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PHRM 864 Module 3 > Parenteral and Enternal Nutrition - Lecture 2 > Flashcards

Parenteral and Enternal Nutrition - Lecture 2 Flashcards

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1
Q

Parenteral nutrition

A

the process of supplying nutrients via an intravenous delivery system (i.e. protein, carbohydrates, fat, electrolytes, vitamins, minerals)
synonyms: TPN, PN, TNA, 3-in-1

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2
Q

PN indications

A

anticipated prolonged NPO course (>7 days)
inability to absorb nutrients via the gut, such as secondary to: small bowel or colonic ileus, extensive small bowel resection, malabsorptive states, intractabl vomiting/diarrhea
enterocutaneous fistulas
inflammatory bowel disease
hyperemesis gravidum
bone marrow transplantation (mucositis)

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3
Q

Routes of administration

A

peripheral
central

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4
Q

Peripheral PN

A

dextrose and amino acid solutions are hypertonic: not well tolerated via a peripheral vein
restrict final dextrose concentration to 5-10% or total osmolarity to < 900 mOsm/L
addition of other substances to solution may enhance vein tolerance

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5
Q

Peripheral PN requires

A

large volumes of fluid: may not be the best choice for HF or AKI/CKD pts
limited in calories: secondary to the osmolality AND fluid
short term access (<7-10 days): does this pt need PN at all?
pharmacy/MD error? (always double-check to confirm peripheral route was intentional)

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6
Q

Central PN advantages

A

allows administration of hypertonic solutions
more calories can be delivered

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7
Q

Central PN disadvantages

A

risk of infection: appropriate central line care is key to prevention
central line is not a benign procedure: pneumothorax, air embolus, thrombus

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8
Q

Central venous access

A

central venous catheter (CVC) insertion sites: subclavian (SC) - under clavicle, internal jugular (IJ) - in neck, femoral - in groin
short term: percutaneously inserted
long term: PICC (peripherally inserted central catheter), tunneled, implanted port

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9
Q

Meeting energy requirements

A

protein calories
non-protein calories (NPC): carbohydrates, fats

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10
Q

Meeting protein requirements

A

one gram protein = 4 kcal - many hospitals actually order protein in gm/day
standard amino acid products: travasol, freamine III, aminosyn II

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11
Q

Carbohydrates (dextrose)

A

max concentration available: D70% (D70W)
one gram dextrose = 3.4 kcal
limitations: a final dextrose concentration > 10% (adults) and >12.5% (peds) should not be infused into a peripheral vein due to vein irritation
max carb utilization: 4-5 mg/kg/min (double check)

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12
Q

IV fat (lipid) emulsion - intralipid

A

provides a concentrated source of calories:
1 gram lipids = ~ 10 kcal
prevents essential fatty acid deficiency
intralipid 10% consists of: soybean oil, glycerin (check for allergies), egg yolk phospholipid (check for allergies), water for injection

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13
Q

IV fat (lipid) emulsion - SMOFlipid

A

SMOFlipid consists of:
soybean oil - omega-6 essential fatty acid
medium-chain triglycerides - rapidly available energy source
olive oil - omega-9 monounsaturated fatty acid
fish oil (check for allergies) - omega-3

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14
Q

SMOFlipid compared to pure soybean oil products

A

improved liver function (lower ALT/AST concentrations)
lower increase in TG levels from baseline

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15
Q

SMOFlipid compared to non-omega-3 PN

A

less pro-inflammatory
less negative impact on liver function
reduced risk of infection
decreased length of hospital stay

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16
Q

Additional lipid considerations

A

max intake - do not exceed: 60% of caloric intake as lipid; generally 1-1.5 gm/kg/day of lipids in adults - max of 2.5 gm/kg/day of lipids in adults if tolerating; 4 gm/mg/day of lipids in infants/peds
propofol is a 10% lipid solution; provides 1.1 kcal/mL

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17
Q

IV fat emulsion - administration

A

IV fat emulsion 10% and 20% are isomolar (isotonic) with serum: may infuse via peripheral vein; piggyback into PN; admix into dextrose/amino acid solution to decrease osmolarity
IV fat emulsion 30%: must be incorporated into total nutrient admixture (3-in-1)

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18
Q

IV fat emulsion - infectious complications

A

IV lipids provide an environment suitable for pathogen growth:
hang-time of IV fat emulsion by itself should be limited to 12 hrs after opening of manufacturer packaging; if added as TNA (3-in-1) safety is increased to 24 hrs

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19
Q

Administration of PN - total nutrient admixture (custom TPN)

A

dextrose, AA, and lipids in one bag
3-in-1 = TPN (total parenteral nutrition)

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20
Q

Administration of PN - conventional administration (custom TPN)

A

dextrose and AA in one bag
lipid 2-3 times a week as a separate IVPB

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21
Q

Administration of PN - premix solution for injection (standard TPN)

A

available with or w/o electrolytes
no lipids

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22
Q

In line filters

A

reduces infusion of particulates, microprecipitates, microorganisms, pyrogens, and air
1.2 micron filter can be used for all total nutrietn admixtures (TNAs) or 3-in-1 (w/ lipids)
0.22 micron filter only used for 2-in-1 formulations (no lipids)

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23
Q

Premix PN solutions (clinimix/clinimix E)

A

standard TPN - not able to customize these products
amino acid in dextrose - with or w/o electrolytes
lipid compatible
peripheral and central line preparations
contains: amino acids + dextrose (+/- Na, K, Mag, Ca, acetate, Cl, Phos)

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24
Q

Clinimix/Clinimix E dosing

A

standard PN order, must assess renal function: CrCl < 50 - standard PN formula, NO electrolytes; CrCl>/= 50 - standard PN formula WITH electrolytes

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25
PN initiation and discontinuation guidelines
start at ~25% of goal and achieve the final rate within 24 hrs initiation: check blood glucose Q4-6 hrs, before each increase in rate; if BG < 200, continue at same rate x 4 hrs and recheck, if repeat BG > 200, consider insulin therapy cessation: decrease rate by half q2hrs until rate < 50mL/hr, then discontinue
26
Cycling PN (for pts going home on PN)
infusion over ~12-18hrs/day transitioning to EN or PO intake pts who desire time free from the infusion pump (home PN pts) rate of infusion generally cut back (tapered) during the first/last hour of infusion to prevent dysglycemias no specific guidelines for cycling PN (max ~200mL/hr)
27
Additives
electrolytes vitamins trace elements
28
Electrolytes
calcium, magnesium, phosphorous, sodium, potassium, chloride, acetate
29
Calcium standard daily range
10-20 mEq
30
Magnesium standard daily range
8-24 mEq
31
Phosphorous standard daily range
15-45 mMol
32
Sodium standard daily range
1-2 mEq/kg
33
Potassium standard daily range
0.5-1 mEq/kg to start
34
Chloride and acetate standard daily range
as needed to maintain acid-base balance chloride ~2/3 acetate ~1/3
35
Electrolyte considerations
in pts with renal disease: caution should be used with potassium, phosphate, and magnesium (b/c these are renally cleared) acid-base balance obtained through balance of acetate and chloride avoid calcium + phosphorous precipitation: avoid Ca (mg/L) x phos (mMol/L) > 150
36
Vitamins
thiamin, riboflavin, niacin, folic acid, panthotenic acid, pyridoxine, cyanocobalamin, biotin, ascorbic acid, A, D, E, K adult and pediatric (>40 kg): 10 mL/day of injectable adult multivitamin-12 pediatric (3 kg-40 kg): 2 mL/day of injectable pediatric multivitamin
37
Trace element adjustments
liver dysfunction (chronic liver disease or LFTs > 2x ULN): discontinue trace elements, supplement individually: zinc 5 mg (1mL), selenium 60 mcg (1mL) renal disease (CKD/ESRD on hemodialysis): consider checking serum levels if use expected beyond 14 days, use selenium and chromium with caution, different rules for CRRT
38
Iron
give IV iron separately addition of iron to PN is not recommended: can destabilize IV fat emulsion in 3-in-1 formulations, may contribute to infectious complications
39
Medications in PN
for the most part, the addition of meds to PN formulations is not advised; may use famotidine (H2 blocker) may be utilized for GERD or stress ulcer prophylaxis PPIs NOT compatible with PN
40
Insulin in PN
regular insulin only! common regimen: 0.1 units/gram of dextrose if BG > 150 mg/dL: 0.15 units/gram dextrose if BG > 300 mg/dL: do not initiate PN until < 200 mg/dL max amount: 0.3 units/gram dextrose 5-10 units stick to the bag
41
Converting phos mMol to mEq
average = 1 mMol phos = 1.4 mEq phos
42
Positive ions
sodium and potassium
43
Negative ions
chloride, acetate, and phos
44
Chloride:acetate balance
total positive and negative ion balance must equal zero consider acid/base status and CMP additional losses can contribute titrate based on response
45
PN complications
mechanical infectious metabolic
46
Mechanical complications
catheter related: clotting of line, displacement
47
Infectious complications
catheter-related sepsis, solution contamination, bacterial translocation
48
Bacterial translocation
time-dependent passage of bacteria or endotoxins from GI tract to extra-intestinal sites enteric organisms cause systemic infections: pneumonia, central line infections, abcesses, multi-organ dysfunction syndrome infectious morbidity and mortality
49
Metabolic complications
electrolyte imbalances, fluid imbalance, hyper- and hypoglycemia, liver function abnormalities: steatosis (fatty liver), intrahepatic chloestasis, cholelithiasis
50
PN baseline monitoring
baseline: CMP, Mg, phos ionized Ca; hepativ function panel; prealbumin/CRP; PT/INR Q6-4H: finger sticks for glucose, residuals, distention, vomiting, aspiration
51
Ongoing PN monitoring - daily
vital signs, intake/output, CMP, feeding tube placement and patency, may decrease frequency when stable
52
Ongoing PN monitoring - twice weekly
weight, CBC, Mg, phos, Ca, prealbumin/CRP, ICU setting --> increase to daily
53
Ongoing PN monitoring - weekly
albumin, transferrin, nitrogen balance, liver function tests, triglycerides, PT/INR, respiratory quotient/indirect calorimetry
54
Additional complications
refeeding syndrome essential fatty acid deficiency
55
Refeeding syndrome
constellation of fluid, micronutrient, electrolyte, and vitamin imbalances occurs within first few days of feeding a starved pt potentially life threatening
56
Clinical finding of refeeding syndrome
hypophosphatemia (most likely to experience! controls muscle contractions, stop breathing), hypomagnesemia, hypokalemia (3 you're most likely to see) respiratory distress paresthesias tetany cardiac arrhytmias hemolytic anemia
57
Risk factors for refeeding
rapid feeding, excessive dextrose infusion low BMI excessive weight loss insufficient caloric intake low levels of K, phos, or Mag prior to feeding high risk comorbidities: alcoholism, anorexia nervosa, marasmus
58
Prevention of refeeding syndrome
replete electrolytes before initiating feeds initiation recommendations (day #1): limit carbs (dextrose) to 100-150 gm, limit fluids to 800mL/day, provide adequate amounts of electrolytes, provide approx 50% of total caloric needs advance calories/dextrose by 20-33% of goal every 1-2 days as tolerated give thiamine 100 mg daily x5-7days
59
Essential fatty acid requirements
estimated to be 4-10% of daily caloreis EFAs include linoleic and linolenic acids
60
Essential fatty acid deficiency MOA
continuous infusion of hypertonic dextrose will increase circulating insulin levels inhibits lipolysis and fatty acid mobilization
61
EFAD clinical onset and symptoms
clinical onset: several weeks on fat-free PN regimen (10-14 days) sx: dry scaly skin, brittle hair, lack of luster
62
Prevention of EFAD
recommended minimum requirement is to provide approx. 4% of caloric intake as lipids prevention: provide at least 500 mL of 10% fat emulsion over at least 3-5hrs twice weekly OR provide at least 250 mL of 20% fat emulsion over at least 5-9hrs twice weekly

PHRM 864 Module 3 (9 decks)

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