ASPEN Self-Assessment questions and answers lately 2023

ASPEN Self-Assessment questions and answers lately 20232. Intolerance to EN trial and supportive care measures. A pregnant patient is admitted with hyperemesis gravidarium. Which of the following is a clinical indication for PN use? 1. Vomiting not controlled with supportive care within 48 hrs. 2. Intolerance to EN trial and supportive care measures. 3. Patient refusal of EN tube placement. 4. Fluid and electrolyte imbalances. B6 & B12 Deficiencies in what two vitamins may lead to neuropathies? Thiamine Deficiency of what vitamin may lead to Wernicke's Encephalopathy? Folic acid Deficiency of what vitamin may lead to neural tube defects? If a pt is unable to take PO feeds after 24-48 hours of supportive therapy. When would EN be trialed on a patient with HG? 1. Thrombophlebitis Rapid IV infusion of KPhos may result in: 1. Thrombophlebitis 2. Hypercalcemia 3. Metabolic alkalosis 4. Vitamin D deficiency 7 mmol/hr What is the maximum infusion rate for phosphorus? Metastatic Ca/Phos deposition with potential resultant organ dysfunction What are 2 potential consequences of exceeding the maximum rate of phos infusion? 4. Hyperglycemia What is the most common complication associated with PN administration? 1. Hypophosphatemia 2. Hypokalemia 3. Hyponatremia 4. Hyperglycemia Insulin resistance, increased gluconeogenesis and glycogenolysis, and suppressed insulin secretion What are 4 reasons for stress-associated hyperglycemia in critically ill patients? 140-180 mg/dl What is the glycemic target for the majority of critically ill patients? Only when can safely be achieved When are lower glucose targets (110-140 mg/dl) appropriate? Hypoglycemia Why are targets <110 mg/dl not recommended? Basal-bolus insulin therapy What is the preferred approach recommended by the American Association of Clinical Endocrinologists & American Diabetes Association for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus? Basal insulin Insulin scheduled to control hepatic glucose output Bolus insulin Insulin scheduled for mealtimes Basal insulin, nutritional component prior to meals, and correctional insulin What are the 3 components of basal-bolus insulin therapy? Glutamine dipeptide What form of glutamine supplementation improves physical compatibility and stability for admixture in PN solutions? Glutamine dipeptide Improves water solubility, stability during heat sterilization, and capability for prolonged shelf life when compounding in PN solutions. Enteral glutamine Protein bound and difficult to determine the exact content. L glutamine powder Used in oral nutrition supplements Do not exceed 65-70% of target energy requirements Recommendation for providing calories estimated by indirect calorimetry in all obese patients (BMI >30) 11-14 kcal/kg/d SCCM and ASPEN calorie recommendations for critically ill obese patients with a BMI 30-50 22-25 kcal/kg IBW/d SCCM and ASPEN calorie recommendations for critically ill obese patients with a BMI >50 >/=2 gm/kg IBW/d SCCM and ASPEN protein recommendations for critically ill obese patients with a BMI 30-50 Up to 2.5 gm/kg IBW/d SCCM and ASPEN protein recommendations for critically ill obese patients with a BMI >50 Iron dextran (Fe 3+; trivalent cation) Which of the following additives has the greatest risk of destabilizing the ILE in a TNA? 1. NaCl 2. Ca acetate 3. Iron dextran 4. KPhos Excess of cations (the higher the cation valence the greater the destabilizing power) What can cause phase separation and liberation of free oil from the destabilization of TNAs Na and K Name 2 monovalent cations Inadequate knowledge regarding PN therapy, certain patient characteristics related to PN therapy, miscalculation of PN dosages, specialized PN dosage formulation characteristics, prescribing nomenclature What are 5 common factors associated with the majority of PN prescribing errors? amounts per day for adults amounts per kg per day for pediatrics/neonates (refers to macronutrients in gms and micronutrients in mEq, mmol, mcg, or mg) How should PN ingredients be ordered? 2. Recommended lab monitoring (recommended on order forms but not required) According to ASPEN PN Safety Consensus Recommendations, all of the following are considered to be mandatory for the PN order form except: 1. Full generic name for each ingredient 2. Recommended lab monitoring 3. Infusion schedule (continuous or cyclic) 4. Electrolytes ordered as complete salt form rather than individual ion Complete patient identifiers, birth date/age, allergies, height and dosing weight in metric units, diagnosis/diagnoses, indication for PN, administration route/vascular access device, contact info for prescriber, date and time order was submitted, administration date and time, volume and infusion rate, infusion schedule, and type of formulation (TNA vs 2-in-1) What should be on the PN order (13 components)? Amounts per day (adults) or per kg per day (pedi/neonate), electrolytes as complete salt form, full generic name for each ingredient, using JCo approved abbreviations only, dose for each macronutrient and electrolyte, dose for vitamins, dose for TEs, dose for each non-nutrient medication How should PN ingredients be ordered (8 rules)? 4. Electrolytes expressed in individual ions According to the ASPEN PN Safety Consensus Recommendations all of the following are mandatory for the inpatient PN label except: 1. Infusion rate expressed in ml/hr 2. Beyond use date and time 3. Size of in-line filter 4. Electrolyte content expressed in individual ions Two patient identifiers, patient location/address, dosing weight in metric units, administration date/time, beyond use date/time, route of administration, prescribed volume and overfill volume, infusion rate in ml/hr, duration of infusion, size of in-line filter, complete name of all ingredients, barcode, all ingredients listed in same sequence/units of measure as PN order, name of institution/pharmacy, institution/pharmacy contact info Components of a PN label (15) 3. EN is contraindicated/unlikely to meet nutrition needs When is PN indicated in severe burn patients? 1. Total body surface area burn exceeds 20% 2. As soon as possible after admit due to extremely high caloric needs 3. EN is contraindicated/unlikely to meet nutrition needs 4. Within 7-10 days after hospital admission Associated with increased mortality What have several studies shown about the use of PN in patients with burns? 4. Severely malnourished The routine use of preoperative parenteral nutrition is indicated for patients with a non-functioning GI tract who are: 1. Normally nourished 2. Mildly to moderately malnourished 3. Mildly malnourished with secondary co-morbidities 4. Severely malnourished No overall reduction in perioperative mortality but significant reductions in perioperative complications in severely malnourished patients who receive >7 d of preoperative PN What have studies shown regarding preoperative PN in surgical patients? Those who are severely malnourished if the therapy can continue for 7-10 days pre-operatively What adult cancer patients may benefit from PN? There was no advantage of PN over EN. Remission rates are similar and there is no evidence that bowel rest with PN has any advantage. What are the study findings regarding PN vs EN in Crohn's disease patients? Those who do not tolerate EN What Crohn's patients may should receive PN? PICC A catheter inserted via peripheral vein whose distal tip lies in the vena cava. Cephalic or Basilic Most common insertion site for PICC Distal tip in the superior inferior vena cava What qualifies a line as "central" 2. Superior vena cava Which of the following is the most appropriate distal catheter tip placement of a PICC? 1. Cephalic vein 2. Superior vena cava 3. Internal jugular vein 4. Supraclavicular vein 1. High rate of coiling or malpositioning 2. Limited patient arm mobility associated with limited ability to perform daily self-care 3. Longer catheter that may be more prone to occlusion What are 3 disadvantages of PICC lines? 1. No risk of pneumothorax or puncture of internal carotid/subclavian arteries 2. Available as single, double, and triple lumens 3. Repeated skin puncture isn't required What are 3 advantages of PICC lines?