TPN

Question 1

What deficiencies can cause abnormal nutrient intake causing malnutrition?

Answer 1

Nutrient intake, Digestion, Absorption, Metabolism, Excretion/Nutrition losses

Question 2

Rapidly developing malnutrition triggered by acute stress and injury, which is short lived, and resolves as patient condition improves is known as?

Answer 2

Acute Malnutrition

Question 3

Happens because of another disease such as cancer, IBD, organ failure, and requires long term monitoring and therapy is known as?

Answer 3

Chronic malnutrition

Question 4

What is the consequence of untreated malnutrition?

Answer 4

-Impaired immunity
-Decreased wound healing
-Increased complications
-Poor response to medical or surgical therapy
-Reduced growth or development of infant or child
-Death

Question 5

You have a patient who has inadequate or unsafe oral intake, and a functional accessible GIT, what type of feeding would you recommend for this person?

Answer 5

Enteral tube feeding

Question 6

You have a patient with inadequate or unsafe oral or enteral intake and a non-functional or perforated GIT. What type of feeding would you recommend for this person?

Answer 6

Parenteral nutrition

Question 7

What does parenteral nutrition include?

Answer 7

Water, Amino acids, Glucose, Lipids, Vitamins, Trace elements, Electrolytes

Question 8

Why might someone use parental nutrition short term?

Answer 8

-Post surgery if the patient is on gut rest (NBM) - for more than 7 days
-Obstruction in the gut
-Severe shock or gut infection
-Malnourished or unable to eat

Question 9

Why might someone use parental nutrition long term?

Answer 9

-Non-functioning gut
-Not enough gut to function due to surgery
*Some patients still eat small amounts, this may or may not be permanent

Question 10

If in oral diet someone has water/volume what do they have in the PN source?

Answer 10

Water/volume

Question 11

If in someone’s oral diet they have protein what would this replace this with in PN?

Answer 11

L-amino acids mixture

Question 12

If someone’s oral diet they have carbohydrates, what is the equivalent to this in PN?

Answer 12

Glucose

Question 13

If someone’s oral diet they have Fat with essential fatty acids, what is the equivalent to this in PN?

Answer 13

Lipid emulsion with essential fatty acids

Question 14

If in someone’s oral diet they have Vitamins what is the equivalent to this is PN?

Answer 14

Vitamins

Question 15

If in someone’s oral diet they have Minerals, what is the equivalent to this in PN?

Answer 15

Trace elements

Question 16

If in someone’s oral diet they have Electrolytes what is the equivalent to this in PN?

Answer 16

Electrolytes

Question 17

What is the equation to work out how much water a patient would require?

Answer 17

Maintenance fluid = 1500ml + (20ml x each kg of weight >20kg)

Question 18

What factors mean that less fluid would be given?

Answer 18

-Fluid overload
-High humidity
-Blood transfusion
-Drugs
-Cardiac failure
-Renal failure

Question 19

What factors mean that more water should be given?

Answer 19

-Dehydration
-Fever
-Acute anabolic state
-High temp
-Low humidity
-GI losses
-Burns/wounds
-Blood loss

Question 20

What is the equation for nitrogen?

Answer 20

0.2g nitrogen/kg/day

Question 21

What is given for amino acids?

Answer 21

Nitrogen

Question 22

Amino acid solutions are hypertonic to blood, what does this mean?

Answer 22

They should not be administered alone in peripheral circulation as they can cause damage to blood vessels.

Question 23

What is the equation for how much Energy is required for a person?

Answer 23

25-35 non-protein kcal/kg/day

Question 24

Where is energy for PN sourced from?

Answer 24

Lipid and Glucose (dual energy source)

Question 25

Why do we need a dual energy source?

Answer 25

Metabolic issues can arise, as they can exceed metabolic capacity.

Question 26

How many 'g' of anhydrous glucose provides 4kcal?

Answer 26

1

Question 27

Why shouldn't glucose be used alone as an energy source?

Answer 27

-Hyperglycaemia -Fatty infiltration of the liver (excess glucose is converted to fatty acids) -Excessive CO2 production -Excessive consumption of oxygen -Essential fatty acid deficiency -Metabolic issues

Question 28

How much lipid should a patient receive?

Answer 28

Patients typically receive 2.5g lipid/kg/day

Question 29

What are some examples of lipid emulsions containing essential fatty acids?

Answer 29

Linoleic acid 52% / 8%

Question 30

What examples of lipid emulsions contain other fatty acids?

Answer 30

*Oleic acid 22% *Palmitic acid 13% *Stearic acid 4% *Other fatty acids 1%

Question 31

What are the two groups of micronutrients?

Answer 31

Trace elements and Vitamins

Question 31

What is the advantage of Lipid Emulsions?

Answer 31

*Large amount of energy in small amount of fluid *Allows peripheral administration -Isotonic -Veno-protective effect *Contains some fat soluble vitamins (E and K) *Prevents/reverses essential fatty acid deficiency

Question 31

What are micronutrients key role?

Answer 31

Intermediary metabolism as both co-factors and co-enzymes, affect enzyme activity and total metabolism

Question 31

What affects micronutrient requirements?

Answer 31

*Baseline nutritional state on starting PN *Increased loss - small bowl fistulae/aspirate (Zinc rich) - Biliary fluid loss (Copper rich) - Burn fluid loss (Zinc, Copper, Selenium rich)

Question 31

What clearance is reduced when someone is in liver failure?

Answer 31

Copper and Manganese

Question 32

What clearance is reduced when someone is in renal failure?

Answer 32

Aluminium, chromium, zinc and nickel clearance

Question 33

What are the commercially available products which are added into TPN?

Answer 33

Additrace and Decan

Question 34

What are the 10 known trace elements?

Answer 34

1) Iron 2) Copper 3) Zinc 4) Fluorine 5) Manganese 6) Iodine 7) Cobalt 8) Selenium 9) Molybdenum 10) Chromium

Question 35

What are fat-soluble vitamins stored in the body?

Answer 35

A - retinol D - Ergocalciferol E - tocopherol K1

Question 36

What are the water-soluble renally cleared vitamins?

Answer 36

B1 - Thiamine B2 - Riboflavin B6 - Pyridoxine B12 C - Ascorbic acid Folic acid Panthothenic acid Biotin Niacin

Question 36

What commercial preparation is availble for fat-soluble vitamins?

Answer 36

Vitilipid N Adult

Question 36

What is in a TPN bag?

Answer 36

Amino acids (nitrogen/proteins), Glucose & Lipids (Energy and fluid), Trace elements, Vitamins, Electrolytes

Question 36

What commercial preparation is available for water-soluble vitamins?

Answer 36

Solivito-N

Question 36

What electrolytes are added according to the patients daily blood tests?

Answer 36

Sodium, Potassium, Calcium, Magnesium, Phosphate, Chloride, Acetate

Question 37

What is the first line administration route for TPN?

Answer 37

Peripheral Administration when for short term. Central Administration for longer term feeding.

Question 38

How many hours before giving TPN should it be taken out of the fridge?

Answer 38

3 hours

Question 39

How can physical stability be affected with TPN?

Answer 39

-Precipitation: *Can cause fatal emboli - cannot be seen if nutrients contains a lipid. -Lipid destabilisation *Lipid globules may come together and coalesce, cause respiratory and circulatory blockages -All PN fluids are passed through a filter when infused into a patient

Question 40

How can Chemical stability be affected in TPN?

Answer 40

Vitamins undergo chemical degradation, they are sensitive to light exposure. -Vitamin C is the least stable and used as a marker for vitamin degradation

Question 41

How can Microbial stability be affected in TPN?

Answer 41

*High nutritious medium - growth *Manipulations are performed using validated aseptic techniques *Staff are trained in aseptic technique when connecting/disconnecting infusions

Question 42

What do we monitor in a patient with TPN?

Answer 42

*DAILY BLOODS* -LFT, Electrolyte, Blood glucose, Haematology, CRP, Calcium, Albumin *ALSO* Clinical symptoms, temperature, blood pressure, fluid balance, weight, nitrogen balance, lipid tolerance, acid-base profile

Question 43

What are the complications when having TPN?

Answer 43

-Line blockages -Line sepsis -Thrombophlebitis -Refeeding syndrome

Question 44

What causes line blockages in TPN lines?

Answer 44

-Fibrin sheath forms around the line or a thrombosis blocks the tip -Internal blockage of lipid, blood clot or salt and drug precipitates -Line Kinking -Blockage of a protective line filter

Question 45

What is Refeeding syndrome?

Answer 45

*Metabolic complication when the infused nutrition exceeds the tolerance of a previously malnourished patient

Question 46

What should be added to a TPN back if the patient is at risk of refeeding syndrome?

Answer 46

Thiamine

Question 47

How many hours should the first bag of TPN be given over?

Answer 47

48 hours

Question 48

What happens in the body in refeeding syndrome?

Answer 48

Fat stores are getting used up when starting TPN, the food changes the metabolising carbohydrate and instead of fat, there is a sudden increase of insulin, this decreases K and Mg causing fluid retention.