Therapeutics Iii Exam 4 - Lectures 5-6 (Nutritional Goals And Guidelines For Adult Parenteral Nutrition)

Front 1

Define parenteral nutrition

Back 1

Parenteral nutrition is the process of supplying nutrients (proteins, carbohydrates, fats, electrolytes, vitamins, minerals and fluids) via an intravenous delivery system.
AKA: hyperalimentation, HA, HAF, HAL, TPN, IVA, IVH, PN, hyperal.

Front 2

Indications of Parenteral Nutrition

Back 2

Oral intake not possible
Oral intake is insufficient
Adjunctive therapy
Oral intake is potentially hazardous

Front 3

What things could make oral intake not possible?

Back 3

1. Gastrointestinal obstruction
2. Gastrointestinal dysfunction
3. After surgery
4. Gastrointestinal fistulas (holes in GI tract)
5. Gastrointestinal tract abnormalities
6. Anorexia nervosa

Front 4

What things could make oral intake insufficient?

Back 4

1. malnutrition
2. malabsorption
3. chronic diarrhea
4. chronic vomiting
5. burns (high calorie requirements)
6. hypermetabolism
7. short bowel syndrome

Front 5

When is parenteral nutrition used as adjunctive therapy?

Back 5

1. inflammatory bowel disease
2. pancreatitis
3. indolent wounds
4. decubitus ulcers
5. hepatic failure
6. renal failure
7. malignancy

Front 6

When is oral intake considered potentially hazardous?

Back 6

1. coma
2. decreased level of consciousness

Front 7

Guidelines of using CENTRAL vein parenteral nutrition

Back 7

Administration of hypertonic dextrose (>10%) and amino acids solutions into the superior vena cava usually for the purpose of providing total nutritional support.

Front 8

Guidelines of using PERIPHERAL vein parenteral nutrition

Back 8

Administration of a 5-10% dextrose plus amino acid solution into any peripheral vein usually accompanied by IV fat. It is for short term use only, maximum of 2 weeks.

Front 9

Deciding when to use central vs. peripheral PN

Back 9

1. Viability of peripheral veins (patients already on many other IV meds may have decreased viability)
2. Length of therapy (if you know its a long stay, go central)
3. Fluid tolerance (the higher amount of dextrose needed, go with central route to decrease fluid amount due to higher available percent available to central)
4. Risks associated with central line

Front 10

Initiation of Central TPN

Back 10

You must be careful of initial dextrose dose; if it's too high it can lead to hyperglycemia. Begin slowly to prevent hyperglycemia (25-40 mL/hr). Increase rate over 48 hours to maximum desired rate or begin with no more than 200-250 (2L of D10, 1L of D20) grams of dextrose the first day and increase daily to a maximum amount of dextrose (increase by 100-150 grams daily until target is reached).

Front 11

Discontinuation of Central TPN

Back 11

Gradually taper over 24 hours, otherwise we get hypoglycemia. Cut rate in half every 2 hours until the concentration is below D10. Run it at this concentration for 2 hours and then stop. If TPN needs to be stopped due to an increased electrolyte/mineral, switch to D10 for 2 hours, then stop.

Front 12

Initiation and Discontinuation of Peripheral TPN

Back 12

You may begin at the maximum desired rate (D10 is max conc for peripheral). You may decrease without tapering because it will already be at D10 or below.

Front 13

What is the maximum infusion rates for fats?

Back 13

10% at 125 ml/hr
20% at 60 ml/hr

Front 14

In peripheral TPN, what are the advantages and disadvantages of 12- and 24-hour infusion?

Back 14

12-hour infusions have less infection risk but can impair the immune system. Use 12-hour if the patient is already immunodeficient.
24-hour infusion is the max length. It has a greater infection risk but no immune system impairment. Give 24-hour if the patient is already infected.

Front 15

Describe intermittent (cyclic) TPNs. When and how are they used and what some precautions?

Back 15

They are used in home TPN, for patient convenience or for treatment of the complications of fatty liver or end-organ response failure.
TPN is given over 10 to 18 hours (EX: 80 ml/hr for the first hour, then 150 ml/hr for 14 hours, then 40 ml/hr for last 2 hours). These rates help prevent hyperglycemia and hypoglycemia.
This technique requires increased fluid tolerance (not good in renal failure, can lead to heart failure or pulmonary edema) over a shorter period of time and is difficult in the presence of diabetes or other states of glucose intolerance.

Front 16

With PN, what should we monitor on a daily basis?

Back 16

1. Weight
2. Fluid intake and output
3. Calorie/protein count
4. Gross lipemia (fat in blood)
5. Vital signs

Front 17

With PN, what should we monitor weekly?

Back 17

1. Nitrogen balance
2. Serum proteins: TSF, prealbumin
3. Serum cholesterol/triglycerides
4. LFTs: SGOT, alkaline phosphate, bilirubin
5. Also blood gases and urine electrolytes as indicated

Front 18

With PN, what is monitored daily for 7 days, then reduced to once every 3 days?

Back 18

1. Blood glucose
2. Na, K, Cl, HCO3, Mg, Phos, Ca

Front 19

With PN, what is monitored 2-3 times weekly?

Back 19

1. Hematrocrit
2. BUN:Creatinine

Front 20

Hyperglycemia
-Predisposing Factors
-Management

Back 20

Predisposing factors: stress, corticosteroids, pancreatitis, diabetes mellitus, peritoneal dialysis
Management: Decrease dextrose intake (rate of infusion or dextrose concentration) and substitute fat calories and/or insulin

Front 21

Hypoglycemia
-Predisposing Factors
-Management

Back 21

Predisposing factors: abrupt withdrawal of dextrose, insulin overdose
Management: increase dextrose intake, decrease insulin, taper rate prior to d/c

Front 22

Excess CO2 Production
-Predisposing Factors
-Management

Back 22

Predisposing factors: excess dextrose intake
Management: decrease dextrose intake, balance calories as fat and dextrose

Front 23

Hyperlipidemia (cholesterol, triglyceride)
-Predisposing Factors
-Management

Back 23

Predisposing factors: stress, familial hyperlipidemia, pancreatitis, excess IVLE dose or rapid infusion rate
Management: decrease fat intake or rate of infusion, discontinue if indicated (no more than 60% of calories should come from fat, fats are usually given every other day, check levels on off days)

Front 24

Serum amino acid imbalance
-Predisposing Factors
-Management

Back 24

Predisposing factors: stress, hepatic failure
Management: modify amino acid intake if possible or decrease amino acid intake

Front 25

Abnormal LFT's (SGOT, alkaline phosphatase, bilirubin)
-Predisposing Factors
-Management

Back 25

Predisposing factors: stress, infection, cancer, excess carbohydrate intake, excess total calorie intake, essential fatty acid deficiency
Management: decrease dextrose intake (substitute fat), decrease total calorie intake, provide essential fatty acids, cycle PN infusion, transition to enteral as soon as possible

Front 26

Increased BUN
-Predisposing Factors
-Management

Back 26

Predisposing factors: renal insufficiency
Management: decrease protein intake (if BUN goes up 10, decrease protein intake by 10)

Front 27

Hypovolemia
-Predisposing Factors
-Management

Back 27

Predisposing factors: GI fluid losses, osmotic diuresis
Management: increase fluid intake

Front 28

Hypervolemia
-Predisposing Factors
-Management

Back 28

Predisposing factors: renal failure, cardiac failure, excess fluid intake
Management: decrease fluid intake, diuretics

Front 29

Hyponatremia
-Predisposing Factors
-Management

Back 29

Predisposing factors: GI losses, fluid overload, diuretics
Management: varies with cause

Front 30

Hypernatremia
-Predisposing Factors
-Management

Back 30

Predisposing factors: dehydration
Management: increase fluid intake

Front 31

Hypokalemia
-Predisposing Factors
-Management

Back 31

Predisposing factors: GI losses, diuretics, anabolism
Management: increase potassium intake

Front 32

Hyperkalemia
-Predisposing Factors
-Management

Back 32

Predisposing factors: renal failure, potassium-sparing drugs, metabolic acidosis
Management: decrease potassium intake, correct metabolic acidosis

Front 33

Hypophosphatemia
-Predisposing Factors
-Management

Back 33

Predisposing factors: phosphate-binding antacids, anabolism, phosphate-free dialysate
Management: discontinue phosphate-binders, increase phosphate intake

Front 34

Hyperphosphatemia
-Predisposing Factors
-Management

Back 34

Predisposing factors: renal failure
Management: decrease phosphate intake

Front 35

Hypomagnesemia
-Predisposing Factors
-Management

Back 35

Predisposing factors: diarrhea, malabsorption, anabolism, magnesium-wasting drugs
Management: increase magnesium intake

Front 36

Hypermagnesemia
-Predisposing Factors
-Management

Back 36

Predisposing factors: renal failure
Management: decrease magnesium intake

Front 37

Hypocalcemia
-Predisposing Factors
-Management

Back 37

Predisposing factors: hypoalbuminemia (do corrected calcium), chronic renal failure
Management: increase calcium intake (with chronic renal failure only)

Front 38

Hypercalcemia
-Predisposing Factors
-Management

Back 38

Predisposing factors: very rare, dehydration, malignancy
Management: decrease calcium intake, increase fluid intake

Front 39

Metabolic acidosis
-Predisposing Factors
-Management

Back 39

Predisposing factors: diarrhea, high output fistula, renal failure, excess amino acid intake
Management: decrease chloride in TPN, increase acetate in TPN

Front 40

Metabolic alkalosis
-Predisposing Factors
-Management

Back 40

Predisposing factors: gastric losses
Management: increase chloride in TPN, decrease acetate in TPN

Front 41

What is refeeding syndrome?

Back 41

Severe rapid decline in serum phosphate, potassium, and magnesium. It is life-threatening.

Front 42

Risks for developing refeeding syndrome

Back 42

1. administration of aggressive nutritional supplementation to a severely malnourished patient with significant weight loss
2. patients with stress or nutritional depletion unfed for 7-10 days
3. patients with chronic undernutrition due to chronic disease (cancer, COPD, cirrhosis, previous morbid obesity with significant weight loss)

Front 43

Prevention of refeeding syndrome

Back 43

provide 25-50% of NPC requirements initially (100-200 grams of dextrose/day) and advance over 3-4 days with monitoring to the desired goal

Front 44

Infectious complications of PN

Back 44

Identifying catheter sepsis in the acutely stressed patient who has multiple potential sources of fever may be difficult. Catheter sepsis is defined as a septic episode in which no other site of infection is obvious, the fever resolves upon catheter removal and cultures of catheter tip and peripheral blood grow the same organism.