intestinal resection and small bowel remnant < 50 cm have been associated w/ chronic cholestasis

Question 26

What should be given to all adult patients receiving PN?

Answer 26

A standard daily dose of PN MVI

Question 27

Chronic metabolic acidosis is associated with what?

Answer 27

Hypercalciuria and metabolic bone disease Excess chloride, diarrhea and acute renal failure are also common causes of metabolic acidosis.

Question 28

A long-term PN patient presents with involuntary movements, tremor, and rigidity. What etiology may explain these symptoms?

Answer 28

Manganese toxicity

Question 29

Catheter related thrombosis caused by fibrin build up within blood vessels adhering to a central venous catheter is called

Answer 29

Mural thrombus

Question 30

The best approach to prevent PN-induced cholelithiasis is what?

Answer 30

Early initiation of oral or enteral feeding, even in small amounts, to stimulate cholecystokinin secretion, bowel motility and gallbladder emptying. Injections of CCK-OP to induce gall bladder contractions and reduce biliary sludge have yielded mixed results and caused gastrointestinal intolerance in some patients

Question 31

What is most likely responsible for elevated serum bicarbonate levels in a home parenteral nutrition (PN) patient?

Answer 31

Excess acetate salts in the PN An elevated serum bicarbonate level is one of the markers of metabolic alkalosis. Metabolic alkalosis may be caused by nasogastric suctioning, volume depletion and diuretic use. In a PN patient, excess use of acetate, which is metabolized to bicarbonate, may precipitate a metabolic alkalosis.

Question 32

What feature of a Groshong® Central Venous Catheter reduces the risk of catheter occlusion?

Answer 32

Pressure sensitive three-way valve

Question 33

What is the only FDA-approved thrombolytic agent for CVAD occlusions?

Answer 33

Cathflow (Alteplase)

Question 34

The most common route of infection for a tunneled central venous access device (CVAD) is what?

Answer 34

Contamination of the catheter hub

Question 35

The most common route of infection for a nontunneled CVAD is what?

Answer 35

Extraluminal colonization of the catheter or intraluminal colonization of the hub and lumen of the CVAD.

Question 36

What is pinch off syndrome?

Answer 36

Pinch-off syndrome occurs when the catheter is being compressed between the first rib and the clavicle, causing intermittent compression and pinching. This can lead to intermittent occlusion of infusion and aspiration and an increased risk of catheer fracture. Changes in the patient’s position can widen or narrow the angle between the rib and clavicle, usually by raising or lowering the arm, which can relieve occlusion of the catheter

Question 37

How is superior vena cava syndrome characterized?

Answer 37

Superior vena cava syndrome is characterized by shortness of breath, dyspnea, cough, cyanosis of face, neck, shoulder and arms, and distended chest or neck veins.

Question 38

Rapid intravenous infusion of potassium phosphate may result in what

Answer 38

thrombophlebitis; Infusion rates of phosphate should not exceed 7 mmol/h because faster infusion rates can often cause thrombophlebitis (ie, potassium phosphate) and metastatic calcium-phosphate deposition with potential resultant organ dysfunction.

Question 39

In a patient with hepatobiliary disease, which trace elements should be withheld or requires a dosage reduction when prescribing parenteral nutrition?

Answer 39

Copper and manganese

Question 40

When compared to the Dietary Reference Intakes (DRIs) for fat- soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are _____

Answer 40

Equal

Question 41

When compared to the Dietary Reference Intakes (DRIs) for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are ____

Answer 41

Higher

Question 42

According to United States Pharmacopeia (USP) Chapter 797, a PN solution prepared from 8.5% amino acid solution with electrolytes and 70% dextrose, with multivitamins, trace elements, and famotidine added would be classified as ____ risk

Answer 42

Medium

Question 43

How does creaming of a TNA appear?

Answer 43

a translucent band at the surface of the emulsion separate from the remaining TNA dispersion. In general, light creaming is a common occurrence and not a significant determinant of infusion safety except in extreme cases.

Question 44

Rapid intravenous infusion of sodium or potassium phosphate may result in what?

Answer 44

Tetany; Rapid infusion of phosphate can result in tetany due to an abrupt decrease in serum calcium concentration.