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Therapeutics > Exam 3 lecture 2 > Flashcards

Exam 3 lecture 2 Flashcards

1
Q

General protein intake guidelines based on type of pt

A

Maintenance of normal person- 0.8-1
Mild-moderate stress (floor hospial)- 1-1.5
Moderate to severe stress (ICU, trauma, surgery, burn- 1.5-2
obesity (BMI>30)- 2 gm/kg/day (ideal body weight)
Severe obesity (BMI>40)- 2.5 gm/kg/day (ideal body weight)

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2
Q

What is NPC? WHat is a good distribution of NPC that we should know for exam? What would 100/0 split mean?

A

Non protein calories. Adequate calories must be present for protein utilization.
NPC distribution should be 70/30
-70-85% dextrose
-15-30% fat

100% of calories come from dextrose and none are from fat

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3
Q

Which is more complicated, PN or EN? Define PN. WHat are other names for PN

A

PN is more complicated

PN is the process of supplying nutrients via an IV delivery system (protein, fats, carbs, electrolytes, vitamins, minerals) also known as TPN, PN, TNA, 3- in- 1

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4
Q

What are PN indications? (EXAM)

A

If patient is
-anticipated prolonged NPO course (>7 days)
-inability to absorb nutrients via gut secondary to
a) small bowel or colon ileus
b) Extensive small bowel resection
c) Malabsorptive states
d) Intractable vomiting/diarrhea
-enterocutaneous fistulas
-inflammatory bowel disease
- hyperemesis gravidum
-bone marrow transplant (mucositis)

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5
Q

what are the ROA of PN

A
  1. Peripheral
  2. Central
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6
Q

How well tolerated in peripheral PN? What is the number for total osmolarity to remember when doing peripheral PN? Concentration of dextrose in PN when giving peripherally?

A
  • not well tolerated via peripheral vein
  • restrict final dextrose concentration to 5-10% or total osmolarity to <900 mOsm/L
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7
Q

What are some limitations of peripheral PN?

A

requires large volumes of fluid (may not be the best choice for HF or AKI/CKD patients)
Limited in calories (secondary to osmolarity and fluid limitations)
Short term access (<7-10 days)
ALWAYS double check to confirm peripheral route was intentional

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8
Q

What are some advantageas and disadvantages of central PN

A

Advantage
- allows administration of hypertonic solutions
- more calories can be delivered

disadvantages
- risk of infection (appropriate central line care is key)
- central line is not a benign procedure
-pneumothorax
-air embolus
- thrombus

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9
Q

What are the three main central venous access points

A
  • subclavian (under clavicle)
    -internal jugular (neck)
    -femoral (groin)

sub clavian or IJ used for TPN, not femoral

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10
Q

What are some long term venous access for central venous access

A

-PICC (peripherally inserted central catherer)
- Tunneled
Implanted port

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11
Q

WHat are the types of catheters? WHat is used in TPN

A
  • single lumen
    -double lumen
    -triple lumen

Triple lumen used in TPN

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12
Q

How many calories in one gram of protein

A

4 kcal

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13
Q

One gram of dextrose is how many kcals? What is the maximum carbohydrate utilization?

A

3.4

4-5 mg/kg/min is max

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14
Q

How many kcal for 1 gram of lipid? WHat is the use of giving fat in TPN

A

10 kcal

prevents essential fatty acid deficiency

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15
Q

What are some IV fat emulsions

A

Intralipid 10%- older product, has egg yolk (no egg allergy patients

SMOF lipid (soybean, medium chain triglycerides, olive oil, fish oil) People with fish allergy can not take this

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16
Q

compare SMOF lipid to pure soybean oil product (intralipid)

A
  • improved LFT, lower TG levels from baseline

less pro inflammatory
less negative side effects

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17
Q

Maximum intake of fat?

A

60% of caloric intake maximum for fat

max of 2.5 gm/kg/day of lipids

Propofol also has fat in it so remember to subtract this from the fat requirements

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18
Q

What are the different rules for IV fat emulsion administration

A

If IV fat emulsion is given alone- it should be 10 or 20% solution

30% if given in a 3 in 1

May be infused via peripheral vein, piggy backed or put into a dextrose amino acid solution to create a 3 in 1

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19
Q

What are some considerations to take to avoid infetious complications when giving IV fat

A

IV lipids provide a suitable environment for pathogen growth

hang time of IV fat emulsion should be limited to 12 hours after opening package
If added as TNA (3 in 1), safety is increased to 24 hrs

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20
Q

Administration of PN summary

A
  1. Total nutrient admixture ( custom TPN)
    - dextrose, AA and lipids in one bag
    - 3 in 1 TPN
  2. Conventional administration (custom tpn
    - dextrose and AA in one bag
    - lipids 2-3 times a week as a separate IVPB
  3. premix solutiojn for injection (standard tpn)
    has no lipids
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21
Q

What is the use of an In-line filters? What sizes should we use?

A

Reduces infusion of particulates and microorganisms

filter size- 1.2 micron filter can be used for all TNAs or 3 in 1 (w/lipids)

0.22 micron size only used in 2 in 1 formulations (no lipids)

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22
Q

What is the name of premix PN solutions for standard TPN

A

clinimix/clinimix-E (e is for electrolyte)

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23
Q

How do we decide whether we are gonna use Clinimix or clinimix E (whether we use electrolytes or not)

A

if Crcl<50- no electrolytes0 only use clinimix

If Crcl > 50- use clinimix E

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24
Q

PN initiation and discontinuation guidelines? How often to check BS? What to do for high BS?

A

Start at 25% of goal and achieve final rate within 24 hours (watch blood sugar)

check BS every 4-6 hours and before each increase in rate

If BG> 200, continue at same rate x 4 hours and recheck
If repeat BG > 200, consider insulin therapy

cessation- Decrease rate by half q 2 hrs until rate < 50 ml/hr, then dx

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25
What is the max rate for cycling PN
200 ml/hr
26
What are some elctrolyte considerations when adding electrolytes
In patients with renal disease- caution should be used with Potassium, phosphate and magnesium Acid-base balance obtained through balance of acetate and chloride Avoid calcium + Phosphorous precipitation (axoid ca x phos)> 150
27
What are considerations to take when giving vitamins parenterally
1) Adult & Pediatric (>40kg) -10 ml/day of injectable adult multivitamin-12 contains small amount of vitamin K (be careful with warfarin) 2) Pediatric - 2 ml/day of injectable multivitamin 40 kg is cut off (rememebr for exam)
28
When should we adjust trace elements
In liver dysfunction- (chronic liver disease or LFTs >2x ULN)- discountinue trace elements. Supplement Zinc and selenium individually In renal disease (CKD, ESRD)- consider checking serum levels if use expected beyond 14 days Use selenium and chromium with caution
29
Is Iron added to PN
NOOO, Fat will not get absorbed. Also has infectious complications. Always use a separate line
30
Can we add medications to PN
For the most part, addition of medications to PN is not advised. Famotidine may be utilized for GERD or stress ulcer prophylaxis Never use pantoprazole (no PPI) with PN Regular insulin only can be added to the bag (not for acute patients)
31
When is a time we give IV insulin
Hyperkalemia
32
When should we use NBW
if wt>130% IBW
33
How many fluid to use in an adult patient
30-40 ml/kg/day
34
How many grams of protein for ICU/surgery patients
1.5-2 gm/kg/day
35
How to calculate the number of mEQ of sodium in parenteral nutrition
Aim for 1/s NS to start. WHich is equal to 1 L = 77 mEq/L example 2.4 L 1 L= 77 MEQ 2.4=? criss cross
36
How to give potassium to PN patient
0.5-1 mEq/kg to start - upto 2 mEq/kg may need to reduce in renal failure
37
How to give calcium with PN
10-20 mEq/day on average start at 10 mEq/day if calcium is normal
38
How to give magnesium in PN patients
start at 8 mEq/day if normal level
39
How to add Phosphorous into PN
0.3 MMol/kg caution in renal failure 1Mmol Kphos = 1.4 mEq Kphos (REMEBER THIS)
40
Things to take into consideration when supplementing Cl in PN
50-100 mEQ/day Acid in PN (must balance against base) (acetate is the base) 2/3 chloride (acid and 1/3 base (acetate) (remember this for exm)
41
What are the positive cations and negatives? Which two are already balanced that we do not include?
Positive- sodium, potassium Negatives- Chloride, acetate, phos Magnesium and calcium are already balanced KNOW HOW TO BALANCE FOR EXAM example- If we give sodium and potassium, we add them up, which gives us our Positives. For this example lets say it is 225 We also calculate the amount of phos given (remember to convert to mEq by multiplying by 1.4. for this example lets say it is 31 mEq 225-31=194 That means we have 194 left to balance. 2/3 should be chloride, 1/3 should be acetate 128 cl 66 mEq
42
Amount of MV to give patients above 40 kg? Amount of multi trace elements to give patients with no renal/liver failure
MVI- 10 ml MTW- 1 ml
43
complications of PN
1)mechanical complications- clotting of the line Displacement 2)Infectious - catheter related sepsis - solution contamination - bacterial translocation
44
What is bacterial translocation? Complications that this could cause?)
Time dependent passage of bacteria or endotoxins from GI tract to extra-intestinal sites Enteric organsims cause systemic infections (pneumonia, central line infection, Abscess, Multi-organ dysfunction syndrome)
45
What are some metabolic complications of PN
Hyper or Hypo glycemia (important) electrolyte and fluid imbalance liver fumction abnormalities
46
Baseline monitoring for PN
- CMP, Mg, Phos, Ca - hepetic function - pre albumin/ CRP - PT/INR Q 4-6 H - finger sticks for glucose
47
What are things to monitor daily for PN? Twice weekly? Weekly?
Daily- Vital signs, I/O, CMP (electrolytes, glucose, BUN/SCr), feeding tube placement, Twice weekly- Weight, CBC, Mg, phos, Ca (prealbumin/CRP) in ICU setting increase to daily Weekly- Triglycerides, Respiratory quocient (RQ)/indirect calorimetry
48
additional complications of PN
Refeeding syndrome and essential fatty acid deficiency
49
What is refeediing syndrome
Potentially life threatening condition that occurs within first few days of feeding starved patient. constellation of fluid, electrolyte vitamin deficiency
50
What are the three most common electrolyte disturbances we see with refeeding syndorme
Hypophosphatemia, hypomagnesemia, hypokalemia
51
risk factors for refeeding
Rapid feeding, low BMI excessive weight loss Insufficient calorie intake low levels of K, Phos or mag prior to feeding loww of SQ fat or muscle mass High risk comorbidities- alcoholism, anorexia, nervosa, marasmus
52
Prevention of refeeding syndrome
Replete electrolytes before initiating feeds Limit carbs to 100-150 gm limit fluids to 800 ml/day Provide 50% of caloric needs on first day advance caloric needs by 20-33% of goal every 1-2 days Give Thiamine 100 mg daily x 5-7 days
53
What percent of daily calories are essential fatty acids
4-10%
54
Mechanism of how EFAD happens? clinical onset? symptoms?
EFAD- essential fatty acid deficiency Mechanism- continous infusion of hypertonic dextrose will increase circulating insulin levels Inhibits lipolysis and fatty acid mobilization onset- 10-14 days on fat free PN regimen sx- dry scaly skin, brittle hair
55
How to prevent EFAD
recommended minimum to avoid EFAD is 4% caloric intake be lipids Provide atleast 500 ml of 10% fat emulsion over 3-5 hours twice weekly OR Provide atleast 350 ml of 20% fat emulsion over 5-9 hrs twice weekly
56
Are most patients gonna be on EN or PN
EN (if the gut works, use it)
57
When do we use EN
If the gut works, use it Oral consumption inadequate Oral consumption contraindicated - esophageal obstruction -Head and neck injury -dysphagia - Trauma - Cerebrovascular accident 0 dementia
58
advantages to EN
Provides GI stimulation - decreased chance for bacterial translocation (EXAM) Avoids risk associated with IVs (line infections, pneumothorax) more physiological than PN less expensive
59
Contraindications to EN (indications for PN)
certain types of fistulas intractable vomiting non mechanical onstruction- ileus mechanical obstruction (hernia, tumor) severe malabsorption severe GI hemorrhage
60
ROA of EN
G= (ends in stomach=gastric) J= ends in jejunum (past stomach) o= oral N == sasal NG- nasogastric OG- orogastric NJ- Nasojejunal OJ- orojejunal Gastrostomy (PEG tube), placed surgically jejunostomy- PEJ
61
How to determine ROA of EN
Risk of aspiration if low risk- May utilize gastric If high risk- jejunal preferred Tolerance Vomiting- Use jejunal Gastric residuals- use jejunal Duration of therapy Long term- COnsider PEG or PEJ
62

Therapeutics (38 decks)

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