TPN

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Author:
alvo2234
ID:
217210
Filename:
TPN
Updated:
2013-05-02 13:12:59
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Final Exam
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Final
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  1. basic nutritional status assessments
    • Height
    • wt
    • IBW/BMI
    • Weight change
    • primary diagnosis
    • co-morbidities
  2. other nutritional status assessments
    • creatinine
    • bilirubin
    • pre albumin
    • liver enzymes
    • triglycerides
    • Input and Output
    • glucose
  3. REE
    rest energy expenditure
  4. signs and sx
    • 10% increase/decrease in wt within 6 mths
    • 5% within 1 mth

    20% over/under IBW

    inadequate intake due to impaired ingestion or absorption
  5. 5 consequences of malnutrition
    • delayed healing
    • re-hospitalization
    • increase stay
    • increased cost
    • increased mortality
  6. 3 ways to calculate energy expenditure
    • predictive
    • energy expenditure (calorimetry)
    • weight based calculations
  7. Harris-Benedict
    • weight
    • age
    • stress
    • height
  8. ireton-jones
    • weight
    • age
    • gender
    • injury
    • obesity
  9. Fick predictive equation
    • CO
    • Hgb
    • SaO2
    • SvO2
  10. how are O2 and CO2 used
    to indirectly measure calories
  11. ADV and dis ADV of indirect calorimetry
    • requires expert skill
    • time consuming (30-60 min)
    • most accurate
    • most expensive
  12. indirect calorimetry is IND for
    • pts who fail on predictive equations
    • individualize nutrition
    • nutrition requirements difficult to establish
  13. where are calories derived from
    macronutrients
  14. what are caloric needs and fluid requirements based on
    • expenditure estimates
    • activity/stress
    • malnutrition history
  15. range of fluid a pt should receive in a day
    20 - 35 kcal/kg/day
  16. amt of total fluids a pt should receive a day
    • 30 - 40 mL/kg/day
    • 1 - 1.5 mL/kcal expended
  17. disadvantages of parenteral
    • cost
    • complex
    • morbidity/mortality increase
  18. what are gastric residual volumes
    accumulation of EN and gastric secretions
  19. complications of EN
    • diarrhea
    • aspiration
    • nausea
    • pneumonia
    • abdominal distention
    • regurgitation/emesis
  20. when do GRVs only occur
    during delayed gastric emptying
  21. how is pneumonia caused with EN
    accumulation of EN leads to aspiration which eventually results in pneumonia
  22. Taylor GRV trial
    determine effects of early enhanced EN in head injured patients requiring mechanical ventilation
  23. Pinilla GRV trial
    compared GI tolerance of two EN protocols in critically ill pts
  24. McClave GRV trial
    determine whether GRV accurately predicts aspiration risk

    there was no difference
  25. Montejo GRV trial
    compare effects of increasing the GRV limit in the adequacy of EN

    no difference
  26. daily salivary output
    1500 ml
  27. daily gastric secretions
    3000 ml
  28. volume of total fluid
    188 ml/hr
  29. EN infusion rate
    25-125 ml/hr
  30. GRV approximation
    residual volumes should plateau between 232 and 464 ml/hr within 3-6 hrs of initial feeds
  31. agents used to treat very high GRV
    • cisapride
    • erythromycin
    • metoclopramide
    • naloxone
  32. elemental formulation contains
    • individual AA
    • glucose polymers
    • low fat
    • LCTs
  33. semi elemental EN contains
    • varying AA
    • glucose polymers
    • low fat
    • MCTs
  34. Standard EN formulation contains
    • intact AA
    • carbs
    • mainly LCTs
  35. complications with EN
    clinical problems (diarrhea, aspiration, metabolic disturbances)

    • clogged feeding tubes
    • high gastric residuals
    • delayed gastric emptying
    • iatrogenic pneumothorax
  36. how do you treat clogged EN feeding tubes
    pancrealipase + bicarbonate
  37. EN metabolic disturbances are less with
    elemental than TPN
  38. what is the #1 side effect in pts on EN
    diarrhea
  39. confounding factors that influence diarrhea in EN
    • medications
    • infections
    • malabsorption
    • co morbid conditions
  40. treatment approaches for diarrhea
    • remove offending medication
    • give probiotic supplements
    • antidiarrheal med (loperamide)
    • change formulation
    • assess fat content in stool
  41. what is the most feared complication of EN
    Aspiration
  42. when will EN likely to cause primary disturbances
    • re feeding
    • hyperglycemia
  43. IND for TPN
    malnurouished prior to hospital or > 7 days in hospital

    Inadequate or expected inadequate oral intake for 7 - 14 days


    catabolic illness with normal energy/protein utilization
  44. TPN goals
    • preserve lean body mass
    • support organ structure/function
    • decrease morbidity and mortality
    • support immune function
  45. list the macronutrients
    • AA
    • dextrose
    • lipids
  46. list the micronutrients
    • electrolytes
    • vitamins
    • minerals
  47. other TPN components
    • water
    • medications
    • -h2 blockers
    • -thiamine
    • -folic acid
    • -vitamin k
    • -insulin
  48. only h2 antagonist used in TPN
    famotidine
  49. what is the primary TPN element
    AA
  50. AA metabolic demands for unstressed/maintenance range
    0.8 - 1 g/kg/d
  51. AA metabolic demands for catabolic
    1.2 - 2 g/kg
  52. AA contain how much protein
    4 kcals/g of protein
  53. AA contain how much acetate
    75 - 150 mEq/L
  54. AA which contain phosphate
    • FreAmine III
    • HepatAmine
    • Hepatasol
  55. AA containing phosphate should not be given with
    Ca++
  56. Which TPN element provides majority of non-protein calories
    Dextrose (lipids provide other non-protein cal)
  57. what does the dextrose load depend on
    glucose tolerance
  58. what are the limits to dextrose
    • 7 g/kg/d
    • 3.4 kcal/g
  59. TPN dextrose does what to fat lvs in pts? what does it eventually lead to?
    • activates insulin and reduces adipose lipolysis
    • leads to linoleic acid deficiency
  60. limit to TPN lipids
    • 2.5 g/kg/d
    • 10 kcals/g for 20-30% IV
    • 11 kcals/g for 10% IV
  61. what is added to TPN lipids to make it stable
    glycerol which adds to the calories
  62. what will dextrose do to electrolyte lvs
    • decrease serum electrolytes
    • IC shift caused by insulin release
  63. how long until patients begin to show signs of fatty acid deficiency
    20 - 21 days
  64. when are trace elements used in TPN
    if pt is not getting food
  65. which MTE contains selenium
    MTE-5
  66. what trace elements are contained in MTE-4
    • chromium
    • zinc
    • copper
    • Mg++
  67. what must you consider with micronutrient trace elements if total bilirubin is elevated
    consider reduction (50%) or removal of trace elements (copper and Mg)
  68. when do you add zinc IV to MTE
    • high output fistula or ostomy
    • open wounds
    • intractable diarrhea
  69. what element helps with wound healing
    zinc
  70. how much zinc is sufficient for positive balance
    12 mg/d
  71. which micronutrient is used for burns and trauma
    glutamine
  72. amt of AA indicated for pt with hepatic disease
    1g/kg/d
  73. what micronutrients should be avoided in pts with hepatic dysfunction
    Cu and Mg (due to accumulation of bilirubin)
  74. what are the special considerations in TPN
    • AKI or CKD
    • DM
    • hepatic dysfunction
    • obesity
    • critical care
  75. how many kcals are given to obese pts
    • 22-25 IBW
    • 11-14 Actual body weight
  76. calories needed for  critical care pts
    25-35
  77. lipid considerations with critical care pt
    • limit is 1g/kg/d
    • avoid giving during acute inflm
    • lipid free TPN for first wk of hospitalization
  78. monitoring for TPN rate advancement
    • metabolic complications
    • -hyperglycemia
    • -refeeding syndrome
    • -electrolytes
  79. goal rate for TPN
    2-3 days
  80. pts at risk for refeeding syndrome
    • prolonged inadequate intake
    • alcoholic
    • morbid obese and large wt reduction
  81. metabolic complications of refeeding syndrome
    • hypokalemia
    • hypophosphatemia
    • hypomagnesemia
    • vitamin deficiencies (thiamine)

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