PHRM 825: Parenteral and Enteral Nutrition Flashcards
(165 cards)
1
Q
The provision of nutrients can be through what routes?
A
- Oral
- Enteral
- Parenteral
2
Q
Purposes of provision of nutrients
A
- Weight maintenance or gain
- Support of anabolism and nitrogen balance
- Preserve/restore lean body mass
- Correct nutritional deficiencies
3
Q
Providing optimal nutrition support therapy requires convergence of which skills of patient care
A
- Assessment of pt nutritional status/requirements
- Identifying proper route and techniques for nutrition therapy
- Relating the pathophysiology of patient/s diseases, clinical conditions, diagnostic tests, lab parameters, and medication therapy
- Evaluating medication-nutrient interactions
- Appropriately formulate, administer, monitor, and adjust nutrition support therapy
4
Q
What are the 3 routes of nutrition support
A
- Enteral nutrition (EN)
- Parenteral nutrition (PN)
- Combination feeding
5
Q
How long is short-term nutrition used?
A
<3 weeks
6
Q
What types of tubes are used to administer short-term enteral nutrition?
A
- Nasogastric (NG)
- Nasoenteric (duodenal (ND), jejunal (NJ)
- Orogastric tube (OG), oroenteric (duodenal (OD), jejunal (OJ)
7
Q
What type of tubes are used to administer long-term enteral nutrition?
A
-PEG
-Gastrostomy
-Jejunostomy
(These are surgically placed)
8
Q
What system is enteral nutrition placed in?
A
Digestive system
9
Q
What system is parenteral nutrition placed in?
A
Cardiovascular system
10
Q
What should never be given in a peripheral vein?
A
TPN
11
Q
What does TPN stand for?
A
Total parenteral nutrition
12
Q
What does PPN stand for?
A
Peripheral Parenteral Nutrition
13
Q
How is PPN administered?
A
- Peripheral vein
- Midline catheter access
14
Q
How long should a peripheral vein be used to administer PPN?
A
<7-10 days
15
Q
How long should a central venous catheter be used to administer central parenteral nutrition?
A
> 6 weeks
16
Q
What types of tubes are used to administer central parenteral nutrition?
A
- Central venous catheter (subclavian (SC), internal jugular (IJ), femoral)
- Peripherally inserted central catheter (PICC)
17
Q
What is combination therapy?
A
Administration of both EN and PN
18
Q
What is bridge therapy?
A
- Type of combination therapy
- EN patients unable to meet caloric/protein requirements may require PN supplementation
19
Q
Combination therapy preserves _____ and ____ of the GI tract
A
enterohepatic circulation; barrier function
20
Q
5 risk factors for malnutrition
A
- Unintentional weight change
- Body weight 20% under BMI
- NPO (>7-10 days)
- Increased metabolic needs
- Inadequate nutrient intake
21
Q
What is a concerning amount of unintentional weight change?
A
> 10% within 6 months or >5% within 1 month
22
Q
What can cause an increase in metabolic needs for a patient?
A
- Trauma
- Burn patients
23
Q
What patients are at risk for inadequate nutrient intake?
A
- Alcoholics/substance abusers
- Chronic disease states with impaired ability to ingest or absorb food adequately
24
Q
2 classifications of malnutrition
A
Acute and chronic
25
What is acute malnutrition?
Status of a protein-depleted patient with adequate fat reserves
26
What is chronic malnutrition?
Depletion of protein and fat stores, with the classic emaciated-appearing malnourished patient
27
What is Kwashiorkor
Type of malnutrition considered to be caused by dietary deficiency (particularly protein) that develops over several weeks/months
28
Features of Kwashiorkor
- Hypoalbuminemia
- Anemia
- Edema
- Muscle atrophy
- Delayed wound healing
- Impaired immunocompetence
29
In the developed world, a syndrome with characteristics similar to kwashiorkor follows what?
The stress response (Can be persistent and severe if feedig is not commenced within 7-10 days)
30
What is Marasmus?
Type of malnutrition classically considered to be caused by dietary deficiency of protein and calories that develops over months to years
31
Features of Marasmus
- Weight loss
- Reduced basal metabolism
- Depletion of subcutaneous fat and tissue turgor
- Bradycardia
- Hypothermia
32
What does marasmus result from?
A mild injury response caused by chronic disease that produces anorexia or semi-starvation, with loss of lean tissue
33
What subjective and objective data is obtained from the nutritional assessment?
- Clinical evaluation (weight, BMI, deficiencies)
- Nutritional history
- Medical history (diseases, medications)
- Anthropometric measurements
- Biochemical/laboratory assessment
34
What are examples of anthropometric measurements and who are they done by?
- Done by dietitions
| - Measurements of skinfold thickness, mid-arm muscle circumference, wast circumference, bioelectrical impedance
35
What are examples of biochemical/laboratory assessments done during the nutritional assessment
- Visceral proteins
- Nitrogen balance studies
- Serum concentrations of trace elements, minerals, vitamins
36
Daily protein requirements can be individualized by what?
Measuring 24-hour urine collection (UUN)
37
What is nitrogen balance?
Measurement of urinary excretion of nitrogen as urea nitrogen
38
What is nitrogen balance used to assess?
Adequacy of protein repletion
39
Nitrogen released from protein catabolism is converted to ___ and excreated in ___
urea; urine
40
Protein demands increase during ____
stress
41
What non-urinary sources is nitrogen lost from?
- Sweat
- Feces
- Respirations
- GI fistulas
- Wound drainage
- Burns
42
What is the nitrogen IN equation?
Nitrogen IN = 24 hour protein intake (grams)/6.25
43
What is the nitrogen OUT equation?
24 hour UUN (grams) + 4
4 is a correction factor that accounts for non-urinary nitrogen losses
44
What does UUN mean?
Urinary urea nitrogen
45
What is the goal for nitrogen balance?
- Zero for maintenance
- +3-5 grams for repletion
- Use 4 grams as general goal
46
How many kcal/g in protein?
4
47
How many kcal/g in carbohydrates?
3.4
48
How many kcal/g in lipids
9
49
How many kcal/g in propofol?
1.1
50
What does refeeding syndrome cause?
Rapid fall in Mg+2, Phos, and K+ levels
51
What are the goals of nutrition support?
- Balance calorie and protein intake to body's metabolic capacities to ensure efficient nutrient utilization
- Accurately estimate or measure the patient's calorie and protein requirements, avoid overfeeding (and potentially beneficial is short-term permissive underfeeding)
- Closely monitor patient's response to nutrition support therapy
52
Adjustments to therapy should be guided by ____; rather than relying solely on protein and energy ____
the patient's tolerance; requirement estimates/measures
53
What does BEE stand for?
Basal energy expenditure
54
What is basal energy expenditure?
Metabolic activity required to maintain life (i.e. respiration, body temperature, other essential functions)
55
What does basal energy expenditure also mean?
Basal metabolic rate
56
What is the harris-benedict equation used to find?
basal energy expenditure (aka basal metabolic rate)
57
What is the resting energy expenditure (REE) also known as?
resting metabolic rate (RMR)
58
What is the resting energy expenditure?
- number of calories required during 24 hours in a non-active state
- ~10% higher than BEE
59
What is total energy expenditure (TEE)?
-Calories required to maintain current body weight
60
What is the total energy expenditure equation?
TEE = BEE X activity or stress factor
61
If actual BW <130% of IBW what weight should you use?
Actual BW
62
If actual BW >1300% of IBW what weight should you use?
Nutritional BW
63
In obese patients with Actual BW > 150% of IBW what weight should you use?
Ideal BW
64
_____ in obesity is associated with better outcomes
permissive underfeeding
65
What is the standard percentage of non-protein calories that are fat?
30%
66
What is the standard percentage of non-protein calories that are dextrose?
70%
67
What does indirect calorimetry measure?
Volume of oxygen consumpton (VO2) and carbon dioxide production (VCO2)
68
What is the respiratory quotient (RQ) equation?
RQ = VCO2/VO2
69
What is the RQ for fat?
0.7
70
What is the RQ for proteins?
0.8
71
What is the RQ for carbohydrates?
1
72
What is the goal RQ?
0.85-0.95
73
What happens if RQ > 1?
Overfeeding and lipogenesis is occurring
74
What happens if RQ < 0.7?
Underfeeding patient
75
What is enteral nutrition (EN)?
Nutrition provided by long-term (gastrostomy or jejunostomy) or short-term (nasogastric, nasoduodenal, or nasojejunal) tube feedings
76
What is the rule when deciding whether to use parenteral or enteral nutrition?
"If the gut works, use it" --> always use enteral when possible
77
What is the first line of nutrition when the gut works but energy needs cannot be met via oral route?
Enteral nutrition
78
Physiologic advantage of EN over PN
Maintain gut integrity, prevent villi atrophy
79
Immunologic advantage of EN over PN
Fewer infectious complication than PN, prevent bacterial translocation
80
Safety advantage of EN over PN
EN avoids catheter sepsis, embolus, arterial laceration, pneumothorax
81
Cost advantage of EN over PN
Less expensive than PN, less equipment/personnel
82
Indications for EN
Inability to consume or absorb adequate nutrients due to inability to consume or where oral consumption is contraindicated
83
Conditions that would result in an inability to consume food or where oral consumption is contraindicated
- CVA; dysphagia
- Dementia
- Head & neck surgery
- Esophageal obstruction
- Trauma/burn
84
Contraindications for EN
- Expected need less than 5-10 days
- Severe acute pancreatitis
- High-output proximal fistulas
- Inability to gain access
- Intractable vomiting and diarrhea
- GI ischemia
- Ileus
85
The ___ and ____ of the intestines dictate the volume, type, and choice of EN
length and absorptive capacity
86
What is the range of caloric density for EN?
1-2 kcal/mL
87
When is 1 kcal/mL used for EN?
Most of the time --> It is the most common density
88
When is 2 kcal/mL used for EN?
For patients with fluid restrictions (CKD, etc.)
89
What is included in an EN formulation?
- Carbohydrates
- Protein
- Fat
- Fiber
- Water
- Electrolytes
- MVI
- Trace elements
- Immune-modulating nutrients
90
What are examples of EN protein supplements and how many grams of protein do they contain?
Prostat 1 gel tube = 15 g protein
| Beneprotein 1 packet = 6 g protein
91
What are examples of EN carbohydrate supplements?
- Polycose
- Duocal
- Benecalorie
92
What is an example of EN fiber supplement?
Benefiber
93
What mechanical complications can occur with EN?
- Feeding tube misplacement, clogging, aspiration
| - Airway/GI injury leading to respiratory compromise or abdominal abscess/infection
94
What gastrointestinal complications can occur with EN?
- Gastroparesis
- GERD (large gastric volume, increased abdominal pressure)
- Diarrhea
- Constipation
95
What metabolic complications can occur with EN?
- Hyperglycemia
- Electrolyte, vitamin and mineral deficiencies
- Refeeding syndrome
- Dehydration
96
When monitoring EN, what 4 factors should you initially look at?
- Intake and output
- Weight
- Feeding tube position
- Gastric residual volume
97
Can drugs be administered via feeding tube?
Yes
98
Many meds can be ___ and administered down a feeding tube, then ___
crushed; flushed
99
When should you not crush medications and put them down a feeding tube?
When they have a special delivery system (sustained-release or enteric coated)
100
Mixing liquid medications with EN formuations can cause _____, which can result in ___ or ___
Physical incompatibilities; drug malabsorption or clogging of feeding tubes
101
How to unclog feeding tubes
Pancreatic enzyme table, sodium bicarbonate tablet, 10 mL of warm water
102
What drug-EN interactions can occur?
Reduced bioavailability or suboptimal pharmacologic effect
103
What is parenteral nutrition (PN)?
Means by which protein, energy, nutrient and metabolic requirements, can be delivered by direct venous infusion for those patients who are unable to tolerate, absorb or accumulate sufficient nutrients by the usual enteral route
104
What is PN composed of?
- Macronutrients
- Micronutrients
- Medications
105
What macronutrients are found in PN?
- Crystalline amino acids as protein
| - Non-protein calories: dextrose and fat emulsions
106
What micronutrients are found in PN?
- Electrolytes
- Vitamins
- Trace elements
107
What does TNA stand for?
Total nutrient admixture
108
What is 3-in-1 TNA?
- Carbohydrates, fat, and amino acids in the same IV admixture
- Milky appearance
109
What is 2-in-1 TNA?
- Carbohydrates and amino acids in the same IV admixture
- Several commercially prepared pre-mixed formulations
- Fat infused separately
110
How is central PN delivered?
Delivered by a large diameter vein
111
What is a PICC line used for?
- ~2-6 week therapy
| - Home use
112
How is peripheral PN (PPN) delivered?
Delivered by a peripheral vein, usually of the hand or forearm
113
What are the limitations of PPN?
- Dextrose (12.5%)
- Calcium and phosphorus content
- Osmolarity max 900-1100 mOsm/L
114
PPN is not recommended for who?
Patients with severe stress, malnutrition, considerable caloric/electrolyte requirements, or PN >5days
115
Indications for PN
- Nonfunctioning/inaccessible GI tract
| - Prolonged NPO course >7 days
116
What makes the GI tract nonfunctioning or inaccessible resulting in need for PN?
- Bowel ischemia
- Intractable vomiting diarrhea
- Hyperemesis gravidum
- Gastrointestinal bowel obstruction/ileus
- Severe inflammatory bowel disease
- Short bowel syndrome
117
What are contraindications for PN?
- Functioning GI tract
- Treatment anticipated <7 days in patients without severe malnutrition
- Inability to obtain venous access
- A prognosis that does not warrant PN
- When the risks of PN exceed the benefits
118
What is custom PN?
PN solution order individualized for a particular patient and compounded in the pharmacy
119
What are standard central or peripheral premixed formulas?
- Sterile ready-to administer packages of IV nutrients
- Intended for direct dosing to patients with minimal adaptation
- With or without electrolytes
- Usually used for patients started on PN during weekends, short-term therapy, ileus, supplement to oral or enteral nutrition
120
What mechanical complications can occur with PN?
- Infusion pump failure
- Catheter-related complications: pneumothorax, migration to wrong vein, improper positioning within cardiac chambers, arterial puncture bleeding
121
What infectious complications can occur with PN?
- Central venous catheter (CVC) infection
| - Infection 2/2 solution contamination
122
What metabolic complications can occur with PN?
PN associated liver disease, hypertriglyceridemia, hyperglycemia, refeeding syndrome, essential fatty acid deficiency, metabolic bone density
123
What is refeeding syndrome?
- Severe fluid and electrolyte abnormalities associated with metabolic complications that develop during nutritional repletion in underweight, severely malnourished, or severely starved patients
- Associated with parenteral, enteral , or oral nutrition
124
How to prevent refeeding syndrome
- Identify patients at risk
- Correct electrolyte abnormalities before initiating nutrition support
- Determine nutritional goals AVOID OVERFEEDING
- "Start low and go slow" (for patients at risk, start ~25% and increase to goal over 3-5 days
125
What factors influence the chemical/physical stability of IV admixtures?
- pH
- Concentrations
- Temperature
- Order/time of mixing
126
Medications frequently used with PN
- Typical additives (electrolytes, vitamins, trace elements)
- Insulin
- Histamine-2 receptor antagonists
127
How to reduce the risk of destabilization of PN
- Keeping the final amino acid concentration at 2.5% or more
- Maintaining a final pH >5
- Keeping final dextrose concentration at 3.3% or greater
- Avoiding trivalent cations (iron dextran)
- Avoiding mixing dextrose and lipid directly
- Add lipid last, after all other components (except vitamins) are mixed
128
What 2 elements are common essential electrolytes
Calcium and phosphorus
129
What happens if the calcium and phosphorus concentrations are too high?
It can result in an insoluble precipitate
130
Calcium-phosphorus precipitation is especially problematic in what type of TPN?
3-in-1
131
What are the 8 steps for writing a TPN?
- Gather pertinent information from the patient's chart
- Calculate patient's goal calorie needs
- Calculate patient's goal protein needs
- Check units
- Electrolytes/additives
- Calculate flow rate
- Start slowly, advance over 2-3 days
- Order appropriate monitoring parameters
132
What information is important to gather when preparing to write a TPN?
- Weight, IBW, NBW
- Height
- Age
- PMH, surgical hx
- Current medications
- Baseline labs, I/Os
- Line access
133
How to calculate protein calories
Protein calories = grams protein X 4 kcal/gram
134
What is the equation for non-protein calories?
non-protein calories = total kcal - protein kcal
135
How to calculate flow rate for TPN?
- Convert all components' calories to mL
- Check solutions used by institution
- Add up TPN volume (all components)
- Divide by 24 hours = rate/hour
136
Initiation of TPN administration
- Calculate total nutrition requirements, plan day 1 calories, order appropriate labs for monitoring, along with accuchecks and possible sliding scale insulin
- Administer with appropriate filter
- Increase to meet goals
137
Discontinuation of TPN
-Taper TPN as patient makes way to transitional feedings; be sure to d/c insulin
138
Cycling TPN administraiton
Not recommended to administer >200 mL/hour
139
How does nutrition vary in people with short bowel syndrome?
- Dietary recs base on presence/absence of a colon
- With colon: high carb-low fat diet
- Vitamin B12 supplement should be considered
140
How does nutrition vary in people with diabetes?
- Maintain glucose levels between 110-220 mg/dL
- Give 30% of total kcal as fat
- Gastric atony and delayed emptying is typical in type 1 diabetes
141
How does nutrition vary in people with cardiac disease?
- Avoid overfeeding
| - Fluid restriction
142
How does nutrition vary in people with renal disease?
- Fluid restriction recommended
- Pre-dialysis: low protein
- Dialysis: standard protein
143
Pre-dialysis: low protein values for people with renal insufficiency
- Renal insufficiency, otherwise "normal" patient: 0.5-0.8 g/kg
- Renal insufficiency who are post-op: 0.5-1 g/kg
144
Dialysis: standard protein values for people with renal insufficiency
- Patients receiving intermittent HD: 1-1.3 g/kg
| - Patients on continuous renal replacement therapy 1.5-2 g/kg (~20% amino acids filtered off)
145
How does nutrition vary in people with pulmonary failure?
- Calories: 20-30 kcal/kg; give 30-50% of total kcal as fat; protein 1-2 g/kg
- Limit carbohydrates; avoid overfeeding
146
How does nutrition vary in people with hepatic disease?
- High calorie intake (35 kcal/kg/day)
- If no encephalopathy, standard protein (1-1.2 g/kg/day)
- If encephalopathy, protein restriction (0.6 g/kg/day)
- Sodium restrictio if ascites or edema
147
How does nutrition vary in people with GERD?
-Make sure H2 antagonist or PPI is ordered, place in TNP if available (famotidine)
148
How does NG suctioning affect nutrition in patients?
May cause hyponatremia, hypokalemia, and/or hypochloremia
149
How does N/V affect nutrition in patients?
May lead to hypovolemia, Na+, imbalance, hypokalemia
150
How does dialysis affect nutrition in patients?
Removes ~10-20% amino acids
151
How does wound healing affect nutrition in patients?
Consider adding zinc, vitamin C
152
How do loop diuretics affect nutrition in patients?
May cause hypokalemia, Na+ imbalances
153
How do steroids affect nutrition in patients?
May increase blood sugars, may need to add insulin
154
Continuous reassessment of nutrition is required because nutrition requirements are ____
dynamic
155
Medications may affect ___ and ___
Nutritional monitoring parameters and goals
156
You should not attempt to correct ___ via TPN
Acute electrolyte disturbances
157
Goal daily calories (kcal/kg/day) for non-stressed, non-depleted patients
20-25
158
Goal daily calories (kcal/kg/day) for trauma/stress/surgery/critically ill patients
25-30
159
Goal daily calories (kcal/kg/day) for major burn patients
45-40
160
Goal daily calories (kcal/kg/day) for obese patients (>150% IBW)
22-25 (IBW)
161
Goal daily protein (grams/kg/day) for maintenance (non-hospitalized) people
0.8-1
162
Goal daily protein (grams/kg/day) for mild-moderate (repletion/medical floor)
1-1.5
163
Goal daily protein (grams/kg/day) for moderate-severe (trauma, surgery, ICU)
1.5-2
164
Goal daily protein (grams/kg/day) for burn patients
2-2.5
165
Goal daily protein (grams/kg/day) for obese >150% IBW
2 (IBW)
