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Above what level of triglycerides should TPN not include lipids?
400
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What drug can cause hyperlipidemia in TPN?
propofol
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What should be done to TPN if BUN is high (>50 mg/dL)?
- start proteins very low
- keep vitamin C low
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Which salt should be used in TPN if the pt is acidotic?
acetate salts
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Which salt should be used in TPN if the pt is alkaline?
chloride salts
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What characterizes refeeding syndrome?
- hypophosphatemia
- hypokalemia
- hypomagnesemia
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What are some symptoms of refeeding syndrome?
- weakness
- convulsions
- resp. failure
- cardiac decompensation
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What causes refeeding syndrome?
the sudden shift from fat to carbohydrate metabolism upon feeding a starving pt, which requires more ATP
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How should you try to avoid causing refeeding syndrome in pt at risk?
start TPN at 1/2 to 1/3 of calculated daily calories and move up slowly
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How do you treat refeeding syndrome once it starts?
- stop TPN
- initiate 10% dextrose
- replace electrolytes
- supportive care (oxygen for resp. distress, diuresis for edema)
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How should TPN be monitored?
- basic metabolic panel
- Ca, Mg, PO4CBC w/differential
- serum albumin, prealbumin, AST/ALT, PT/INR
- TGs
- 24h urinary urea nitrogen (if necessary)
- ability to use GI tract
- functional status
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Which parameters should be monitored weekly in the initial period of TPN?
- TG
- CBC
- prealbumin
- PT/PTT, AST, ALT
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What should be monitored daily when the patient is stable on TPN?
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What should be monitored weekly for long-term TPN?
fluid status
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What should be monitored quarterly for long-term TPN?
- PT/PTT, AST, ALT
- trace elements
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What is the half-life of albumin?
20 days
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What is the half-life of prealbumin?
2-3 days
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What is the normal range of albumin?
3.5 - 5.0 g/dL
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What is the normal range for prealbumin?
20-40 mg/dL
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How many lipid-based calories does propofol provide?
1.1 kcal/ml of infusion
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What nutrition weight should be used for underweight patients?
ideal body weight
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What nutrition weight should be used for obese patients?
adjusted body weight = IBW + 1/4(ABW - IBW)
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How do you determine calorie needs for TPN?
Basic Energy Expenditure (BEE) x stress factor
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What are the stress factors for calorie need?
- confined to bed = 1.2
- out of bed = 1.3
- surgery = 1.2
- severe infection = 1.4
- trauma = 1.5
- burn = 1.7
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How do you determine fluid goal for TPN?
1500 mL for the first 20 kg of wt, then add 20 mL/kg for each add'l kg
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How do you determine the protein goal for TPN?
- range = 0.6 g/kg/d - 2.0 g/kg/d
- usually = 1.2 - 2.0 g/kg/d
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How do you determine the lipid goal for TPN?
no more than 1/3 of the total non-protein calories
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How do you determine the dextrose goal for TPN?
about 2/3 of the total non-protein calories
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What should the glucose infusion rate be limited to for TPN?
< 5 mg/kg/min or 7 g/kg/d on a 24h TPN
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How much sodium should be in a TPN?
1-2 mEq/kg (80-150 mEq)
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How much potassium should be in a TPN?
1-2 mEq/kg (40-100 mEq)
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How much magnesium should be in a TPN?
6-12 mEq
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How much calcium should be in a TPN?
4-10 mEq
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How much phosphate should be in a TPN?
15-45 mmol
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What is the usual salt used in TPN?
chloride salt
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What is the conversion for sodium to phosphate?
4.0 mEq Na for every 3 mmol PO4
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What is the conversion for potassium to phosphate?
4.4 mEq K for every 3 mmol PO4
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What is the dose for multivitamins in adults on TPN?
10 mL daily
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How much trace elements should be used in a TPN?
1-2 mL/d (each mL contains 5 mg Zn, 1 mg Cu, 0.5 mg Mn, 10 Mcg Cr)
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What infections are common complications of TPN tx?
- coagulase-negative staph
- staph areus
- strep pyogenes
- fungal infection (most common)
- candida
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What should dextrose infusion rate be limited to in order to avoid causing hyperglycemia?
5 mg/kg/min
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What causes hypercapnia?
excessive carbon dioxide production d/t excessive calories and dextrose
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