TPN

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alvo2234
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272641
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TPN
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2014-05-01 03:39:42
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TPN
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  1. metabolic stress response considerations
    • hypermetabolism
    • SIRS
    • hyperdynamic
  2. what decreases in metabolic response to injury
    • protein synthesis
    • SVR
    • growth hormones
  3. what nutritional assessment tools are not validated in critical care
    • albumin
    • prealbumin
    • anthropometry
  4. what are the visceral serum proteins
    • albumin
    • prealbumin
    • transferrin
  5. what does an increase in visceral proteins reflect
    a + nitrogen balance
  6. how can the nitrogen output be determined and how much is added for insensible loss
    by a 24 hour urinary urea nitrogen (UUN) with 2-4 grams added for insensible loss
  7. what is the goal of nitrogen balance
    to achieve a positive balance (4-6 grams)
  8. what are the most common methods of determination of energy needs
    • harris-benedict basal energy expenditure
    • clinical estimation of energy expenditure
    • indirect calorimetry
  9. what is the harris-benedict equation
    • 66 + 13.8(wt) + 5(ht) - 6.8(age)
    • 665 + 9.6(wt) + 1.8(ht) - 4.7(age)
  10. what is the clinical estimated energy expenditure based on ABW
    25 - 35 kcal/kg/day
  11. what is the clinically estimated energy expenditure for obese pts
    • 11 - 14 kcal/kg/day for ABW or
    • 22-25 kcal/kg/day for IBW and
    • >=2g/kg IBW (BMI 30 - 40)
    • >=2.5g/kg IBW (BMI >=40)
  12. what is the preferred route of nutrition for the critically ill patient who requires nutrition support
    Enteral nutrition
  13. when should enteral feeding be started following admission in the hospital
    24-48 hrs
  14. how should a pt needing EN with hemodynamic compromise be handled
    EN should be withheld in the pt until the pt is fully resuscitated
  15. what are the benefits of early EN
    • improve N balance
    • improve wound healing and host immune funct
    • preserve intestinal mucosa, decr bact transloc
    • reduce length of hospital stay
    • decrease ICU/hospital mortality
  16. methods of enteral feeding
    • continuous
    • intermittent (3-4 meals/day)
  17. what is the best tolerated EN feeding route
    continuous feeding
  18. which EN route is not for small bowel feedings
    intermittent route
  19. what are the protein requirements for pts with BMI < 30 in EN feeding
    1.2 - 2 g/kg ABW
  20. what is the dosing for Enteral Feeding in critically ill obese pts when EN is recommended
    • 11-14 kcal ABW or 22-25 IBW
    • BMI 30-40 protein req (>=2 IBW)
    • BMI >40 protein req (>=2.5 IBW)
  21. when should immune-modulating enteral formulations be used
    • surgical/ medical ICU pts
    • major surgery
    • trama
    • burns
    • head neck cancer
    • mechanical ventilation
  22. EN recommendations for ICU pts with acute renal failure or AKI
    should be placed on standard enteral formulations and standard protein and calorie requirements
  23. EN recommendations for pts with renal failure receiving hemodialysis or continuous renal placement therapy
    increase protein up to max 2.5 gm/kg/day
  24. EN recommendations for pts with hepatic failure
    use standard EN formulations for acute and chronic liver disease and avoid restricting protein
  25. when should EN BCAAs be used
    pts encephalopathic patient
  26. example of BCAA
    nutrihep
  27. EN recommendations for pts with ARDS/Severe acute lung injury
    EN formulation characterized by an anti-inflammatory lipid profile
  28. type of anti-inflm lipid EN formulations
    • omega 3 fatty acid
    • borage oil
    • antioxidants
  29. which type of special formulations are not recommended for pts with pulmonary disease
    high lipid-low carb
  30. which formulations are recommended for pts with pulmonary disease
    fluid restricted calorically dense formulations
  31. how should EN continuous feeding be initiated and progressed
    • initiate at a rate of 10 - 30 cc/hr
    • and increase 10-20 cc q 4 -24 hrs based on tolerance up the goal rate
  32. how should EN intermittent feeding be initiated and progressed
    • initiate with 1/2 can formula 30+ min 3-4/day
    • increase by 1/2 can per feeding daily
  33. how should flush tubes be initiated and progressed
    • 30-60 cc TID for patency
    • before/after all feeding and medications
  34. how to handle gastric residuals
    • <250 (return to pt)
    • 250-500 (continue feed and recheck in 1 hr if greater than 250 than notify MD)
    • >500 (hold EN and notify MD)
  35. PN macronutrients
    • dextrose
    • lipids
    • AAs
  36. what rate are lipids infused in PN for 2 in 1 mixtures
    0.1g/kg/hr
  37. what are the advantages of PN 3 in 1 mix
    • decrease:
    • rate of microbial growth
    • pharm prep time
    • compounding supplies
  38. disadvantages of PN 3 in 1
    • cannot see particulate matter
    • cannot filter with 0.22 micron in line filter
    • risk of fat emulsion instability
  39. what is the mean droplet size of commercially available fat emulsions
    between 0.2 - 0.5
  40. size micron filter used for 3 in 1 PN mixture
    1.2 micron in line filter
  41. PN combatibility issues deal with which electrolytes
    calcium and phosphate
  42. dextrose kcal/g
    3.4
  43. AA kcal/g
    4
  44. why are electrolytes added to PN formulations
    to maintain physiologic serum concentrations
  45. what is the initial nutrition plan for PN
    • 1. at least 1 g protein/kg/day (based on wt)
    • 2. at least 2 g dextrose/kg/day (dosing weight)
    • 3. evaluate serum TGs prior to initiating IV lipids
    • 4. provide no more that 15 total kcal/g/day (usually 10)¬†for the first 24 to 48 hours until serum electrolytes and glucose are stabilized
  46. how to write a PN
    • calculate caloric requirements
    • determine fluid requirements
    • calculate protein requirements
    • calculate remaining calories (20-30% lipids)
    • remaining is dextrose (about 70%)
  47. what are the fluid requirements for pt on PN
    30-35 ml/kg/day
  48. usual protein requirement for PN
    1.5-2 g/kg/day
  49. protein requirements for pts with kidney failure without dialysis
    0.8 - 1
  50. protein requirements for pt with kidney failure with dialysis
    1.2 - 1.5
  51. what should be done before giving pt micronutrients
    • evaluate lab results
    • evaluate measured electrolytes
    • evaluate renal function
  52. catheter related infections are caused by which organisms
    • s. aureus
    • candida albicans
  53. how to prevent overfeeding complication from PN
    • initiate slowly (2g/kg/day)
    • dextrose should be <4mg/kg/min or <=6g/kg/d
  54. sx of refeeding syndrome
    • hypophosphatemia
    • hypomagnesemia
    • hypokalemia
  55. how to prevent refeeding syndrome
    provide no more than 15 total kcal/kg/day for first 24 to 48 hours
  56. what are the essential fatty acids
    linoleic and linolenic acid
  57. sx from FA deficiency
    • scaly dermatitis
    • alopecia
    • thrombocytopenia
    • anemia
    • impaired wound healing
  58. effects of aluminum toxicity
    • osteopenia
    • neurotoxicity
  59. what are the guidelines on when to use PN on the critically ill
    • 1. if pt previously health with NO protein energy malnutrition prior, use PN only after first 7 days
    • 2. if protein energy malnutrition, start PN immediately
    • 3. major surgery: if pt is malnourished delay surgery and initiate PN 5 to 7 days pre-op, wait 5 to 7 days after surgery, initiate PN post op
    • 4. initiate only if duration of tx is anticipated to be >= 7 days
  60. benefit of arginine
    improve immune function and decrease infectious complications and mortality
  61. arginine is a precursor to
    NO synthesis
  62. glutamine is a precursor to
    nucleotide synthesis
  63. what is the potential benefit of glutamine
    • healing of GI mucosa
    • heat shock proteins
    • anti-oxidant
  64. why is glutamine not usually included in PN
    instability
  65. when should glutamine be added to PN
    • burn
    • trauma
    • mixed ICU pts
  66. what should be done to pts whose energy requirements have not been met after 7-10 days on EN
    initiate PN

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