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Question 1

14. Which of the following is a conditionally essential amino acid?
    a. Phenylalanine
    b. Threonine
    c. Tyrosine
    d. Tryptophan

Answer 1

Answer: c. Tyrosine

Phenylalanine, threonine, and tryptophan are all essential amino acids.

Tyrosine is made from phenylalanine and is conditionally-essential in its absence.

Question 2

13. Which SCFA (short-chain fatty acids) has the most significant impact on colonic
    a. Acetate
    b. Butyrate
    c. Glutamate
    d. Propionate

Answer 2

Butyrate is the most important SCFA in regulation and maintenance of colonic tissue. Addition of butyrate has been shown to prevent PN-associated mucosal atrophy and improve epithelial surface proliferation.

Butyrate is a short-chain fatty acids (SCFAs) produced by the fermentation of dietary fiber in the colon.

Other SCFAs include acetate and propionate, but butyrate is the most important for colon health.

Butyrate enemas are sometimes used in inflammatory bowel disease (not common, but might appear in clinical references)

Question 3

In which population are use of immune-modulating enteral formulas recommended?
a. Postoperative surgical patients
b. Severe trauma
c. Medical ICU patients
d. ARDS and ALI (acute liver injury)

Answer 3

Answer: a. Postoperative surgical patients

Immune-modulating formulas are recommended for routine use in the surgical ICU postoperative patients requiring EN.

They should not be routinely used in the medical ICU and no current recommendations exist to support use in ARDS or severe trauma and TBI.

Question 4

What is the max recommended amount of lipid in IV lipid emulsion in PN?
a. 1.0 g/kg/day
b. 1.5 g/kg/day
c. 2.0 g/kg/day
d. 2.5 g/kg/day

Answer 4

Answer: d. 2.5 g/kg/day
Some data supports providing < 1.0 g/kg/day lipids in critically ill patients, but the max recommended IVLE in PN is 2.5 g/kg/day.

Question 5

Which amino acid is the primary fuel for intestinal cells?
a. Arginine
b. Cysteine
c. Glutamine
d. Homocysteine

Answer 5

C glutamine

Question 6

2. Within how many hours of abdominal surgery can early EN initiation be tolerated?
   a. 4
   b. 6
   c. 12
   d. 24

Answer 6

6 hours

Full return of small bowel function should be achieved within 24 hours and return of function for stomach and large intestine can range 48-72 hours.
However, ASPEN recommends early EN within 6 hours to stimulate the bowel and prevent mucosal atrophy.

Question 7

Which electrolyte is critical to glucose and vitamin transport?
a. Sodium
b. Phosphorus
c. Magnesium
d. Calcium

Answer 7

Sodium

Glucose and water-soluble vitamins require Na transporters for absorption.
Sodium-dependent glucose transporters are involved in the active ATP-dependent absorption of glucose from the intestinal lumen.

Question 8

What is the minimum amount of carbohydrates needed to prevent ketosis

Answer 8

50 grams

Question 9

29. A patient with a J-tube requires a non-formulary product available in resealable 8 oz bottles that must be transferred to a feeding bag for infusion. What is the maximum safe duration for the feeding to hang?
    a. No more than 4 hours
    b. 4- 8 hours
    c. 8 - 12 hours
    d. 24 hour

Answer 9

Answer: b. 4-8 hours
This is an open system = 8 hrs

Human breast milk and reconstituted formula have a max hang time of 4 hours.

Open system EN has a max hang time of 8 hours.

Closed system EN has a max hang time of 24-48 hours.

Question 10

30. In critically ill patients receiving enteral nutrition, what situation is most frequently linked with the use of semi-elemental feeds?
    a. Inefficacy of standard TF formula
    b. Impaired digestion and absorption
    c. Need for immune-enhancing formulas
    d. Management of hyperkalemia and hyperphosphatemia in CKD patients

Answer 10

B impaired digestion and absorption

Question 11

31. Which of the following strongly indicates the need for parenteral nutrition (PN)?
    a. High output fistula
    b. Crohn’s disease
    c. Pancreatitis
    d. Hyperemesis gravidarum

Answer 11

Answer: a. High output fistula

EN is safe and recommended as preferred line of therapy for Crohn’s pancreatitis, and hyperemesis patients requiring nutrition support.

PN is appropriate following failed EN trials in these patient populations.

EN may be appropriate in low output fistulas, but high output fistulas require bowel rest and PN to allow healing.

Question 12

Which of the following interventions is NOT appropriate for PN-associated cholestasis?
a. Remove copper and manganese
b. Decrease total nonprotein kcal
c. Decrease only lipid kcal in TPN
d. Initiate trophic EN as able

Answer 12

Answer: c. Decrease only lipid kcal in TPN

The most effective treatment for PN-associated cholestasis is initiation of EN support as able to stimulate CCK. Removal of copper and manganese may be indicated in impaired hepatic function, as these trace elements rely on the hepatobiliary system for elimination. It is recommended to avoid overfeeding of total kcal from all macros, not just lipid.

Question 13

36. In which of the following situations is a UUN measurement useful for assessing protein provision?
    a. High output fistulas
    b. SLEDD patient
    c. Polytrauma with frequent trips to the OR
    d. TBI patient unable to maintain weight

Answer 13

Answer: d. TBI patient unable to maintain weight

Accuracy of UUN measurement is affected by renal dysfunction, errors estimating intake, and incomplete urine, stool, fistula, or ostomy collection.

Fistulas, wounds, and dialysis all contribute to excess protein losses and are often difficult to estimate.

Question 14

Following a trauma patient in the surgical ICU who was initially started on standard high-protein formula due to increased needs, the patient develops AKI with hyperkalemia (K+ 5.9). Given Kayexalate, calcium gluconate, and D50 with insulin, what intervention would be appropriate?
a. Hold TF until patient starts dialysis
b. Continue high protein formula and observe for initiation of dialysis
c. Change to semi-elemental formula
d. Change to renal formula

Answer 14

Answer: d. Change to renal formula

TF may need to be held until K+ declines, but may not necessarily require dialysis. Semi-elemental formula may be slightly lower in K+ content but is not appropriate in absence of other clinical indications. Appropriate intervention would be changed to renal formula to manage and prevent further hyperkalemia.

Question 15

For adult critically ill patients, considering the provision of supplemental PN versus no supplemental PN during the first week of critical illness, which recommendation provides a high evidence grade according to the 2022 Critical Care Guidelines?
a. Range 12-25 kcal/kg for 1st 7-10 days ICU stay
b. Either mixed oil ILE or 100% soybean oil ILE can be provided for appropriate PN candidates,
c. Similar caloric intake as primary feeding modality in the first week of critical illness is acceptable
d. Do not initiate prior to day 7 of ICU stay.

Answer 15

Answer: d. Do not initiate prior to day 7 of ICU stay
All of the above are recommended in the 2022 Critical Care Guidelines, but only
d) initiation not before ICU day #7 is high-grade evidence.

Question 16

39. In the context of obesity in critical illness, what is a recommended approach for the initiation of enteral nutrition?
    a. Use standard polymeric formula and advance as fluid volume resuscitation is completed (24-48 hrs of admission)
    b. Provide trophic EN in the initial phase, advance as tolerated after 24-48 hrs to > 80% target energy goal
    c. Use weight-based energy and protein guidelines, as BMI-based recommendations remain controversial
    d. Implement high-protein, hypocaloric feedings to preserve lean body mass and mobilize adipose stores

Answer 16

mass and mobilize adipose stores
Answer: d. Implement high-protein, hypocaloric feedings to preserve lean body Both options a & b are appropriate recommendations based on current critical care guidelines; however, the recommendation for high-protein, hypocaloric feedings are specifically indicated in obese patients.

Question 17

PN safety USP chapter 797

Answer 17

• USP (United States Pharmacopeia) Chapter {797) safety guidelines:
• PN is moderate risk, refrigerate up to 9 days, temp -4C

Question 18

ASPEN PN Safety Consensus Recommendations for labeling:

Answer 18

• Macronutrient content should be listed in grams per 24-hr nutrient infusion to avoid misinterpretation

• Electrolytes ordered as complete salt form rather than individual ion

• Full generic name for each ingredient (unless brand name can identify unique properties of specific dosage form)

Question 19

PN Label needs to have;

Answer 19

Patient identifiers & date of birth

Indication(s) for PN

Height & dosing weight in metric
units

Allergies

Diagnosis/diagnoses

Administration route/vascular access device

Contact information for prescriber

Date & time order submitted

Administration date
& time

Volume, infusion rate, continuous vs cyclic

Type of formulation
(3-in-1 or 2-in-1)

Question 20

PN Access Devices - ideal vessel?

Answer 20

• PN requires a dedicated catheter lumen

• The SVC (superior vena cava) is ~7cm long and 20-30mm in diameter with estimated blood flow 2000mL/min, making it the preferred vessel for central access for rapid dilution of PN solutions that are hypertonic with > 900 mOsm/L

Question 21

Catheter measurement:

Answer 21

• French size is a measure of the outer diameter (1mm = 3Fr).

• Gauge is a unit of measure that is inversely proportional to the catheters outer diameter

An increasing gauge size implies a decreasing diameter (16G has > diameter than 24G catheter)

Question 22

Groshong CVC

Answer 22

have a 3-way slit valve that eliminates the need for daily heparinized flushes and catheter clamping before discontinuation at the catheter hub

Question 23

Catheters are most often made of

Answer 23

polyurethane or silicone

Silicone devices are soft and cause less damage to the vessel intima but are prone to fibrin sleeve formation due to serum protein adsorbing to
surface

Question 24

Central access must have tip in

Answer 24

distal SVC, IVC or R atrium

Question 25

Femoral access most prone to

Answer 25

infection - use discouraged

Question 26

Peripheral venous access (sheath over needles)

Answer 26

PPN must have final concentration not exceeding 10% dextrose or 900 mOsm/L • Peripheral devices reserved for when fluid restriction not needed • Most common complication is peripheral venous thrombophlebitis • CDC guidelines recommend close monitoring of peripheral access, with the line removed no more frequently than every 72-96 hours unless clinically indicated Midline catheters have tip no further than the axillary vein and have lower phlebitis rates than standard short peripheral catheters and lower rates of infection than CVADs • Can remain in for 2-6 weeks • Safe for PPN formulations only

Question 27

Central Venous Access Devices and renal patients

Answer 27

• Repeated use of SCV (subclavien vein) is associated with risk of stenosis which is problematic for renal patients who require AV fistulas or shunts for hemodialysis • Nephrologists should be consulted before PICC insertion Right internal jugular is the most direct approach to SVC for patients with CKD who may require dialysis

Question 28

Peripherally Inserted Central Catheter (PICC) Possible complications:

Answer 28

Luminal occlusions Malpositioning and dislodgement Superficial thrombophlebitis Infection of insertion site Venous thromboembolism CRBSI/sepsis Use with caution in patients with cancer or who are critically ill

Question 29

Tunneled Central Catheters

Answer 29

Safe and effective for therapies ranging from months to years

Question 30

Benefit of ports and cancer patients

Answer 30

• Implanted ports have the lowest rates of CRBSI in cancer patients

Question 31

Catheter insertion care bundle

Answer 31

Requires the application of care bundle guidelines, hand hygiene, skin antisepsis using 0.5% chlorhexidine in alcohol solution, max sterile barrier precautions, and selection of appropriate venous access

Question 32

Care of the catheter exit site and hub play a pivotal role in decreasing the risk for CRBSI and recommend ____ on skin for prep

Answer 32

CDC guidelines recommend skin prep with >0.5% CHG preparation containing alcohol

Question 33

Catheter flushing should be

Answer 33

Flushing volume should be twice the volume of the catheter

Question 34

°Antiseptic lock solutions

Answer 34

include ethanol, taurolidine, citrate, 26% sodium chloride and EDTA Note: CVADs made of polyurethane material have ruptured and split with ethanol locks, more safe for use with silicone catheters

Question 35

____ is the most frequent cause of intraluminal contamination in long term use of VADs

Answer 35

Hub contamination

Question 36

Infection commonly seen for VAD

Answer 36

Gram postive, coagulase staphylococcus is the most prominent pathogen associated with infections from biomedical devices

Question 37

When to 100% remove catheter

Answer 37

Removal of the catheter is recommended for documented fungal infections and Staph. aureus

Question 38

What is common infection for long term PN patients

Answer 38

Coagulase negative staphylococci occur in ~60% of CVC infections in long term PN patients

Question 39

Common infection with SBS patients

Answer 39

Recurrent gram-negative infections of central lines observed with SBS patients

Question 40

Malassezia furfur

Answer 40

- type of yeast (fungus) that lives on skin rich in oil (scalp, face, chest, back) superficial fungal infections of the skin and associated structures Can cause systemic infections for immuncompromised pts or on TPN with ILE - ILE presumably provides growth factors required for replication of the organism • Appropriate treatment: administration of antifungal therapy, discontinuation of IVFE, and removal of the intravascular catheter, especially with non-tunneled catheter infections

Question 41

Central Line Bundles and Other Risk Reduction Strategies

Answer 41

• Includes: hand hygiene, maximum barrier precautions, chlorhexidine skin antisepsis, optimal catheter site selection, daily review of line necessity

Question 42

70% ethanol locks and CRBSI prevention

Answer 42

• Use of 70% ethanol-impregnated caps (lock) has been found to reduce the incidence of CRBSIs by >40%, decrease LOS, and lower hospital costs

Question 43

Should you use abx ointment for a CVA device?

Answer 43

No CDC recommends against use of antibiotic ointment on central venous access

Question 44

Noninfectious Venous Access Device Complications

Answer 44

Air embolism Pulmonary embolism Catheter migration Cardiac tamponade Nerve injury

Question 45

Catheter pinch-off syndrome:

Answer 45

related to postural changes caused by catheter compression between the catheter and first rib " Changing the patient's position, by raising the ipsilateral arm, relieves the occlusion * Can lead to catheter transection and embolus so catheter removal is recommended

Question 46

Pneumothorax related to cvad placement is considered a

Answer 46

Pneumothorax as a result of inappropriate placement is a sentinel

Question 47

Thrombophlebitis

Answer 47

- swelling or inflammation of vein, often caused by blood clot (thrombus) forming inside of it • Presents with swelling and redness at access site

Question 48

Device Occlusion

Answer 48

- most common noninfectious catheter-related complication Occurs in up to 50% of CVCs (central venous catheters) • Presents as inability to flush or pull back on line

Question 49

Thrombotic occlusion -

Answer 49

primary source of catheter dysfunction and usually due to vessel wall damage, blood flow changes, and systemic alteration in coagulation

Question 50

Thrombus occlusion risk factors

Answer 50

As catheter size increases, venous blood flow decreases. MAGIC expert panel recommends 1:3 catheter to vein ratio to reduce the risk for catheter-related DVT • Risk factors for thrombus formation: catheter tip position, catheter material, type of infusate, length of catheter duration • 3 baseline factors with 1 risk: multiple insertion attempts, ovarian cancer, previous CVC

Question 51

Mural thrombus

Answer 51

Develops when fibrin build up inside the vein causes the vascular access device to adhere to the vessel wall Mural: wall-> think fibrin inside the vein is sticking to the WALL

Question 52

Fibrin sheath

Answer 52

Layer of fibrin that develops around the outside of a central venous catheter (CVC) secondary to aggregation of fibrin from the presence of a central venous catheter within a vein

Question 53

Fibrin tail or flap

Answer 53

Fibrin build up on the CVC tip that will allow for infusion through the CVC, but will inhibit withdrawal of blood Think tail/flap= the TIP

Question 54

Intraluminal thrombus

Answer 54

Clot within the catheter lumen and is caused by inadequate flushing and blood reflux Luminal=inside lumen Luminal=liquid=lack of liquid in lumen= luminal thrombus

Question 55

Concern with SVC thrombosis

Answer 55

SVC (superior vena cava) thrombosis can result in permanent vascular obstruction/loss of future access Blood clot that forms inside the superior vena cava

Question 56

Treatment for intraluminal clot and fibrin sheath formation:

Answer 56

thrombolytics (streptokinase, urokinase, alteplase) • Alteplase (TPA) dwells 30 min to 4 hours before aspiration attempted - dose may be repeated • If doesn't clear following 2 trials of TPA, replace line

Question 57

How much K in 1 mmol of KPhos

Answer 57

1 mmol IV K+Phos = 1.47 mEq K

Question 58

How much Na in 1 mmol NaPhos

Answer 58

1 mmol IV Na Phos = 1.33 mEq Na

Question 59

Correction of hyponatremia

Answer 59

Rate of Correction: Avoid rapid correction of sodium to prevent osmotic demyelination syndrome; generally, increase serum sodium by no more than 8-10 mEq/L in 24 hours.

Question 60

Serum osmolality lab in hyponatremia

Answer 60

All will have low serum osmolality except Isotonic = normal Hypertonic = high

Question 61

Urine osmolality in hyponatremia

Answer 61

All will have high urine osmolality Except Isotonic and hypertonic = variable

Question 62

Hypervolemia hyponatremia labs

Answer 62

Fluid OVERLOAD • Serum Osmolality: Low (<275 mOsm/kg) • Urine Osmolality: >100 mOsm/kg • Urine Sodium: • <20 mEq/L: Common in heart failure, cirrhosis • >20 mEq/L: Seen in renal failure

Question 63

Euvolemic hyponatrmia lab findings

Answer 63

Serum Osmolality: Low (<275 mOsm/kg) • Urine Osmolality: >100 mOsm/kg (inappropriately concentrated) • Urine Sodium: >30 mEq/L

Question 64

Isotonic and hypertonic hyponatremia lab findings

Answer 64

Isotonic Hyponatremia (Pseudohyponatremia) • Serum Osmolality: Normal (280–295 mOsm/kg) • Urine Osmolality: Variable • Urine Sodium: Variable • Serum Lipids/Proteins: Elevated (e.g., hyperlipidemia, hyperproteinemia) 5. Hypertonic Hyponatremia • Serum Osmolality: High (>295 mOsm/kg) • Urine Osmolality: Variable • Urine Sodium: Variable • Serum Glucose: Elevated (e.g., in hyperglycemia)

Question 65

sARCF questionaire assesses

Answer 65

sarcopenia

Question 66

what tests can measure muscle mass

Answer 66

CT - but exposes to raditioan dual energy x-ray - DEXA scan BIA - bioimpedence anaylsis

Question 67

healthy older adult calorie and protein needs

Answer 67

25-30 kcal/kg values ranging from 18-40 kcal/kg have been suggested depending on weight and clinical status MSJ to measure BMR - then multiplied by stress/activity factor 1.0-1.2 kcal/kg for healthy // 1.2-1.5 g/kg for acute/chronic illnesses // critical illness is 2 g/kg fiber: 25-35 g/day (DRI is 30g for men, 21 g for women)

Question 68

Fluid in the healthy older adult

Answer 68

adjusted holiday sugar: 1500 mL for the first 20 kg of actual weight + 15 mL per kg thereafter 30 mL/kg (greater than or equal to 1500 mL/d) 1 mL/kg (greater than or equal to 1500 mL/d) *MINIMAL fluid intake set for older adults= 1500 mL/d ESRD: may be as low as 1000 mL, CHF: usually <30 mL/kg higher for wounds: ~35 mL/kg

Question 70

Catheter gauge

Answer 70

Gauge (G) refers to the diameter of the NEEDLE used for insertion (larger number gauge = smaller diameter) Think gauge = opposite The bigger the gauge= the smaller the needle Ex: 22G needle is thinner than an 18G needle The higher the number, the skinnier it is

Question 71

Catheter French size

Answer 71

French (Fr) scale is used for catheter diameter (larger number = larger diameter): • 1 Fr = 0.33 mm in diameter. Common PN catheters range from 4 Fr to 9 Fr depending on age, access site, and purpose. Neonates: 3-5 French Pediatrics/small adults: 5-7 French Adults/central PN: 7-9 French Multilumen access/HD Cath: >/=9 French Think- the bigger the number the bigger the size A 10fr catheter is bigger than a 5fr catheter It is based on circumference

Question 72

Symptoms (SVC syndrome):

Answer 72

• Swelling of face, neck, and upper limbs • Distended neck and chest veins • Shortness of breath or cough • Headache, dizziness, or vision changes • Cyanosis (bluish skin) These occur because blood can’t drain properly from the upper body.

Question 73

Calculate final concentration of this PN mixture 500 mL of a 70% dextrose infusion 300 mL of 15% amino acid infusion What is the final % of dextrose and final % of AA?

Answer 73

Step 1: Calculate grams of each solute Dextrose • 70% dextrose = 70 g per 100 mL • 500 mL × (70 g / 100 mL) = 350 g dextrose Amino Acids • 15% AA = 15 g per 100 mL • 300 mL × (15 g / 100 mL) = 45 g amino acids ⸻ Step 2: Add total volume • 500 mL (dextrose) + 300 mL (AA) = 800 mL total ⸻ Step 3: Calculate final concentrations Dextrose concentration • (350 g / 800 mL) × 100 = 43.75% dextrose Amino acid concentration • (45 g / 800 mL) × 100 = 5.625% amino acids ⸻ Final Answer: • Dextrose: 43.75% • Amino acids: 5.63%

Question 74

Potassium can be irritating to peripheral veins. What is the max K concentration for PIV infusions ?

Answer 74

< 60 meq/L or preferably < 40 meq/L <10 meq/hr

Question 75

What is the smallest pore size filter recommended for TNA A

Answer 75

1.2 micron

Question 76

What will increase the ca:phos solubility? A. Use of calcium chloride as chloride salt B. Use of phosphate as sodium salt C. Increased amino acid concentration D. Increased temperature

Answer 76

C. Increased AA

Question 77

How should dextrose be expressed on the PN label

Answer 77

Grams of dextrose per day

Question 78

What is a catheter cuff

Answer 78

Serve as subcutaneous anchors and mechanical barriers Dacron cuffs are most often attached to tunneled catheters They are positioned in the subcutaneous tissue and anchor the catheter

Question 79

Thrombotic occlusions are most commonly treated with A. Thrombolytics (alteplase) B. Anticoagulant (warfarin) C. 0.1N hydrochloric acid D. 5% sodium bicarbonate solution

Answer 79

A. Alteplase /others include streptokinase, urokinase

Question 80

Which is preferred VAD for a patient requiring long term TPN 1. Midclavicular catheter 2. Percutaneous nontunneled catheter then replace with implanted port 3. Single lumen tunneled cuffed catheter 4. Place triple lumen antibiotic coated catheter to ensure adequate access for future needs

Answer 80

3. Single lumen tunneled cuffed catheter Safe and effective for long term access - months to years

Question 81

Steatosis / hepatic fat accumulation is more common in ___

Answer 81

Adult patients than peds Presents with modest elevation in serum aminotransferase within 2 weeks of PN therapy Steatosis -can be complication of Overfeeding

Question 82

PNAC or PN associated cholestasis

Answer 82

Impaired bile secretion or biliary obstruction Primarily seen in children but can occur in adults on long term PN Presents as elevated alk phos, conjugated direct bilirubin , with or without jaundice

Question 83

Gallbladderstasis

Answer 83

During PN can lead to gallstones or gallbladder sludge with subsequent cholecysitits More related to lack of enteral stimulation. Lack of PO/EN leads to decreased CCK. duration of PN therapy usually correlates with development of biliary sludge.

Question 84

Vitamin C

Answer 84

Absorption occurs predominantly in the small intestine - ileum with some in the jejunum • If taking allopurinol, should avoid large intake of vitamin C because of the risk of kidney stones is high • Vitamin C supplementation is contraindicated in those with renal failure. kidney stones, and those receiving heparin or warfarin - Potential interaction: High doses of vitamin C may reduce the effectiveness of warfarin

Question 85

Thiamine

Answer 85

- Necessary for the conversion of pyruvate to acetyl-CoA • Alcohol use is the most common cause of impaired thiamin absorption • Key biochemical functions include energy transformation, synthesis of pentose and reducing NADPH, plays a key role in carb metabolism • Often the first nutrition deficiency noted when food intake is limited or when absorption is impaired due to its short half-life • Magnesium is necessary for the conversion of thiamin therefore supplementation is only effective when Mg is within normal limits • Supplementation is recommended when deficiency is probable, especially in alcohol abuse & PN • Wernicke's-Korsakoff syndrome - develops after Wernicke's encephalopathy, in the absence of thiamin, inhibition of pyruvate dehydrogenase drives carb metabolism towards lactic acid fermentation

Question 86

Riboflavin needed for 2 major coenzymes ___ and ___

Answer 86

Precursor to 2 major coenzymes derivatives; flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) and these participate in electron transport

Question 87

Niacin

Answer 87

Absorbed rapidly in the stomach and intestines Component of NAD and NADP which serve as a hydrogen donor or electron acceptor for more than 200 enzymes involved in metabolism • Pellagra is due to niacin deficiency and is rare as fortification is prevalent; affects the GI tract, skin, and nervous system • Known as the 3D's: dermatitis, diarrhea, and dementia • can be used to treat hyperlipidemia but may cause vasodilation

Question 88

B6 or pyridoxine

Answer 88

(pyridoxine, pyridoxal and pyridoxamine) ° Participates in more than 100 enzymatic reactions such as protein, amino acid and lipid metabolism, gluconeogenesis, and steroid receptor binding

Question 89

Vitamin A needs ___ for transport

Answer 89

• Retinol binding protein is required to transport vitamin A from the liver to the target tissues • Presence of protein-energy malnutrition and or zinc deficiency may compromise circulating serum vitamin A levels • Used to enhance wound healing in individuals with comorbidities such as diabetes, tumors, and radiation *Carotenoids *Liver *Eggs *Fortified milk *def= Night blindness, Hyperkeratosis, risk in fat-malabsorptive disorders *know relationship with zinc= *PCM or zinc deficiency may compromise circulating Vitamin A levels

Question 90

Vitamin D

Answer 90

Principal function is to maintain serum calcium and phosphorous levels, support neuromuscular function and bone calcification • Calcidiol can be used to evaluate vitamin D status, but status is better defined when using PTH & calcium *Status best defined using Calcidiol in combination with PTH & Ca *UV light on skin converts to active form → 25 D3 in liver → kidneys convert to 1,25 dihydroxy active form *affected by calcium status *Sunlight *Fatty fish *Fish liver oils *Fortified milk *Fortified cereals Toxic-*Soft tissue calcification *Hypercalcemia *Hypercalciuria Def= *Bone disease *Osteopenia *Osteomalacia

Question 91

Vitamin E may interfere with

Answer 91

Intake of greater than 1200 mg/day can interfere with absorption and metabolism of vitamin K • Excess supplementation may decrease platelet adhesion Def= *platelet aggregation *Hemolytic anemia *Sensory & motor neuropathy, ataxia *Retinal degeneration * *Vegetable oils *Wheat germ * Asparagus *Peanuts

Question 92

Vitamin k

Answer 92

Synthesized in gut by microflora in distal SB & colon • Excess vitamin K decreases the INR and warfarin increases the INR • Every 100 mcg of vitamin k (beyond 150mcg) causes a .02 decrease in INR • Vitamin K is present in lipid emulsions and propofol *Fish oils *Meat *Leafy greens • Administration of warfarin with continuous enteral nutrition leads to decreased warfarin absorption so it requires holding of feeds (warfarin binds with plastic tubing)

Question 93

Parenteral Vitamins

Answer 93

• Include ascorbic acid (C), retinol, ergocalciferol or cholecalciferol, thiamine (b1), folic acid (b9) cyanocobalamin (b12), biotin, phyntonadione (K) riboflavin, pyridoxine, niacinamide, dexpanthenol, dl-a tocopheryl acetate • Addition of Vitamin K creates concern for those who are on anticoagulation to maintain patency of IV devices Vitamin D preparations are challenging because high-dose parenteral formulas of Vitamin D are unavailable in the US

Question 94

Iron

Answer 94

• PN iron should only be considered if cannot take anything via mouth • When adding iron to PN, it can only be added to dextrose + AA concentrations as it destabilizes lipid emulsions Parenteral use of iron is contraindicated during acute illness and sepsis *toxicitiy=Hemochromatosis, organ damage, especially liver, heart, pancreas *Parenteral iron can only be added to 2-in-1 PN because it destabilizes IVLE *PN iron contraindicated in acute illness & sepsis *Vitamin C helps enhance absorption on non-heme iron *Menstruating women & those on oral contraception have incr needs *Phytates decr iron absorption *Chromium toxicity can contribute to iron deficiency *Heme - MFP **meat, fish, poultry *Nonheme **Beans **Leafy greens **Broccoli **Peas **Bran **Enriched whole grains

Question 95

Zinc

Answer 95

• Wound drainage can cause GI zinc losses • Plasma and urinary zinc are reliable biomarkers • Zinc supplementation can induce copper deficiency • Supplementation recommended in patients with losses from thermal injury, in hypermetabolic states such as TBI, and with excessive GI losses *Seafood *Meats *Greens *Whole grains *Plasma & urinary zinc reliable biomarkers *Wound drainage can cause zinc losses *Supplementation recommended for thermal injury, hypermetabolic states, TBI, & excessive GI losses *Supplemental dose = 3-5 mg/day *Celiac, malabsorptive

Question 96

Copper deficiency can lead to ___

Answer 96

Deficiency can lead to impaired absorption of iron • At risk: celiac, malabsorptive disorders, post-intestinal surgery, hemodialysis • Supplementation should be avoided in those with hepatic dysfunction- same w copper *Liver *Cocoa *Beans *Nuts *Whole grains *Dried fruits

Question 97

Manganese eliminated via —

Answer 97

• Exclusively eliminated via hepatobiliary system, therefore, any patient with hepatobiliary disease may be predisposed to toxicity Def= rare *Iron competes for binding Manganese *Nuts *Oats *Whole grains

Question 98

Selenium required for ___ metabolism

Answer 98

• Required as a cofactor in glutathione, iodine, and thyroid metabolism • At risk: patients with thermal injury and long-term TPN without Selenium

Question 99

Iodine is a part of ___ hormones

Answer 99

Integral component of thyroid hormones T4 and T3 During states of deficiency, insufficient T4 is produced which eliminated negative feedback on TSH which results in a constant release of TSH therefore causing hyperplasia (enlargement) of thyroid gland, also known as goiter • Elevated TSH is an indicator of both iodine deficiency and toxicity

Question 100

Chromium required for

Answer 100

• Essential trace metal required for glucose and lipid metabolism • Increases the action of insulin

Question 101

PN Trace Elements

Answer 101

• Published recommendations for daily parenteral intake of zinc, copper, manganese, and chromium as well as selenium supplementation Zinc: Usual supplemental dose 3-5 mg. Increased needs in patients with consistent high GI losses. Start 3 mg/day. Consider holding selenium if impaired renal function May need to decrease chromium in renal failure Current TE formulation provides › recommended manganese & copper If T bili ≥ 3, hold TE & give 5mg Zn + 60 mcg Se

Question 102

Normal ABG levels

Answer 102

pH (7.35-7.45) PaO2 (75-100 mm Hg) PaCO2 (35-45 mm Hg) HCO3 (22-26 mEq/L) Base excess/deficit (-4 to +2) SaO2 (95-100%) The PaCO2 indicates whether the acidosis or alkalemia is primarily from a respiratory or metabolic acidosis/alkalosis

Question 104

use the mnemonic "MUDPILES" for high anion gap metabolic acidosis and "HARD ASS" for normal anion gap metabolic acidosis

Answer 104

MUDPILES: M: ethanol U: remia D: iabetic Ketoacidosis P: ropylene Glycol I: soniazid L: actic Acidosis E: thylene Glycol S: alicylates HARD ASS: H: yperchloremia (e.g., strong acid ingestion) A: ddison's Disease R: enal Tubular Acidosis D: iarrhea A: cetazolamide S: pironolactone S: aline Infusion

Question 105

Metabolic alkalosis causes - CLEVER PD

Answer 105

CLEVER PD": Contraction alkalosis Licorice Endocrine Vomiting/gastric suction Excess alkali Refeeding alkalosis Post-hypercapnic Diuretics.

Question 106

Acute Iliness or Injury Related Malnutrition weight loss- MODERATE

Answer 106

1-2% / 1 week 5% / 1 month 7.5% / 3 months <75% intake for >7 days or >/=1 month Chronic - 10% / 6 months 20% / 1 year <75% for >/=3 months

Question 107

Malnutrition

Answer 107

Question 108

Normal serum sodium

Answer 108

135-145 PN dose: 1-2 meq/kg for adults Total body Na is ~40 meq/kg in a 70’kg patient Major extra cellular CATion

Question 109

Most common hyponatremia consists of ___ osmolality state

Answer 109

Hypotonic or a low osmolality

Question 110

Chloride

Answer 110

98-108 meq/l As needed for acid base balance

Question 111

Potassium

Answer 111

3.5-5 PN 1-2 meq/kg for adult dose Decrease dose by 50% for renal Patients 10-30 meq/d usually sufficient to prevent hypokalema Doses of 40-100 meq/d divided into 2-4 doses to correct hypokalemia 10 meq of IV potassium will bring up serum K by 0.1 mg/dL <10 meq/hr can be peripheral Infusion rate should not exceed 40meq/hr if it’s >10meq/hr,pt wil need via central access and need continuius cardiac monitoring to assess for elevated T waves on ECG

Question 112

CO2 lab

Answer 112

23-30 As needed for acid base balance

Question 113

Calcium

Answer 113

8.5-10.5 10-15 meq/day in PN for adults iCal is the active form Normal iCal= 4.4-5.4 mg/DL or 1.1-1.35 mmol/mL Calcitriol will increase Ca and Phos Calcitonin will decrease Ca and Phos PTH will increase Ca and decr Phos Correct hypomagnesemia to correct Ca Hypocalcemia - if vit D low, supplementation of vitamin D can increase Ca Hypercalcemia - IVF normal saline and diuretics first, Calcitonin can also be used but can cause tachyphylaxis, HD can also be used

Question 114

Phosphorus

Answer 114

2.5-4.5 20-40 mmol/day Replacemenr- Infusion rate <7mmol/hr Hyperphos- usually CKD, serious sx is soft tissue calcification, secondary hyperparathyroidism, ca and phos should not exceed 55 mg/dL

Question 115

Magnesium

Answer 115

1.7-2.4 8-20 meq/day in PN dose Infusion rate should not exceed 1g/hr (8 meq/hr) repletion Each 1 gram of magnesium (8 meq) will increase serum Mg by ~0.1 mg/dl

Question 116

Hyperkalemia tx

Answer 116

k cocktail Calcium gluconate - 1-2 min/ 10-30 min onset/durarion Next quickest is albuterol- Albuterol can also take 30 min onset/1-2 hr duration Insulin- shifts K into cell within 15-45 min -2-6 he na bicarb within 30’min- 2-6 hrs