Parenteral Nutrition: Safe Prescribing and Administration
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Questions and Answers

What is the primary goal of the evidence-based guidance provided for clinical practices involving PN?

  • To improve PN ordering through prescriber education
  • To optimize clinical outcome and patient care (correct)
  • To promote the use of 2-in-1 PN admixtures
  • To reduce the cost of PN admixtures

    • What is the purpose of the GRADE format in developing PN guideline recommendations?

  • To apply concepts of evidence grading and recommendation development (correct)
  • To promote the use of 3-in-1 PN admixtures
  • To prioritize the use of premade PN formulations
  • To standardize the osmolarity of PN admixtures

    • What is the primary focus of question 3 in the PN guideline development process?

  • Determining the maximum safe osmolarity of PN admixtures for peripheral vein administration
  • Optimizing calcium intake and calcium-phosphate ratios in PN for neonatal bone mineralization (correct)
  • Evaluating the clinical advantages of 2-in-1 compared with 3-in-1 PN admixtures
  • Assessing the contamination of micronutrients in parenteral stock solutions

    • What is the primary advantage of 3-in-1 PN admixtures over 2-in-1 PN admixtures?

    <p>Not mentioned in the content</p> Signup and view all the answers

    What is the primary purpose of question 8 in the PN guideline development process?

    <p>To assess the contamination of micronutrients in parenteral stock solutions</p> Signup and view all the answers

    What is the role of the A.S.P.E.N. Board of Directors in the PN guideline development process?

    <p>Reviewing and approving the guideline recommendations</p> Signup and view all the answers

    What is the primary focus of question 4 in the PN guideline development process?

    <p>Comparing commercially available premade (“premixed”) multichambered PN formulations with traditional/customized PN formulations</p> Signup and view all the answers

    What is the purpose of the expert work group in the PN guideline development process?

    <p>To conduct systematic reviews of the best available evidence</p> Signup and view all the answers

    What is the primary goal of the PN Safety Task Force?

    <p>To develop evidence-based policies for PN practices</p> Signup and view all the answers

    What is the recommended maximum safe osmolarity of PN admixtures for peripheral vein administration?

    <p>900 mOsm/L</p> Signup and view all the answers

    What is the primary benefit of providing education to healthcare professionals on PN ordering?

    <p>Reducing PN-related medication errors</p> Signup and view all the answers

    What is the grade of the recommendation for providing education to healthcare professionals to improve PN ordering?

    <p>Weak</p> Signup and view all the answers

    What is the primary focus of the A.S.P.E.N. Clinical Guidelines work group?

    <p>Evaluating the evidence for PN-related questions</p> Signup and view all the answers

    What is the result of interdisciplinary teams applying education as part of an overall quality intervention in PN practices?

    <p>Reduced unnecessary PN use and decreased errors</p> Signup and view all the answers

    What is the primary benefit of safe prescribing education programs in general medication prescribing?

    <p>Safer practices</p> Signup and view all the answers

    What is the result of educating healthcare professionals on safe PN prescribing, according to small observational studies?

    <p>Substantial decrease in overall PN prescription errors</p> Signup and view all the answers

    What is the primary goal of the 2004 revision of the Safe Practices for Parenteral Nutrition?

    <p>To standardize practices surrounding PN</p> Signup and view all the answers

    What is the role of the A.S.P.E.N. PN Safety Task Force in developing guidance documents for healthcare organizations?

    <p>To provide ongoing commitment to patient safety with PN</p> Signup and view all the answers

    What is the primary limitation in the administration of peripheral PN?

    <p>Osmolarity of the infused formula</p> Signup and view all the answers

    What is the recommended elemental calcium intake for short-term PN in neonates?

    <p>76 mg/kg per day</p> Signup and view all the answers

    What is the suggested Ca:P ratio in short-term PN in neonates?

    <p>1.7:1 mg:mg</p> Signup and view all the answers

    What is the primary reason for the development of thrombophlebitis in peripheral PN?

    <p>Osmotic content of the infused formula</p> Signup and view all the answers

    What is the benefit of coinfusion of intravenous fat emulsion (IVFE) in peripheral PN?

    <p>No benefit has been shown</p> Signup and view all the answers

    What is the significance of the Ca:P ratio in short-term PN in neonates?

    <p>Affects bone mineralization</p> Signup and view all the answers

    What is the benefit of using commercially available premade multichambered PN formulations?

    <p>Increased safety and efficiency</p> Signup and view all the answers

    What is the significance of heparin addition in peripheral PN?

    <p>May influence the incidence of thrombophlebitis</p> Signup and view all the answers

    What is the limitation of studies on calcium-phosphate ratio in long-term PN therapy?

    <p>The longest study lasted only 6 weeks</p> Signup and view all the answers

    What is the significance of alternate-day provision of calcium and phosphate in PN?

    <p>Associated with significant urinary losses of both calcium and phosphate</p> Signup and view all the answers

    What is the primary drawback of the 3-in-1 PN delivery system?

    <p>Requirement for a larger pore size filter</p> Signup and view all the answers

    What is the suggested final concentration of injectable lipid emulsion to maintain stability in 3-in-1 admixtures?

    <p>≥2%</p> Signup and view all the answers

    What is the primary advantage of 2-in-1 PN delivery systems?

    <p>Reduced risk of emulsion destabilization</p> Signup and view all the answers

    What is the suggested final concentration of amino acid to maintain stability in 3-in-1 admixtures?

    <p>≥4%</p> Signup and view all the answers

    What is the primary disadvantage of 3-in-1 PN delivery systems in the homecare setting?

    <p>Increased risk of catheter occlusion</p> Signup and view all the answers

    What is the recommended temperature for storing 3-in-1 admixtures for up to 9 days?

    <p>5°C</p> Signup and view all the answers

    What is the primary factor affecting calcium and phosphate solubility in PN admixtures?

    <p>All of the above</p> Signup and view all the answers

    What is the suggested duration for which PN solutions with calcium and phosphate remain stable?

    <p>24-48 hours</p> Signup and view all the answers

    What is the primary consideration for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures?

    <p>All of the above</p> Signup and view all the answers

    What is the primary advantage of using a 0.22-µm filter in 2-in-1 PN delivery systems?

    <p>Eliminates particulate matter including some bacteria</p> Signup and view all the answers

    What is a critical consideration for determining BUD?

    <p>Stability</p> Signup and view all the answers

    What is unique about commercially available IVFEs in the United States?

    <p>They are preservative-free</p> Signup and view all the answers

    What is the primary goal of nutrition therapy in the critically ill population?

    <p>To attenuate the metabolic response to stress</p> Signup and view all the answers

    What is the purpose of nutrition risk indicators in the ICU?

    <p>To identify patients who will most likely benefit from nutrition therapy</p> Signup and view all the answers

    What is the result of poor nutrition status in critically ill patients?

    <p>Deterioration of nutrition status and malnutrition</p> Signup and view all the answers

    What is the primary benefit of early EN therapy?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of CSPs?

    <p>Preparations prepared according to manufacturer's labeled instructions</p> Signup and view all the answers

    What is a common consequence of critical illness?

    <p>Catabolic stress state</p> Signup and view all the answers

    What is a benefit of nutrition therapy in critically ill patients?

    <p>Favorable modulation of immune responses</p> Signup and view all the answers

    What is an important consideration in the ICU?

    <p>Nutrition status</p> Signup and view all the answers

    What is the primary purpose of nutrition screening in hospitalized patients?

    <p>To determine nutrition risk</p> Signup and view all the answers

    Which of the following tools is used to evaluate both nutrition status and disease severity?

    <p>NRS 2002 and the NUTRIC score</p> Signup and view all the answers

    Why are traditional serum protein markers not used in critical care?

    <p>They are not validated in critical care</p> Signup and view all the answers

    What is emerging as a tool to measure muscle mass in the ICU?

    <p>Ultrasound</p> Signup and view all the answers

    What is the suggested method for determining energy needs in critically ill adult patients?

    <p>All of the above</p> Signup and view all the answers

    What is the limitation of using traditional nutrition indicators in critical care?

    <p>They are affected by the acute-phase response</p> Signup and view all the answers

    What is the purpose of assessing comorbid conditions in nutrition assessment?

    <p>To determine nutrition risk</p> Signup and view all the answers

    What is the role of ultrasound in nutrition assessment?

    <p>To measure muscle mass</p> Signup and view all the answers

    What is the limitation of anthropometrics in assessing nutrition status?

    <p>They are affected by fluid status</p> Signup and view all the answers

    What is the goal of nutrition assessment in critically ill patients?

    <p>To establish the goals of nutrition therapy</p> Signup and view all the answers

    What is the primary reason for monitoring protein provision independently from energy provision in critically ill patients?

    <p>To support healing wounds and immune function</p> Signup and view all the answers

    What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?

    <p>Maintaining the functional integrity of the gut</p> Signup and view all the answers

    Why may patients with suboptimal EN due to frequent interruptions benefit from protein supplementation?

    <p>To support healing wounds and immune function</p> Signup and view all the answers

    What is the primary limitation of using serum protein markers to determine adequacy of protein provision in the critical care setting?

    <p>They are not validated for determining adequacy of protein provision</p> Signup and view all the answers

    Why are predictive equations less accurate than IC measurements in the ICU?

    <p>They do not accurately predict energy and protein needs</p> Signup and view all the answers

    What should be accounted for when deriving nutrition therapy regimens to meet target energy goals in the ICU?

    <p>Additional energy provided by dextrose-containing fluids and lipid-based medications</p> Signup and view all the answers

    What is the primary benefit of achieving energy balance as guided by IC measurements compared with predictive equations in the ICU?

    <p>Leading to more appropriate nutrition intake</p> Signup and view all the answers

    Why are weight-based equations used to monitor adequacy of protein provision in critically ill patients?

    <p>Because nitrogen balance studies are not available to assess needs</p> Signup and view all the answers

    What is the primary reason for initiating EN within 24–48 hours in critically ill patients who are unable to maintain volitional intake?

    <p>To maintain the functional integrity of the gut</p> Signup and view all the answers

    What is the primary consequence of adverse changes in gut permeability in critically ill patients?

    <p>Increased bacterial challenge and risk of systemic infection</p> Signup and view all the answers

    What is the primary concern with regard to the stability of PN solutions beyond 48 hours?

    <p>Lack of validation studies</p> Signup and view all the answers

    Which of the following minerals is most frequently found as a contaminant in PN components?

    <p>Chromium</p> Signup and view all the answers

    What is the primary reason for recommending against the inclusion of heparin in PN admixtures?

    <p>Multifactorial nature of central venous access-related complications</p> Signup and view all the answers

    What is the primary reason for including heparin in PN?

    <p>To reduce the risk of thromboembolic complications</p> Signup and view all the answers

    What is the primary advantage of using individual rather than fixed-dose multi-trace element products?

    <p>Dosing flexibility for patient PN regimens</p> Signup and view all the answers

    What is the effect of heparin on the stability of fat emulsion in PN?

    <p>It destabilizes the emulsion due to an interaction with calcium</p> Signup and view all the answers

    What is the primary requirement for including non-nutrient medication in PN admixtures?

    <p>Both pharmaceutical and clinical data</p> Signup and view all the answers

    What is the recommended beyond-use date for IVFE in the original container spiked for infusion?

    <p>12-24 hours</p> Signup and view all the answers

    Which of the following is a potential advantage of including medication in the PN admixture?

    <p>Consolidating drug dosing and volume</p> Signup and view all the answers

    What is the primary reason for not recommending the repackaging of IVFE into syringes?

    <p>All of the above</p> Signup and view all the answers

    What is the primary concern with regard to trace element contamination in PN components?

    <p>Presence of at least a dozen minerals as contaminants</p> Signup and view all the answers

    What is the recommended method for reducing the risk of thromboembolic complications in patients with central venous catheters?

    <p>All of the above</p> Signup and view all the answers

    What is the recommended approach to addressing mineral contamination in PN components?

    <p>Purchasing products that accurately describe levels of contamination</p> Signup and view all the answers

    What is the purpose of the GRADE format in the development of PN guidelines?

    <p>To provide a framework for evaluating the strength of evidence</p> Signup and view all the answers

    Which of the following is a characteristic of PN admixtures in the absence of drug additives?

    <p>Pharmaceutically complex</p> Signup and view all the answers

    What is the recommended infusion time for IVFE in neonates and infants?

    <p>Continuous infusion up to 3 g/kg per day</p> Signup and view all the answers

    What is the primary limitation of including non-nutrient medication in PN admixtures?

    <p>Lack of data on physicochemical compatibility and stability</p> Signup and view all the answers

    What is the primary concern with using polyethylene catheters?

    <p>Fibrin accumulation</p> Signup and view all the answers

    What is the recommended method for reducing the risk of microbial contamination in IVFE?

    <p>Providing IVFE as part of a TNA</p> Signup and view all the answers

    What is the primary concern with repackaging IVFE into smaller patient-specific volumes?

    <p>All of the above</p> Signup and view all the answers

    What percentage of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow transplant patients?

    <p>50%–65%</p> Signup and view all the answers

    What is the correlation between the percentage of goal energy delivered and mortality in high-risk ICU patients with NUTRIC scores ≥6?

    <p>Direct correlation</p> Signup and view all the answers

    What is the recommended range of protein requirements for critically ill patients?

    <p>1.2–2.0 g/kg/d</p> Signup and view all the answers

    What is the association between protein provision and mortality in mechanically ventilated patients?

    <p>Inverse association</p> Signup and view all the answers

    What is the limitation of using nitrogen balance or NPC:N in determining protein requirements in the ICU?

    <p>It is of limited value</p> Signup and view all the answers

    What is the benefit of providing sufficient preoperative nutrition therapy in high-risk surgery patients?

    <p>Reduced risk of nosocomial infections</p> Signup and view all the answers

    What is the quality of evidence for the recommendation of providing sufficient protein in critically ill patients?

    <p>Very Low</p> Signup and view all the answers

    What is the effect of providing sufficient protein and energy targets on mortality in critically ill patients?

    <p>50% decrease in mortality</p> Signup and view all the answers

    What is the association between protein provision and mortality in a mixed MICU/SICU?

    <p>Stepwise decrease in mortality with increased protein provision</p> Signup and view all the answers

    What is the limitation of small RCTs in determining the effect of protein provision on mortality in critically ill patients?

    <p>They show no difference in mortality</p> Signup and view all the answers

    What is the primary purpose of providing enteral nutrition (EN) to critically ill patients?

    <p>All of the above</p> Signup and view all the answers

    What is the recommended approach for critically ill patients who require nutrition support therapy?

    <p>Use EN over PN</p> Signup and view all the answers

    What is the significance of GI contractility in initiating EN in critically ill patients?

    <p>GI contractility is not required prior to initiating EN</p> Signup and view all the answers

    What is the preferred level of infusion of EN in critically ill patients at high risk for aspiration?

    <p>Diverted lower in the GI tract</p> Signup and view all the answers

    What is the outcome effect of EN compared to PN in critically ill patients?

    <p>Reduced infectious morbidity and ICU length of stay</p> Signup and view all the answers

    What is the primary reason for GI dysfunction in ICU patients?

    <p>All of the above</p> Signup and view all the answers

    What is the benefit of initiating EN in critically ill patients within the initial 36–48 hours of admission to the ICU?

    <p>Feasibility and safety of EN</p> Signup and view all the answers

    What is the definition of GI intolerance in ICU patients?

    <p>Vomiting, bowel dilatation, diarrhea, GI bleeding, or high gastric residual volumes</p> Signup and view all the answers

    What is the role of the gut in EN therapy?

    <p>All of the above</p> Signup and view all the answers

    What is the primary benefit of using EN over PN in critically ill patients?

    <p>Improved patient outcomes</p> Signup and view all the answers

    What is the primary consideration when deciding the level of infusion within the GI tract?

    <p>Ease and feasibility of placing small bowel enteral access devices</p> Signup and view all the answers

    What was the result of the largest multicenter RCT comparing gastric versus small bowel EN in critically ill patients?

    <p>No difference in clinical outcomes between groups</p> Signup and view all the answers

    What is the estimated improvement in nutrient delivery with small bowel feedings?

    <p>11.06%; 95% CI, 5.82–16.30%</p> Signup and view all the answers

    When should EN be withheld in adult critically ill patients?

    <p>During periods of hemodynamic instability</p> Signup and view all the answers

    What is a rare complication associated with EN?

    <p>Ischemic bowel</p> Signup and view all the answers

    What is the benefit of early EN in patients treated with multiple vasopressors?

    <p>Lower OR of hospital mortality</p> Signup and view all the answers

    What is the purpose of trophic feeds in low- to moderate-risk patients?

    <p>Both a and b</p> Signup and view all the answers

    What is the recommended goal for achieving the clinical benefit of EN over the first week of hospitalization?

    <p>80% of estimated or calculated goal energy and protein within 48–72 hours</p> Signup and view all the answers

    Study Notes

    Parenteral Nutrition (PN) Guidelines

    • PN is a high-alert medication that requires evidence-based policies, procedures, and practices to ensure safe use and optimal clinical outcomes.
    • The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) provides guidelines for clinical practices involving PN prescribing, order review, and preparation.

    Education of Prescribers

    • Education of healthcare professionals can improve PN ordering and reduce errors.
    • PN is a complex prescription therapy associated with significant adverse effects, and appropriate education is essential to ensure safe prescribing.

    Osmolarity of PN Admixtures

    • PN with an osmolarity of up to 900 mOsm/L can be safely infused peripherally.
    • Higher osmolarity limits may be tolerated, but the evidence to support a safe limit is lacking.

    Calcium Intake and Calcium-Phosphate Ratios in PN

    • For short-term PN in neonates, an elemental calcium intake of 76 mg/kg per day is recommended.
    • A Ca:P ratio of 1.7:1 (mg:mg) or 1.3:1 (mmol:mmol) is suggested for short-term PN in neonates.

    Commercially Available Premade PN Formulations

    • Commercially available premade multichambered PN products can be considered as an available option for patients alongside compounded (customized or standardized) PN formulations.
    • The advantages and disadvantages of each delivery method must be critically examined.

    2-in-1 vs 3-in-1 PN Admixtures

    • There is no clinical difference in infectious complications between the two PN delivery systems.
    • 3-in-1 formulations administered in the homecare setting may increase the risk for catheter occlusion and shorten catheter lifespan.

    Macronutrient Dosing Limits for 3-in-1 Admixtures

    • Total nutrient admixtures should maintain final concentrations of amino acid ≥4%, monohydrated dextrose ≥10%, and injectable lipid emulsion ≥2% to be more likely to remain stable for up to 30 hours at room temperature or for 9 days refrigerated followed by 24 hours at room temperature.

    Calcium and Phosphate Compatibility in PN Admixtures

    • The compatibility of calcium and phosphate in PN admixtures depends on various factors, including amino acid concentration, pH, and the presence or absence of fat emulsion.
    • Published graphs for specific products provide adequate guidance, but the stability of PN solutions beyond 24-48 hours is not well established.

    Micronutrient Contamination in Parenteral Stock Solutions

    • Micronutrient contamination is present in parenteral stock solutions used to compound PN admixtures.
    • Practitioners should purchase products that accurately describe levels of contamination and take that exposure into account when recommending or reviewing trace element dosing.

    Non-Nutrient Medication Delivery in PN Admixtures

    • Non-nutrient medication should be included in PN admixtures only when supported by pharmaceutical data and clinical data confirming the expected therapeutic actions of the medication.
    • Extrapolation beyond the parameter limits of the given data is discouraged.

    Heparin in PN Admixtures for Reducing Central Vein Thrombosis

    • Heparin should not be included in PN admixtures for reducing the risk of central vein thrombosis in adults.
    • The inclusion of heparin in PN admixtures may compromise the stability of the emulsion.

    Repackaging of IVFE into Smaller Patient-Specific Volumes

    • Repackaging of IVFE into syringes for administration to patients is not recommended.
    • Other methodologies, such as drawn-down IVFE units, are preferable for repackaging IVFE.### IVFE Administration
    • IVFE supports the growth of bacteria and fungi, and microorganisms have been identified in IVFE after infusion to patients.
    • Systemic infection in neonates has been linked to multiple bedside caregivers withdrawing IVFE doses from a single unit.
    • Administration errors with IVFE, including overdose, have been documented in neonates.

    Beyond-Use Date for IVFE

    • The beyond-use date (BUD) for unspiked IVFE in the original container should be based on the manufacturer's provided information.
    • The BUD for IVFE in the original container spiked for infusion should be 12–24 hours.
    • When repackaging IVFE, the BUD should be 12 hours.

    Nutrition Support Therapy

    • Nutrition therapy is thought to help attenuate the metabolic response to stress, prevent oxidative cellular injury, and favorably modulate immune responses in critically ill patients.
    • Early enteral nutrition (EN) is seen as a proactive therapeutic strategy to reduce disease severity, diminish complications, and decrease length of stay in the ICU.

    Nutrition Assessment

    • A nutrition risk indicator (e.g., NRS 2002, NUTRIC score) should be performed on all patients admitted to the ICU to identify those who will most likely benefit from nutrition therapy.
    • Nutrition risk is defined by evaluating baseline nutrition status and disease severity.

    Determining Energy Needs

    • Indirect calorimetry (IC) is the best method for determining energy needs in critically ill adult patients, when available.
    • In the absence of IC, a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/d) can be used.

    Protein Provision

    • Protein provision should be monitored independently from energy provision in critically ill adult patients.
    • Protein requirements are proportionately higher than energy requirements and thus are not easily met by provision of routine enteral formulations.

    Enteral Nutrition

    • Early EN within 24–48 hours is recommended for critically ill patients who are unable to maintain volitional intake.
    • EN supports the functional integrity of the gut by maintaining tight junctions, stimulating blood flow, and inducing the release of trophic endogenous agents.
    • EN maintains structural integrity by maintaining villous height and supporting the mass of secretory IgA-producing immunocytes.

    Initiation of EN

    • EN can be initiated regardless of bowel sounds, as long as GI dysfunction is evaluated when initiating EN.
    • The level of infusion within the GI tract (i.e., stomach, duodenum, or jejunum) may be determined by patient selection and institutional framework.

    Safety of EN

    • EN should be withheld during periods of hemodynamic instability in adult critically ill patients.

    • Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.### Enteral Nutrition in Critically Ill Patients

    • Caution should be exercised when providing EN to patients on chronic, stable low doses of vasopressors.

    • EN should be withheld in patients who are hypotensive (mean arterial blood pressure < 80% of estimated or calculated goal).

    Energy and Protein Requirements

    • Trophic feeds (10-20 mL/h or 10-20 kcal/h) may be sufficient to prevent mucosal atrophy and maintain gut integrity in low- to moderate-risk patients.
    • High-risk patients require >50%-65% of goal energy to prevent intestinal permeability and systemic infection, promote cognitive function, and reduce mortality.
    • High-risk surgery patients who receive sufficient preoperative nutrition therapy (≥10 kcal/kg/d for 7 days) have significant reductions in nosocomial infections and overall complications.
    • Increasing the percentage of goal energy delivered correlates significantly with reductions in mortality in high-risk ICU patients.
    • The lowest mortality is achieved with EN providing >80% goal energy.

    Protein Requirements

    • Sufficient (high-dose) protein should be provided to adult critically ill patients.
    • Protein requirements are expected to be in the range of 1.2-2.0 g/kg actual body weight per day and may be higher in burn or multitrauma patients.
    • Provision of protein is more closely linked to positive outcomes than provision of total energy in critical illness.
    • Achievement of both protein (1.3 g/kg) and energy targets is associated with a 50% decrease in 28-day mortality.
    • A stepwise decrease in 28-day mortality is demonstrated with increased protein provision (0.79 g/kg, 1.06 g/kg, and 1.46 g/kg).

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    Description

    This quiz assesses knowledge on evidence-based policies and procedures for safe use and optimal clinical outcomes of parenteral nutrition. It covers PN prescribing, order review, and preparation.

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