What are 2 things that should never go together in the same TPN Bag.
Sodium and bicarbonate.
Acetate should be used in TPN instead of bicarb.
1 mEq acetate = 1 mEq bicarb
What are the caloric values of dextrose, protein, alcohol, fat (per gram), 10% fat emulsion (profpfol?), and 20% fat emulsion?
3.4
4
7
9
1.1
2
What is the caloric value of dextrose?
3.4
What is the caloric value of protein?
4
What is the caloric value of alcohol?
7
What is the caloric value of fat (per gram)?
9
What is the caloric value of 10% fat emulsion (propofol?)?
1.1
What is the caloric value of 20% fat emulsion (per ml)?
2
What is a common protein dose in non-dialyzed renal failure and standard for most people?
Protein: 0.5 - gram/kg
Also review types of amino acid formulations in RF.
What can be caused by Vitamin B12 or folic acid deficiency?
Megaloblastic Anemia
Both can treat the megaloblastic part, only B12 can treat the neuropathies...
What are the pore sizes of filters used for AA/Dex and TNA TPNs?
0.22 and 1.2
Fat particles are too large for the 0.22 micron filters, therfore require 1.2.
60 year old male with pancreatitisPrealbumin = 6.2 (low)
TPN = 105% BEE and 1.2 g/kg protein
BEE = basal energy expenditure.
this is and underfed patient
A better TPN would + 150% BEE and 1.5-1.6 g/kg PRO
What is refeeding syndrome?
Shift of K, Mg, and phos into the cell when a patient is fed after a period of little or no intake?
can happen with PO, enteral, or TPN, so watch out in case those levels DROP so you can fix them!
What is an amino acid added to Pediatric AA formulations?
Taurine
Necessary for proper growth in neonates and peds
What are the 2 major reasons for tapering TPN containing greater than 10 percent DEXTROSE?
To prevent hyper and hypo glycemia.
Some people think it is unnecessary, but why take the chance on having problems when it is relatively easy to do and has been a standard of practice for years?
What can be caused by excessive linoleic (omega -6) fatty acids?
Inflammation and immunosuppression
Where do we find Omega-6 fatty acids in the course? {soy oil-based} IV Fat Emulsion
What is NPC: N?
(Dextrose kcal + fat kcal)/ protein in grams
Non-Protein Calorie to Nitrogen Ratio
What is Positive Nitrogen Balance?
A goal for nutrition support. Generally requires a 24 hour UUN (urine collection).
Want anything above zero. Generally 2-4.
Negative nitrogen balance means the patient is likely catabolic and losing lean tissue. This is bad.
Can't tell by how the patient feels.
Why is it recommended to infuse PB lipid over 12 hours or less?
Risk of infection may be increased with a 24 hour infusion.
Because lipid is most conducive to microbial growth (more so than AA or DEX)
This recommendation does not apply to three in ones where you mix it all in the same bag.
Which form of injectable iron requires a test dose?
Iron Dextran
Observe for 1 hour after the test dose watching for signs of anaphylaxis.
Don't give it IM
Not compatible in TPN
Which type of AA formulation is appropriate for most adults?
Standard
Specialty AA's often not cost-effective for most patients, but you should know when they can be useful...
What is a calculation often used for nutritional dosing?
Adjusted or Estimated LBW
Nutritional Dosing Weight = uses 20-25% of the difference between Ideal Body Weight and actual Weight if the patient is overweight, NOT 40% as used for aminoglycoside dosing.
What is the main source of non-protein calories in PPN?
IV Fat emulsion in Peripheral TPN (PPN)
What are 2 IV components that are incompatible with each other?
Iron dextran and IV fat emulsion
What is the maximum rate of infusion for 20% IV fat emulsion?
60 ml per hour
What is the maximum rate of infusion for 10% IV fat emulsion?
125 ml/hr
What is the energy need range for maintenance therapy? (% of basal energy expentiture, BEE)
120-130%
What is the energy need range for general surgery? (% of basal energy expentiture, BEE)
150%
What is the energy need range for major surgery/sepsis? (% of basal energy expentiture, BEE)
up to 200%
What is one method to calculate fluid requirements in pediatrics? (LBW "Neons" - use ranges)
Memorize this!
100 per kg for the 1st 10 kg + 50 per kg for next 10 kg then 20 per kg after that.
What are the symptoms of generalized deficiency of B vitamins?
angular fissures and vertical cracks on the lips, shiny smooth tongue
What are the symptoms for zinc deficiency?
A blistery periorbital rash. (around nose, mouth and anus)
What is the maximum recommended GIR (glucose infusion rate) for adults receiving TPN?
5 mg/kg/minute
The acceptable range is generally higher for peds.
What is the mOsm value for AA per 1 gram % final concentration in a TPN?
100
For example 5% AA or 50 grams/L = 500 mOsm/L
What is the mOsm value for DEX per 1 gram % final concentration in a TPN?
50
For example 10% DEX or 100 grams/L = 500 mOsm/L
What is the mOsm value for Lytes per 1 mEq in a TPN?
1
regarding specialized TPN for patients with renal failure on CRRT...
Which is most appropriate?
1. may need up to 2.5g/kg IVFE
2. NephrAmine or Renamin
3. Standard AA's
4 Fluid restr. AA's
3 or 4
Standard AAs or Fluid restricted AAs
Standard probably best because you can control for fluids with dialysis machine.
Which of the following is true or associated with the refeeding syndrome?
1. Occurs only with TPN
2. Treat with Thiamine
3. High potassium
4. Low serum Phos
4. Low serum Phos
All of the following trace elements may need to decrease in long term TPN except
1. Zinc
2. Copper
3. Chromium
4. Maganese
1. Zinc
Pediatric Fluid Equation
Memorize it!
Including heparin in TPN might help prevent all of the following except.
1. Line clotting off
2. high lipoproteins
3. Thrombophlebitis
4. high TRIG levels
2. high lipoproteins
All of the follwing are risk factors for Calcium and phosphorus Precip in TPN except...
1. High Ca and Phos
2. Calcium Chloride
3. Lower Temp
4. low AA conc
5. Slow infusion rate
6. phos 1st, ca next..
7. what this again?
3. Lower temperature
This makes it MORE soluble.
BTW ... There was a recent shortage in calcium gluconate.
Watch breeze presentation on metabolic stress
PP 66-71 on the PDF
daslkfj
know the glucose infusion rate equation and peds fluid equation
memorize these
What RQ indicates the patient is being overfed?
B. 1.1
Maintenance kcal for adult on TPN would be?
20-30
Maintenance kcal for an obese adult on TPN would be?
10-20
Repletion/stress kcal for adult on TPN would be?
30-40
Maintenance kcal for adolescent on TPN would be?
30-40
Aids patient kcal for adult on TPN would be?
greater than 40
How many mcg of vitamin K are contained in adult MVI?
150
Which vitamin is critical to provide during a shortage in injectible multivitamins for TPN?
Thiamine
Since PPN requires a low osmolarity, the majority of calories are provided by...
IV Fat
Dextrose
AA
EFA's
IV Fat
In central TPN the majority of calories are provided by...
