2. Intolerance to EN trial and supportive care measures. - correct answer 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 - correct answer Deficiencies in what two vitamins may lead to neuropathies?
Thiamine - correct answer Deficiency of what vitamin may lead to Wernicke's Encephalopathy?
Folic acid - correct answer 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. - correct answer
When would EN be trialed on a patient with HG?
1. Thrombophlebitis - correct answer Rapid IV infusion of KPhos may result in:
1. Thrombophlebitis
2. Hypercalcemia
3. Metabolic alkalosis
4. Vitamin D deficiency
7 mmol/hr - correct answer What is the maximum infusion rate for phosphorus?
Metastatic Ca/Phos deposition with potential resultant organ dysfunction - correct answer
What are 2 potential consequences of exceeding the maximum rate of phos infusion?
4. Hyperglycemia - correct answer 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 - correct answer What are 4 reasons for stress-associated hyperglycemia in critically
ill patients?
140-180 mg/dl - correct answer What is the glycemic target for the majority of critically ill
patients?
Only when can safely be achieved - correct answer When are lower glucose targets (110-140
mg/dl) appropriate?
Hypoglycemia - correct answer Why are targets <110 mg/dl not recommended?
Basal-bolus insulin therapy - correct answer 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 - correct answer Insulin scheduled to control hepatic glucose output
Bolus insulin - correct answer Insulin scheduled for mealtimes
Basal insulin, nutritional component prior to meals, and correctional insulin - correct answer
What are the 3 components of basal-bolus insulin therapy?
Glutamine dipeptide - correct answer What form of glutamine supplementation improves
physical compatibility and stability for admixture in PN solutions?
Glutamine dipeptide - correct answer Improves water solubility, stability during heat
sterilization, and capability for prolonged shelf life when compounding in PN solutions.
Enteral glutamine - correct answer Protein bound and difficult to determine the exact content.
L glutamine powder - correct answer Used in oral nutrition supplements
Do not exceed 65-70% of target energy requirements - correct answer Recommendation for
providing calories estimated by indirect calorimetry in all obese patients (BMI >30)
11-14 kcal/kg/d - correct answer SCCM and ASPEN calorie recommendations for critically ill
obese patients with a BMI 30-50
22-25 kcal/kg IBW/d - correct answer SCCM and ASPEN calorie recommendations for critically
ill obese patients with a BMI >50
>/=2 gm/kg IBW/d - correct answer SCCM and ASPEN protein recommendations for critically ill
obese patients with a BMI 30-50
Up to 2.5 gm/kg IBW/d - correct answer SCCM and ASPEN protein recommendations for
critically ill obese patients with a BMI >50
,Iron dextran (Fe 3+; trivalent cation) - correct answer 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) - correct
answer What can cause phase separation and liberation of free oil from the destabilization of
TNAs
Na and K - correct answer 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 - correct answer 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) - correct
answer How should PN ingredients be ordered?
2. Recommended lab monitoring
(recommended on order forms but not required) - correct answer 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) - correct answer
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 - correct answer How should PN ingredients be ordered (8 rules)?
4. Electrolytes expressed in individual ions - correct answer 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 - correct answer Components
of a PN label (15)
3. EN is contraindicated/unlikely to meet nutrition needs - correct answer 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 - correct answer What have several studies shown about
the use of PN in patients with burns?
4. Severely malnourished - correct answer The routine use of preoperative parenteral nutrition
is indicated for patients with a non-functioning GI tract who are:
1. Normally nourished
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 - correct answer Deficiencies in what two vitamins may lead to neuropathies?
Thiamine - correct answer Deficiency of what vitamin may lead to Wernicke's Encephalopathy?
Folic acid - correct answer 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. - correct answer
When would EN be trialed on a patient with HG?
1. Thrombophlebitis - correct answer Rapid IV infusion of KPhos may result in:
1. Thrombophlebitis
2. Hypercalcemia
3. Metabolic alkalosis
4. Vitamin D deficiency
7 mmol/hr - correct answer What is the maximum infusion rate for phosphorus?
Metastatic Ca/Phos deposition with potential resultant organ dysfunction - correct answer
What are 2 potential consequences of exceeding the maximum rate of phos infusion?
4. Hyperglycemia - correct answer 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 - correct answer What are 4 reasons for stress-associated hyperglycemia in critically
ill patients?
140-180 mg/dl - correct answer What is the glycemic target for the majority of critically ill
patients?
Only when can safely be achieved - correct answer When are lower glucose targets (110-140
mg/dl) appropriate?
Hypoglycemia - correct answer Why are targets <110 mg/dl not recommended?
Basal-bolus insulin therapy - correct answer 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 - correct answer Insulin scheduled to control hepatic glucose output
Bolus insulin - correct answer Insulin scheduled for mealtimes
Basal insulin, nutritional component prior to meals, and correctional insulin - correct answer
What are the 3 components of basal-bolus insulin therapy?
Glutamine dipeptide - correct answer What form of glutamine supplementation improves
physical compatibility and stability for admixture in PN solutions?
Glutamine dipeptide - correct answer Improves water solubility, stability during heat
sterilization, and capability for prolonged shelf life when compounding in PN solutions.
Enteral glutamine - correct answer Protein bound and difficult to determine the exact content.
L glutamine powder - correct answer Used in oral nutrition supplements
Do not exceed 65-70% of target energy requirements - correct answer Recommendation for
providing calories estimated by indirect calorimetry in all obese patients (BMI >30)
11-14 kcal/kg/d - correct answer SCCM and ASPEN calorie recommendations for critically ill
obese patients with a BMI 30-50
22-25 kcal/kg IBW/d - correct answer SCCM and ASPEN calorie recommendations for critically
ill obese patients with a BMI >50
>/=2 gm/kg IBW/d - correct answer SCCM and ASPEN protein recommendations for critically ill
obese patients with a BMI 30-50
Up to 2.5 gm/kg IBW/d - correct answer SCCM and ASPEN protein recommendations for
critically ill obese patients with a BMI >50
,Iron dextran (Fe 3+; trivalent cation) - correct answer 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) - correct
answer What can cause phase separation and liberation of free oil from the destabilization of
TNAs
Na and K - correct answer 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 - correct answer 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) - correct
answer How should PN ingredients be ordered?
2. Recommended lab monitoring
(recommended on order forms but not required) - correct answer 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) - correct answer
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 - correct answer How should PN ingredients be ordered (8 rules)?
4. Electrolytes expressed in individual ions - correct answer 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 - correct answer Components
of a PN label (15)
3. EN is contraindicated/unlikely to meet nutrition needs - correct answer 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 - correct answer What have several studies shown about
the use of PN in patients with burns?
4. Severely malnourished - correct answer The routine use of preoperative parenteral nutrition
is indicated for patients with a non-functioning GI tract who are:
1. Normally nourished
