by jwilli


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What is the purpose of lipids in the diet?
For essential fatty acids
When do adults become deficient of essential fatty acids? Babies?
7 days for adults to become deficient
3 days for babies to become deficient
Why can't you just always give parenteral feeding?
The GI system needs to be working and if your only giving parenteral feeding your not using the GI system which causes problems
How soon should parenteral feeding begin?
Within 24 hours
The overall goal of Parenteral vs. enteral feeding?
You want to get patient back to eating an oral diet ASAP
What should you be looking for on the TPN bag?
Indications and limitations...it's pretty strict
How is the fat portion usually given?
In a seperate bag, but it doesn't have to be.  Can also be given in a 3 in 1 bag.
What is the limitation to giving fat in a seperate bag?
You can only give fat for 12 hours
How long can fat be given through a 3 in 1 bag?
24 hours since
What is the maximum osmolarity for a peripheral line?
900-1100 mOsm/L...usually use the lower limit though
What should you be doing to be extra cautious with the calculations?
Double check every calculation every time
What is the purpose of Nutritional support therapy? (from slide)
To enhance therapeutic outcomes due to a contributing illness, improve the quality of life and minimize complications
As far as amount your feeding a patient, what do you want to avoid?
Over or under feeding. Can have lots of complications is you over or under feed
What are the risks of underfeeding?
Decreased respiratory muscle strength
Impaired organ function
Failure to wean from mechanical ventilation
Low transport protein levels in the absence of inflammation or infection
Increased risk of Noscomial infection
Poor wound healing
Immunosuppression
Decreased ventilatory drive
What are the complications of overfeeding?
Hyperglycemia
Azotemia
Hyperglyceridemia
Alterations in hydration status
Hepatic steatosis
Immunosuppresion
Electrolyte imbalance
Failure to wean from mechanical ventilation
What are the special circumstances to consider with Underfeeding?
Severe malnutrition
Systemic inflammatory response syndrome
Hypercapnia
Hyperglycemia
Chronic obstructive pulmonary disease
Acute respiratory distress syndrome
Multiple organ dysfunction syndrome
Persistent elevations in respiratory rate
Hypertriglyceridemia
Obesity (BMI > 30)
Refeeding Syndrome
S
What is the refeeding syndrome?
When you are low in electrolytes because carbohydrates were given and the electrolytes were used up to metabolize the carbohydrates.  Need to check electrolyte levels before giving Carbohydrates to avoid this...patient can die from this!
Before giving a parenteral solution what should you do?
Check the electrolytes to make sure those don't have to be supplemented first prior to giving carbs (parenteral solution)
What is a possible issue in patients with COPD when giving carbs?
If you give a lot of carbs they will have a hard time expelling the CO2.  CO2 is one of the breakdown products of Carbohydrates
What if a non-diabetic patient who has been underfed has high blood glucose?
You still need to feed the patient carbs.  Once you feed them carbs this will cause a shift of the glucose into the cells, lowering the blood sugar!
Definition of refeeding syndrome (from slide)?
Delivery of calories may induce a metabolic and physiological shifts of fluid, electrolytes and minderals that occur as a result of aggressive nutrition support...especially the administration of carbohydrates!
Explanation of how carbohydrate delivery will deal with high blood sugar.
Carbohydrate delivery stimulates insulin secretion, which causes an intracellular shift of these electrolytes and minerals with the potential for severe...hypomagnesemia, hypokalemia, hypophosphatemia
To avoid risk of refeeding syndrome what should we do?
Give electrolytes and initiate calories but give slowly
Are there standard preparations used in parenteral nutrition?
No, there are not standard preparations used in parenteral nutrition.  Enteral nutrition does have standard preparations.
What is a 3-in-1 TPN?
Three things being given.
Carbohydrates (dextrose)
Fats
Protein
Contains all macronutrients and micronutrients
What size of needle must you use when giving 3 in 1 TPN?
1.2u filter
What is not being given if a patient is being given 2-in-1 TPN?
Fat. No intravenous fat emulsions included
What are some indications for TPN?
1) Inability to absorb nutrients via the GI tract
2) Critical care patients who will be NPO for prlonged periods of time
3) GI fistulas, extreme shor bowel syndrome
4) Acute exacerbations of a GI disorder leading to malabsorption..(Crohn's disease)
5) Perioperative support of patients with moderate to severe malnutrition
6) Severe acute necrotizing pancreatitis
What are some clinical conditions where you would use TPN?
1) Hyperglycemia Glucose > 300 mg/dL
2) Azotemia BUN > 100 mg/dL
3) Hyperosmolality Serum Osmolality > 350 mOsm/kg
4) Hypernatremia Na>150 mEq/L
5) Hypokalemia K<3 mEq/L
6) Hypercholremic Cl > 115 mEq/L
7) Metabolic acidosis or alkalosis
8) Hypophosphatemia phosphorus < 2 mg/dL
What are the intravenous components of TPN?
Dextrose
Intravenous Fat Emulsion (IVFE)
Protein
Electrolytes
Vitamins
Trace Elements
What are the ranges that Dextrose is available in?
2.5% to 70%
When should you only give dextrose through a central line?
If the concentration is above 10%, give Dextrose through a central line
What potential problem can occur with Dextrose given through a peripheral line of greater than 10%?
Risk of thrombophlebitis in the peripheral veins
Dextrose administration should not exceed this rate?
4-5 mg/kg/min or
20 50 25 kcal/kg/d to avoid hyperglycemia
Abrupt discontinuation of Dextrose can lead to?
Hypoglycemia
What is the caloric contribution from dextrose?
3.4 kcal/gram
IVFE includes this?
Soybean oil, safflower oils, egg yolk phospholipid as an emulsifier and Vitamin K
Glycerin to render the formulation isotonic
Glycerol a sugar alcohol which provides how much energy?
4.3 kcal/g
What does it mean if something is an emulsifier?
Makes things dissove in water to prevent it from clumping
To properly determine energy from fat we need to know this?
The percentage of fat we are using.
usually
10kcal/g is our energy from fat
What is the caloric value of Liposyn in kcal/ml?
1.1 kcal/ml
Why do we add Sodium Hydroxide to our IVFE solution?
To adjust the final pH to a range of (6-9)
What does IVFE stand for?
Intravenous Fat Emulsion
What type of pore filter does a 3-in-1 preparation require?
1.2 microns since we are giving 3-in-1 preparation.  This leaves the patient more vulnerable to infection because we can't use the 0.22 micron filter which is bacteria-eliminating.
When you use a 1.2 micron pore size when giving a 3-in-1 preparation, what bacteria will you not be able to eliminate?
S. epidermidis
Ecoli
Why is it ok to have IVFE in combination with other micro and macro nutrients hanging for 24 hours?
Because dexrtrose and amino acid formulations are not conducive to bacterial growth (high osmolarity and acidic pH)
What properties of Dextrose and amino acid formulations make it not conducive to bacterial growth?
High Osmolarity & acidic pH
How long does IVFE have to run for if given alone?
12 hours
IVFE should be restricted to this amount of the calories per day?
less than 30% of the calories per day
or
1g/kg/d and be provided slowly over no less than 8 to 10 hours if administered separately to avoid
Why is there a restriction on the amount of fat given per day?
To avoid hypertriglyceridemia
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