Parenteral Nutrition Flashcards
(173 cards)
1
Q
A
2
Q
___ is the terminal state of emulsion destabilization in TPN
A
Cracking
Cracking occurs when small lipid particles coalesce to form larger droplets.
3
Q
In the ___ stage of emulsion destabilization, small lipid particles coalesce to form large droplets ranging in size from ___ or more microns. These oil droplets pose potential clinical danger.
A
-Cracking
-5-50 microns or more
Larger oil droplets can pose potential clinical danger.
4
Q
What is the initial stage in emulsion breakdown?
A
Creaming
Creaming occurs almost immediately upon standing after mixing ILE with other chemical constituents.
5
Q
What visual sign indicates the presence of “creaming” in an emulsion?
A
Visible at the surface of the emulsion as a translucent band separate from the remaining TNA dispersion
This band separates from the remaining TNA dispersion.
6
Q
Although the lipid particles in the “cream” layer are destabilized, their individual droplet identities are generally ___.
A
Preserved
This means that the individual droplets can still be recognized.
7
Q
Is mild “creaming” a significant determinant of infusion safety?
A
No, except in extreme cases
Light creaming is a common occurrence.
8
Q
What characterizes low-risk compounding?
A
Only transfer, measuring, and mixing manipulations with closed or sealed packaging systems
Examples include reconstitution of a single-dose vial of lyophilized powder with sterile diluents.
9
Q
What is classifies something as “medium-risk” in compounding?
A
Compounding of PN using manual or automated devices with multiple injections, detachments, and attachments
This process delivers all nutritional components to a final sterile container.
10
Q
What distinguishes high-risk compounding from low- and medium-risk compounding?
A
Involves using non sterile ingredients or non sterile devices prior to terminal sterilization
An example is extemporaneously compounded L-glutamine for supplementation in a PN formulation.
11
Q
Low, medium or high risk levels are assigned according to the probability of contaminating a compounded sterile preparation with what 2 contaminants?
A
- Microbial contamination
- Chemical and physical contamination.
12
Q
The following compounding situation would be ___ risk: reconstitution of a single-dose vial of lyophilized powder with sterile diluents for transfer into another container)
A
Low
13
Q
The following compounding situation would be ___ risk: extemporaneously compounded L-glutamine for supplementation in a PN formulation
A
High
14
Q
What osmolarity of PN can be safely infused peripherally?
A
Up to 900 mOsm/L
Infusion of hypertonic parenteral solutions exceeding this osmolarity may result in complications such as phlebitis.
15
Q
What complication may occur if hypertonic parenteral solutions exceeding 900 mOsm/L are infused through a peripheral catheter?
A
Phlebitis
This complication arises due to the irritation caused by high osmolarity solutions.
16
Q
What type of IV access is required for solutions with an osmolarity greater than 900 mOsm/L?
A
Central access
Central access is necessary to avoid complications associated with peripheral infusion of high osmolarity solutions.
17
Q
Which % dextrose solutions (2) are most often used for peripheral administration?
A
5% and 10% dextrose solutions
These lower concentrated solutions are safer for peripheral administration.
18
Q
What is the osmolarity of 10% dextrose?
A
500 mOsm/L
This osmolarity is suitable for peripheral infusion.
19
Q
What is the osmolarity of 3% amino acid solution?
A
300 mOsm/L
This osmolarity is also suitable for peripheral infusion.
20
Q
Ingredients on the TPN label should be expressed in the same ___ and ___ of measure as the PN order.
A
-Sequence
-Units
21
Q
Electrolytes are to be ordered as complete ___ forms as opposed to individual ions.
A
Salt
22
Q
The size of in-line filers are either ___ or ___ micron
A
1.2 or 0.22 micron
23
Q
What information should be included on the ILE label if infused separately?
A
Two patient identifiers, patient location or address, dosing weight, administration date and time, route of administration, prescribed amount of ILE and volume required, infusion rate in mL/hr, duration of infusion, complete name of ILE, beyond use date and time, name of institution or pharmacy, and institution or pharmacy telephone number.
24
Q
___ hours is the maximum duration of infusion for ILE
A
12
25
What information should included on the PN label?
1. two patient identifiers
2. patient location or address
3. dosing weight in metric units,
4. administration date and time
5. beyond use date and time
6. route of administration (central versus peripheral)
7. prescribed volume and overfill volume
8. infusion rate in mL/h
9. duration of infusion (continuous versus cyclic)
10. size of in-line filter (1.2 or 0.22 micron)
11. complete name of all ingredients
12. barcode
13. name of institution or pharmacy
14. institution or pharmacy contact information (including telephone number).
26
What should be included on the ILE infusion label?
1. two patient identifiers
2. patient location or address
3. dosing weight
4. administration date and time
5. route of administration (central versus peripheral)
6. prescribed about of ILE and volume required to deliver that amount
7. infusion rate in mL/hr
8. duration of infusion (not longer than 12 hours)
9. complete name of ILE
10. beyond use date and time
11. name of institution or pharmacy
12. institution or pharmacy telephone number
27
Rapid infusion of ___ can result in tetany due to an abrupt decrease in serum calcium concentration.
Phosphate
28
Phosphate salts are __(acidic or alkaline) __ in nature
Acidifying
29
Tetany is a medical condition characterized by involuntary muscle contractions, typically caused by low levels of ___ in the blood
Calcium
30
The preferred approach for subcutaneous insulin administration is ___ insulin therapy
Basal-bolus
31
Why is it called "basal-bolus" insulin?
Basal insulin is given to account for hepatic glucose output + scheduled bolus insulin administered to cover meal times
32
What are the 3 components to basal-bolus insulin therapy?
1. basal insulin
2. nutritional component prior to meals
3. correctional insulin
33
In critically ill patients with BMI >30 kg/m2, calories should not exceed ___-___% of REE
65% to 70%
34
How would you calculate calorie needs for an ICU patient with a BMI 30-50 kg/m2 (if IC not available)?
11-14 kcal/kg actual weight
35
What recommendations did the 2021 addendum to the 2016 critical care guidelines provide regarding specific caloric recommendations for obesity?
NOTHING! It did not provide specific additional caloric recommendations
36
How would you calculate calorie needs for an ICU patient with a BMI >50 kg/m2 (if IC not available)?
22-25 kcal/kg ideal body weight
37
True or false: replacement of temporary catheters during bacteremia should be done over a guidewire
FALSE. Should NOT be done with a guidewire due to source of infection (colonization of skin to insertion site)
38
How do increased concentrations of amino acids affect calcium phosphate precipitation?
They reduce the risk by forming soluble complexes with calcium, lowering free calcium ions available for precipitation
39
Higher concentrations of amino acids ___ the pH of PN formulations and ___ calcium phosphate solubility
-Lower
-Improve
40
Which calcium salt dissociates more readily: calcium chloride or calcium gluconate?
Calcium chloride
41
Calcium ___ increases the free calcium ions available to bind with phosphate ions
Chloride
42
___ temperature increases the dissociation of calcium salts. Storage under refrigeration ___ risk of calcium phosphate precipitation.
-Increases
-Reduces
43
Why is it bad to add calcium and phosphate salts back-to-back?
Adding the calcium and phosphate salts back-to-back causes locally high concentrations of these salts prior to adequate mixing
44
When compounding PN, it is recommended to add the ___ first and then add the ___ near the end of compounding to utilize the maximum volume of the PN formulation to dilute the salts
-Phosphate
-Calcium
45
Current water-soluble vitamin daily parenteral doses are ___ to ___ times greater than the Recommended Dietary Allowance (RDA) or Adequate Intake (AI)
2 to 2.5 times greater
## Footnote
This adjustment is due to increased requirements from various conditions.
46
What 3 factors contribute to the increased daily parenteral doses of water-soluble vitamins?
Increased requirements due to:
1. malnutrition
2. baseline vitamin deficiencies
3. increased urinary excretion of water-soluble vitamins when used intravenously
## Footnote
These factors necessitate higher doses to meet physiological needs.
47
True or false: Manganese is an essential trace element
True
48
Is manganese deficiency common?
No, manganese deficiency is exceedingly rare.
49
What can excess manganese lead to?
Accumulation of manganese in the brain leading to Parkinson disease-like symptoms such as tremor, involuntary movements, and rigidity.
50
Who is at an increased risk for manganese toxicity?
Patients with abnormal liver function (due to manganese being excreted via bile)
51
How is manganese primarily excreted from the body?
Bile
52
How can manganese contamination occur in PN solutions?
During manufacturing and delivery
53
What is the current recommendation for long-term PN patients regarding manganese?
To serially monitor liver function as well as signs and symptoms of manganese toxicity.
54
True or False: There is strong evidence supporting manganese-free PN solutions for patients without symptoms of toxicity.
False.
55
Many studies have identified the ___ malnourished patient as benefiting from preoperative nutrition support with PN
Severely
56
Results from multiple preoperative PN studies of surgical patients have shown no overall reduction in ___ ____. However, significant reductions in perioperative complications are achieved in the severely malnourished patient receiving more than ___ days of preoperative PN.
-Perioperative mortality
-7 days
57
True or false: There is currently no recommendation for use of mild as a degree of malnutrition.
True
58
Metabolic acidosis, tissue catabolism, and pseudohyperkalemia result in an ___cellular shift of potassium
Extracellular
## Footnote
Metabolic acidosis occurs when the body produces excess acid or when the kidneys are not removing enough acid from the body.
59
Metabolic acidosis results in an extracellular shift of ___ to maintain electroneutrality.
Potassium
60
For every 0.1 decrease in pH, potassium will increase by ___mEq per liter generally.
0.6
## Footnote
This relationship highlights the impact of acid-base balance on potassium distribution.
61
What is the effect of correcting metabolic acidosis on potassium levels?
It redistributes potassium into the intracellular space and corrects hyperkalemia.
## Footnote
Correcting the underlying acidosis is crucial for managing elevated potassium levels.
62
Clinical manifestations of hyper___ are related to changes in neuromuscular and cardiac function
Hyperkalemia
## Footnote
Symptoms may include muscle weakness, fatigue, palpitations, and arrhythmias.
63
What may need to be adjusted based on serum potassium level?
The potassium content in the PN formula and exogenous potassium.
## Footnote
PN stands for parenteral nutrition, which provides nutrients intravenously.
64
Name 2 disadvantages of PICC lines
1. high rate of malposition or coiling
2. limited patient arm mobility associated with limited ability to perform daily self-care due to the availability of only one hand
65
Name a disadvantage of PICC lines with longer catheters
May be more prone to occlusion
66
Name 4 advantages of PICC lines
1. No risk of pneumothorax
2. No risk of puncture of internal carotid or subclavian arteries
3. Available in single, double, and triple lumens
4. Repeated skin puncture is not required.
67
What is the product called when two or more oils are mixed together?
A physical mixture
68
What are structured lipids?
Designer TG molecules synthesized in the lab via enzymatic methodology through genetic engineering
69
What does the triglyceride mixture of structured lipids contain?
Esterified MCTs and LCTs within the same TG molecule
70
What do structured lipids rapidly deliver?
Medium chain fatty acids
71
What is a result of the rapid delivery of MCFAs from structured lipids?
Preferential absorption & rapid provisions of EPA/DHA
72
List some benefits of structured lipids.
1. Better fatty acid absorption
2. Lower infection rates
3. Improved hepatic function
4. Improved renal function
5. Improved immune function
73
The leading complication with peripheral intravenous infusion is ___ (an inflammation at the cannulation vein)
Thrombophlebitis
74
Name 4 hallmark signs of thrombophlebitis
1. Pain
2. Erythema
3. Tenderness
4. Palpable cord
75
The risk of thrombophlebitis increases by day ___
4
76
Infusion rates of phosphate should not exceed ___ mmol/hr because faster rates can cause ___ and soft tissue calcium-phosphate deposition.
-7
-Thrombophlebitis
77
When considering the diluent (dextrose vs saline), dextrose solutions may worsen the hypokalemia by stimulating ___ release that promotes intracellular shifts of K+
Insulin
78
Hypokalemia is refractory to treatment unless the ___ deficit is corrected.
Magnesium
79
Metabolic acidosis presents as ___ pH, CO2, HCl & ___ PO4 & K+, low Ca
-Low
-High
80
___ may cause neuromuscular adverse effects, such as rhabdomyolysis.
Hypophosphatemia
81
Does ASPEN recommend using pediatric intravenous multivitamins for adults in TPN?
NO
82
Should pediatric IV multivitamins be used when there is a shortage?
NO
83
During a shortage, how should TPN patients be given vitamins and minerals
Supplement vitamins enterally if possible
84
During IV vitamin shortages, special considerations are paid to to ___ soluble vitamins
Water
85
During IV vitamin shortages, what 4 water soluble vitamins may need to be given on a daily basis?
1. Thiamine
2. B6
3. Folic acid
4. Vitamin C
86
___ supplementation in TPN is indicated if a patient receives carbohydrates & is at risk for deficiency (which can happen in patients on PN who do not receive vitamins for 3-4 weeks)
Thiamine
87
How long does it is take for thiamine deficiency to occur in TPN patients not receiving vitamins?
3-4 weeks
88
What can result from the destabilization of TNAs due to excess cations (positively charged molecules)?
Phase separation and liberation of free oil
phase separation refers to the destabilization and separation of the lipid emulsion (oil) from the aqueous phase (water).
89
In TPN additives; the higher the cation valence, the ___ the destabilizing power
Greater
90
Trivalent cations such as Fe +3 (from iron dextran) are ___ disruptive than divalent cations such as calcium and magnesium.
More
91
___ cations such as sodium and potassium are least disruptive to the emulsifier, yet when given in sufficiently high concentrations, they may also produce instability
Monovalent
92
True or false: there is no safe concentration of iron dextran in any TNA.
True
93
The most serious complication of hyperphosphatemia is ___ and ___ calcifications
-Soft tissue
-Vascular
94
Calcification occurs when the serum calcium level multiplied by the serum phosphorus level exceeds ___ mg per deciliter
55
95
Additional consequences of hyperphosphatemia (other than calcification) include was 3 things?
1. Secondary hyperparathyroidism
2. Renal osteodystrophy
3. Hypocalcemia.
96
When transitioning from parenteral to enteral nutrition, patients may receive nutrients in excess during overlap of therapy leading to ___.
hyperglycemia
97
Appropriate adjustments to limit total carbohydrate intake to no greater than ___ to ___ mg/kg/min can prevent this metabolic complication in many critically ill adult patients.
4-5
98
Name 5 common factors associated with the majority of PN prescribing errors
1. Inadequate knowledge regarding PN therapy
2. Certain patient characteristics related to PN therapy (e.g., age, impaired renal function)
3. Miscalculation of PN dosages
4. Specialized PN dosage formulation characteristics
5. Prescribing nomenclature.
99
Provide at least ___% to ___% of the total caloric intake as linoleic acid to prevent EFAD
2% to 4%
100
Provide at least ___% to ___% of the total caloric intake as alpha linolenic to prevent EFAD
0.25-0.5%
101
Is "recommended lab monitoring" requiring to be on the PN order form?
No, but it is strongly recommended
## Footnote
Although it is not required, it is strongly recommended.
102
What 14 things should a complete PN order contain?
1. Complete patient identifiers
2. Birth date or age
3. Allergies
4. Height and dosing weight in metric units
5. Diagnosis/diagnoses
6. Indication(s) for PN
7. Administration route/vascular access device
8. Contact information for prescriber
9. Date and time order submitted
10. Administration date and time
11. Volume and infusion rate
12. Infusion schedule (continuous or cyclic)
13. Type of formulation (TNA versus dextrose/amino acids with separate ILE)
14. The dose for each macronutrient, electrolyte, vitamin, element and medication
## Footnote
Each item is crucial for the completeness of the PN order.
103
How should PN ingredients be ordered for adult patients?
Amounts per day
## Footnote
For pediatric and neonatal patients, amounts should be ordered per kilogram per day.
104
Electrolytes in TPN should be ordered in the complete ___ form
Salt
## Footnote
This ensures clarity and precision in the order.
105
True or false: ISMP error prone abbreviations and symbols are acceptable to include in the PN order form
FALSE
## Footnote
This is crucial for patient safety.
106
Many PN products are contaminated with ___ from the introduction of raw materials during the manufacturing process.
Aluminum
107
Products of primary concern for ___ contamination include calcium and phosphate salts, heparin and albumin (with variable levels also noted with some trace element, vitamin, and macronutrient products).
Aluminum
108
What causes variation in the amount of aluminum contamination?
Manufacturers, lots, vial sizes and concentrations.
109
The body has no effective barriers to aluminum contaminants given intravenously and must rely on ____ excretion as the primary route of elimination to prevent toxicity
Renal
110
About 60% of infused aluminum is eliminated in patients with adequate ___ function. The remainder is deposited in ___, including the brain, bones, lung and liver
-Renal
-Tissues
111
Alterations in bone formation and mineralization, parathyroid hormone secretion, and urinary calcium excretion have been attributed to ___ toxicity.
Aluminum
112
Who are most at risk for aluminum toxicity?
Infants, children, those with renal insufficiency, and those on chronic PN
113
True or false: The FDA mandates that all manufacturers list the maximum aluminum concentration at product expiration
FALSE. The FDA only recommends this, but not required for expiration (besides small volume additives)
114
The upper limit of acceptable aluminum exposure is ___ mcg/kg/day per the 2004 FDA ruling.
5
115
Several studies have found that the use of PN in patients with burns has been associated with ___ mortality.
Increased
116
When should PN be used in patients with burns?
When they are unable to be fed enterally.
117
Preparing PN with an ACD is not an error-free process, and error rates are reported to be ___% when automated and ___% when manually prepared
22% and 37%
118
What does ACD stand for?
Automated Compounding Devices (ACDs)
## Footnote
Error rates are higher for manual preparation, reported at 37%.
119
What are the benefits of compounding with ACDs?
1. Improved compounding accuracy
2. Enforcement of proper compounding sequence
3. Reduction in opportunities for human touch contamination
## Footnote
ACDs help streamline the compounding process and minimize errors.
120
The Institute for Safe Medication Practices recommends to install, test, and maximize automated dose-limit warnings in the pharmacy and ACD order entry systems with each organization developing ___ based dosing limits applicable to their patient population.
Weight
## Footnote
Each organization should develop weight-based dosing limits applicable to their patient population.
121
The American Society of Health-System Pharmacists guidelines for the safe use of ACDs states that the pharmacy department should develop a monitoring and surveillance plan that includes a review of ___ limit alerts and overrides
Dose
122
True or false: When an ACD is used, it should deliver all PN ingredients.
True
123
Manual PN compounding is appropriate when the volume of a PN component is ___ than the ACD can accurately deliver or if there is an ___ between a PN component and ACD component.
-Less
-Interaction
124
Manual compounding is also appropriate when chemical interactions between PN components cannot be mitigated by ___ the addition of the ingredients, or as a part of a conservation effort during drug ___.
-Sequencing
-Shortages
125
Facilities that care for adult, pediatric, and neonatal populations should ___ TPN preparation for each population and develop separation strategies to minimize error.
Separate
126
The current recommendation for glycemic target is to maintain the glucose level between ___-___mg/dL for the majority of critically ill adult patients.
140-180
127
Why are lower glucose targets not generally recommended?
Lower glucose targets (110 mg/dL to 140 mg/dL) may be appropriate for some patients, but this is only appropriate when this can be safely achieved. Targets less than 110 mg/dL are not recommended due to the adverse effects of hypoglycemia.
128
The Institute for Healthcare Improvement (IHI) Central Line ___ should be used for central vascular access devices.
Bundle
129
What is the "central line bundle"?
A group of evidenced-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.
130
What is one of the key components of the "central line bundle."
Optimal catheter site selection, with avoidance of central venous access devices with high risk for infection, such as femoral catheters, when alternate access is available
131
Any adult patient with a gastrointestinal obstruction that precludes oral intake for at least ___ ___ may benefit from nutrition support.
One week
132
Moderately malnourished patients do not require PN unless oral intake is anticipated to be inadequate for more than ___ ___
One week
133
When is the palliative use of nutrition support in terminally ill cancer patients is indicated?
Very rarely. Most side effects of chemotherapy and radiation can be managed without the use of PN.
134
Adult cancer patients scheduled for surgery who are severely malnourished may benefit from PN if the therapy can continue for ___-___ days preoperatively.
7 to 10 days
135
What is PNALD
Liver dysfunction results from a complex set of risk factors present in patients receiving PN, called PN associated liver disease (PNALD)
136
Recommended dosage for all types of ILE are ___-___ g/kg/day, not to exceed ___g/kg/day
-1-2 g/kg/day
-2.5 g/kg/day
137
True or false: L-carnitine deficiency exacerbates lipid abnormalities
True
138
Does carnitine supplementation correct hypertriglyceridemia?
Existing evidence has NOT confirmed that supplementation corrects hypertriglyceridemia
139
Alternative ILEs may preserve liver function and prevent hypertriglyceridemia due to their lower content of ___ Oil and ___
Soybean oil and phytosterols
140
___ are structurally similar to cholesterol, and may interfere with bile synthesis and transport
Phytosterols
141
Phytosterols and high concentrations of peroxidation-sensitive PUFAs in plant-based ILE could lead to free radical damage of ___ cells.
Liver
142
Lipid free PN can cause EFAD within ___ weeks in acutely ill patients. Although physical evidence of deficiency may not be noticed, biochemical deficiencies can be suspected by elevated AST, ALT and confirmed by ___ratio.
-2
-Triene: tetraene
143
Serum ___ provide a reasonable estimate of body lipid clearance.
Triglycerides
144
Hypertriglyceridemia in adults has resulted in impaired ___ function, ___ suppression and increased risk of pancreatitis.
-Pulmonary
-Immune
145
When serum triglyceride levels exceed ___ mg/dL, ILE infusion should be decreased to levels that prevent fatty acid deficiency.
400
146
Parenteral ___ products are available with or without vitamin K
Multivitamin
147
___ are also a source of vitamin K, though the amount is variable.
ILE
148
Patients receiving PN who are also on ___ may require dosing adjustments to account for the additional vitamin K.
Warfarin
149
In patients on warfarin and TPN, their ___ level should be closely monitored to ensure it is within therapeutic range
INR
150
The current recommended daily dose for parenteral fat-soluble vitamins is approximately ___ as the oral Recommended Dietary Allowance (RDA) or Adequate Intake (AI)
The same
151
Though bioavailability of intravenous vitamins is much ___ than those received orally, patients requiring parenteral nutrition are frequently found to have ___ vitamin requirements.
-Greater
-Higher
152
What are some reasons that patient's on PN have higher vitamin requirements?
Patients presenting with malnutrition, baseline vitamin deficiencies and metabolic changes secondary to acute and chronic illness.
153
The provision of high parenteral vitamin doses has been in practice for over 30 years and ___ cases of toxicity have been reported.
Zero!
154
Use of branched-chain amino acid-enriched diets nutrition support formulas is only indicated in chronic ___ for those who cannot tolerate at least 1gm/kg/day of standard protein despite optimal ___.
-Encephalopathy
-Pharmacotherapy
155
True or false: The use of BCAA solutions is fully supported by the literature in hepatic encephalopathy
FALSE. It is not fully supported
156
Protein consumption within the recommended range does not worsen hepatic encephalopathy and in fact leads to improved ___ ___. composition.
Body composition
157
ASPEN recommends the use of ___ formulations for critically ill patients with acute or chronic liver disease.
Standard
158
Parenteral nutrition is a major source of ___ exposure due to contamination of its various components
Aluminum
159
Where does aluminum contamination usually occur in the TPN process?
Contamination usually occurs during manufacturing through raw materials and byproducts of the manufacturing process.
160
True or false: Nearly all parenteral components contain some aluminum though content varies from manufacturer-to-manufacture
True
161
What electrolytes are major contributors to aluminum contamination of solutions?
Calcium and phosphate salts, particularly calcium gluconate and potassium phosphate,
162
True or false: Due to the evidence linking parenteral nutrition to aluminum toxicity, the FDA mandates all manufacturers to measure and report the maximum content of aluminum in their products.
TRUE
163
Large volume components such as amino acids, dextrose, lipids and water, must contain less than ___ mcg/L of aluminum.
25
164
Small volume additives require labeling of aluminum content at the time of ___ on the container label.
Expiry
165
True of false: catheter misplacement is a rare complication of central venous catheters inserted at the bedside
FALSE. A common complication of central venous catheters inserted at the bedside is catheter misplacement
166
A pneumothorax is a complication of bedside catheter insertion caused by ____
Misplacement
167
The use of ___ during catheter insertion allows immediate repositioning of the catheter tip to its correct location in the superior vena cava.
Fluoroscopy
168
PN solutions can be started immediately if the catheter was inserted with the use of fluoroscopy. However, central catheters placed at bedside without fluoroscopy should be ___ confirmed and documented in the medical record before initial use.
Radiographically
169
Is auscultation a method to determine central venous catheter tip placement?
NO
170
Excretion of ___ and ___ is impaired in patients with hepatobiliary disease
Copper and manganese
171
Due to toxicity risk, reductions in copper and manganese should be considered in patients with ____ disease
Hepatobiliary
172
Why will patients still receive some manganese in their TPN, even if trace elements are removed?
Manganese is a contaminant found within the PN solution components, thus patients will likely receive small doses of manganese even if eliminated from the PN trace element prescription.
173
If copper and manganese are removed from PN, ongoing monitoring for their ___ should be implemented.
Deficiency
