MNT Exam 1-Parenteral nutrition

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MNT Exam 1-Parenteral nutrition
2012-02-26 22:36:32
Parenteral nutrition

Parenteral nutrition
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  1. What is the general definition for parenteral nutrition and the two types?
    • PN refers to the provision of nutrients by any route that does not involves the intestine tract.
    • 1.Total parenteral nutrition (more common)
    • 2. Periperal/partial parenteral nutrition
    • Delivering nurition thru vein, pass the GI
    • Fluid is broken down when go thru vein
  2. What are some things to know about the hanging bags of solution?
    • once spiked they can hang for 48 hrs
    • the yellow bag contains vitamins, mineral, and lipid and is given its color because if B vitamin (plus may be added seperatly)
    • The white bag is typically CHO, protein, and lipid
    • Both connect at base forming a "Y" shape
  3. What are indications for PN?
    • a not working GI
    • npo (nothing by mouth) for more than 7 days
    • Fistula in GI
    • short bowel syndrme
    • Needed GI res-massive bowel ressection
    • intractable vomiting/diarrhea-pregnancy
  4. what are contraindications for PN?
    • tx anticipated for more than 5 days
    • a working GI
    • no venous access
    • terminal condition-put someone at higher risk
    • risks are higher than benefits
  5. What is the definition for tpn?
    • all nutrition!
    • central access for catheter tip placement in large, high blood flow vein ( superior vena cava, jugular or femoral)
  6. what are two common ways to deliver access thru ppn and tpn?
    • PICC line:
    • *threated into superior vena cava (in arm)
    • *one at bedside by RN's-surgery??
    • *in subclavian vein
    • *can be used for many things
    • *thick and dense
    • *not comforatble

    • IJ(interal jugular) vein:
    • *easiest, go straight to heart
    • *high risk because of infection
  7. what are some important things about ppn?
    • It is not commonly used
    • its peripheral access
    • it avoids risk of central route
    • has lower osmolality(because of sm vein)
    • short term(no more than 5 days)
    • can increase fluid (because low conc.= high fluid)
  8. what are the indications for ppn?
    • for short term nutrition (5 days-so vein wont burst)
    • to avoid risk linked to central route placement
    • intermediate way to wean from tpn (dont switch right away)
  9. what are the macronutrients for pn?
    dextrose (cho's), amino acids (protein), fat/essential f.a's (lipids)
  10. What are some important things to know about dextrose?
    • = 3.4 kcals/kg
    • con. of 5-70%, 5-20% in soltn.
    • limit venous access because hypertonicity
    • limit to 5mg/kg/min (limit per body per minute, to control blood sugar, keeps vein healthy)
    • max 10% for ppn
  11. What are some important things to know about a.a's?
    • =4 kcals/kg
    • crystalline a.a's ( so small)
    • provides all Eaa's and 10-12 non-Eaa's
    • max at 4% for ppn
    • usually 10-20% kcal
  12. What are some important things to know about fatty acids?
    • in 10% or 20% conc.
    • 100 ml (kids), 250 ml, or 500 ml
    • provide 20-30% kcal
    • max at 60% of 2 mg/kg/min
    • use egg phospholipid (if allergic to egg then dont use!)
    • stablized by glycerol
  13. What patients may benefit from higher fat?
    • those who need less fluid (heart failure, not raise bp)
    • glucose intolerance( low CHO, so increase fat)
    • respiratory compromise( CHO make breath out CO2)
  14. what are the contraindications for using lipid emulsions?
    • hyperlipidemia
    • acute pancreatitis with hypertrygliceridemia
    • high amount lipid-contain medicine
    • bad egg allergy
  15. what are some important things about electrolytes?
    • they vary in need by patient
    • they increase amount from GI, skin, and urine loss
    • they correct severe imbalances
  16. what are some important things about vitamins?
    • 10-12 ml MVI added daily
    • larger doses to correct deficinecies
    • vitamin K not incuded in addition
    • RD/pharmacists determine
  17. what are some important things about trace elements?
    • added daily
    • withhold cu and mg because liver failure
    • xtra zn for GI loss
    • fe not really added because burns
  18. what is the mixture of totoal nutrient admixture solutions (3 in 1)?
    dextrose, fats, a.a's, vitamins, trace elements, electrolytes
  19. what are pro/con of total nutrient admixture?
    • pro: convinience, ensure mixed fuel
    • con: not stable, limited info, $$$, higher contamination, not felxible
  20. What do you consider when doing a nutrition Rx?
    • dosing weight
    • protein needs
    • distribute remaining kcal between pro and fat
    • electrolyte, vitamins/min needed
    • fluid needs
  21. when calcualting fluid needs what is something important to take into consideration?
    that it should be 30 ml/kg??
  22. what do you moniter with regards to a nutrition Rx?
    • check lytes, BUN, ca/mg/po4 until stable
    • check TG and liver function tests every 7-10 days
    • change medicine
    • weight
    • actual intake
    • signs of GI function
  23. what is the tpn advancing guidelines?
    • start at 30 cc/hr
    • advance 20-25 cc/hr q every 12 hrs
    • (q 12-24 hr in icu)
    • start slow!!
  24. what are the advancement guidelines for ppn?
    • start at half the goal rate
    • advance to goal after 12 hrs
    • max dextrose at 10% and AA at 4%
  25. what are complications associated with pn?
    • hyper/hypoglycemia
    • electroltye imbalance
    • infection
    • mechanical issues (power die)
    • liver problems
    • under/over feed
    • refeeding syndrme
    • gut bacterial translocator
  26. what is the etiology of hyperglycemia?
    • increases CHO
    • high steriod doses
    • diabetes
    • overfeed total kcal
    • sepsis/stress/infect
    • insulin in tpn bag
  27. what is rebound hyperglicemia?
    can happen with abrupt stopping of tpn, need to ween off tpn
  28. what are important things about refeeding syndrome?
    • can occur thru pn, enteral, etc
    • labs show low PO4, MG, CA, K, high BG
    • due to cell uptake of increased CHO
    • people can die from low PO4+ MG= cardio death
  29. what patients are at risk for re-feeding syndrome?
    • anorexia
    • classic kwashiorkor
    • chronic malnutrition/underfeed
    • chronic alcoholism
    • morbid obesity
    • unfed 7-10 days
    • fasting
  30. how do you prevent refeeding syndrome?
    • be aware of signs within 24 hrs
    • recognition of patients with risk
    • do lab tests
    • re-feed slooww
  31. what are the infectious and mechanical complications?
    • line sepsis
    • pneumothroax
    • venuos thrombosis
    • vein/ line occulusion
    • pump problems
  32. what are hepatic complications?
    • fatty liver
    • cholestasis
  33. what are some important things about fatty liver?
    • happen within 2-3 weeks of TPN- with overfeeding
    • labs show increase LFTS
    • return to normal after stop tpn, or modify delivery
  34. what are the etiologies/implications of fatty liver?
    • too much: kcal, glucose (more than 5mg/kg/min), fat
    • EFA and carnitine deficient
  35. what are some important things about cholestasis?
    • etioligy unknown
    • stones cause blockage in liver
    • increase billi, and alk phos in labs
  36. how would you prevent/manage hepatic condidtions?
    • limit CHO (5 mg/kg/min)
    • dont overfeed
    • used mixed fuel source
    • carnitine supplement
    • find other causes
    • use GI
    • cycle tpn and lipids
  37. why would you use cyclic/intermittent pn?
    • allow motility
    • lessens load on organs
    • allow adminster blood products
  38. what are benefits of enteral nutrition?
    • more physiologic
    • maintain gut
    • provide glutamine
    • avoid complications with pn
    • less $$$