116 Questions
What is the primary goal of the evidence-based guidance provided for clinical practices involving PN?
To optimize clinical outcome and patient care
What is the purpose of the GRADE format in developing PN guideline recommendations?
To apply concepts of evidence grading and recommendation development
What is the primary focus of question 3 in the PN guideline development process?
Optimizing calcium intake and calcium-phosphate ratios in PN for neonatal bone mineralization
What is the primary advantage of 3-in-1 PN admixtures over 2-in-1 PN admixtures?
Not mentioned in the content
What is the primary purpose of question 8 in the PN guideline development process?
To assess the contamination of micronutrients in parenteral stock solutions
What is the role of the A.S.P.E.N. Board of Directors in the PN guideline development process?
Reviewing and approving the guideline recommendations
What is the primary focus of question 4 in the PN guideline development process?
Comparing commercially available premade (“premixed”) multichambered PN formulations with traditional/customized PN formulations
What is the purpose of the expert work group in the PN guideline development process?
To conduct systematic reviews of the best available evidence
What is the primary goal of the PN Safety Task Force?
To develop evidence-based policies for PN practices
What is the recommended maximum safe osmolarity of PN admixtures for peripheral vein administration?
900 mOsm/L
What is the primary benefit of providing education to healthcare professionals on PN ordering?
Reducing PN-related medication errors
What is the grade of the recommendation for providing education to healthcare professionals to improve PN ordering?
Weak
What is the primary focus of the A.S.P.E.N. Clinical Guidelines work group?
Evaluating the evidence for PN-related questions
What is the result of interdisciplinary teams applying education as part of an overall quality intervention in PN practices?
Reduced unnecessary PN use and decreased errors
What is the primary benefit of safe prescribing education programs in general medication prescribing?
Safer practices
What is the result of educating healthcare professionals on safe PN prescribing, according to small observational studies?
Substantial decrease in overall PN prescription errors
What is the primary goal of the 2004 revision of the Safe Practices for Parenteral Nutrition?
To standardize practices surrounding PN
What is the role of the A.S.P.E.N. PN Safety Task Force in developing guidance documents for healthcare organizations?
To provide ongoing commitment to patient safety with PN
What is the primary limitation in the administration of peripheral PN?
Osmolarity of the infused formula
What is the recommended elemental calcium intake for short-term PN in neonates?
76 mg/kg per day
What is the suggested Ca:P ratio in short-term PN in neonates?
1.7:1 mg:mg
What is the primary reason for the development of thrombophlebitis in peripheral PN?
Osmotic content of the infused formula
What is the benefit of coinfusion of intravenous fat emulsion (IVFE) in peripheral PN?
No benefit has been shown
What is the significance of the Ca:P ratio in short-term PN in neonates?
Affects bone mineralization
What is the benefit of using commercially available premade multichambered PN formulations?
Increased safety and efficiency
What is the significance of heparin addition in peripheral PN?
May influence the incidence of thrombophlebitis
What is the limitation of studies on calcium-phosphate ratio in long-term PN therapy?
The longest study lasted only 6 weeks
What is the significance of alternate-day provision of calcium and phosphate in PN?
Associated with significant urinary losses of both calcium and phosphate
What is the primary drawback of the 3-in-1 PN delivery system?
Requirement for a larger pore size filter
What is the suggested final concentration of injectable lipid emulsion to maintain stability in 3-in-1 admixtures?
≥2%
What is the primary advantage of 2-in-1 PN delivery systems?
Reduced risk of emulsion destabilization
What is the suggested final concentration of amino acid to maintain stability in 3-in-1 admixtures?
≥4%
What is the primary disadvantage of 3-in-1 PN delivery systems in the homecare setting?
Increased risk of catheter occlusion
What is the recommended temperature for storing 3-in-1 admixtures for up to 9 days?
5°C
What is the primary factor affecting calcium and phosphate solubility in PN admixtures?
All of the above
What is the suggested duration for which PN solutions with calcium and phosphate remain stable?
24-48 hours
What is the primary consideration for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures?
All of the above
What is the primary advantage of using a 0.22-µm filter in 2-in-1 PN delivery systems?
Eliminates particulate matter including some bacteria
What is a critical consideration for determining BUD?
Stability
What is unique about commercially available IVFEs in the United States?
They are preservative-free
What is the primary goal of nutrition therapy in the critically ill population?
To attenuate the metabolic response to stress
What is the purpose of nutrition risk indicators in the ICU?
To identify patients who will most likely benefit from nutrition therapy
What is the result of poor nutrition status in critically ill patients?
Deterioration of nutrition status and malnutrition
What is the primary benefit of early EN therapy?
All of the above
What is a characteristic of CSPs?
Preparations prepared according to manufacturer's labeled instructions
What is a common consequence of critical illness?
Catabolic stress state
What is a benefit of nutrition therapy in critically ill patients?
Favorable modulation of immune responses
What is an important consideration in the ICU?
Nutrition status
What is the primary purpose of nutrition screening in hospitalized patients?
To determine nutrition risk
Which of the following tools is used to evaluate both nutrition status and disease severity?
NRS 2002 and the NUTRIC score
Why are traditional serum protein markers not used in critical care?
They are not validated in critical care
What is emerging as a tool to measure muscle mass in the ICU?
Ultrasound
What is the suggested method for determining energy needs in critically ill adult patients?
All of the above
What is the limitation of using traditional nutrition indicators in critical care?
They are affected by the acute-phase response
What is the purpose of assessing comorbid conditions in nutrition assessment?
To determine nutrition risk
What is the role of ultrasound in nutrition assessment?
To measure muscle mass
What is the limitation of anthropometrics in assessing nutrition status?
They are affected by fluid status
What is the goal of nutrition assessment in critically ill patients?
To establish the goals of nutrition therapy
What is the primary reason for monitoring protein provision independently from energy provision in critically ill patients?
To support healing wounds and immune function
What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?
Maintaining the functional integrity of the gut
Why may patients with suboptimal EN due to frequent interruptions benefit from protein supplementation?
To support healing wounds and immune function
What is the primary limitation of using serum protein markers to determine adequacy of protein provision in the critical care setting?
They are not validated for determining adequacy of protein provision
Why are predictive equations less accurate than IC measurements in the ICU?
They do not accurately predict energy and protein needs
What should be accounted for when deriving nutrition therapy regimens to meet target energy goals in the ICU?
Additional energy provided by dextrose-containing fluids and lipid-based medications
What is the primary benefit of achieving energy balance as guided by IC measurements compared with predictive equations in the ICU?
Leading to more appropriate nutrition intake
Why are weight-based equations used to monitor adequacy of protein provision in critically ill patients?
Because nitrogen balance studies are not available to assess needs
What is the primary reason for initiating EN within 24–48 hours in critically ill patients who are unable to maintain volitional intake?
To maintain the functional integrity of the gut
What is the primary consequence of adverse changes in gut permeability in critically ill patients?
Increased bacterial challenge and risk of systemic infection
What is the primary concern with regard to the stability of PN solutions beyond 48 hours?
Lack of validation studies
Which of the following minerals is most frequently found as a contaminant in PN components?
Chromium
What is the primary reason for recommending against the inclusion of heparin in PN admixtures?
Multifactorial nature of central venous access-related complications
What is the primary reason for including heparin in PN?
To reduce the risk of thromboembolic complications
What is the primary advantage of using individual rather than fixed-dose multi-trace element products?
Dosing flexibility for patient PN regimens
What is the effect of heparin on the stability of fat emulsion in PN?
It destabilizes the emulsion due to an interaction with calcium
What is the primary requirement for including non-nutrient medication in PN admixtures?
Both pharmaceutical and clinical data
What is the recommended beyond-use date for IVFE in the original container spiked for infusion?
12-24 hours
Which of the following is a potential advantage of including medication in the PN admixture?
Consolidating drug dosing and volume
What is the primary reason for not recommending the repackaging of IVFE into syringes?
All of the above
What is the primary concern with regard to trace element contamination in PN components?
Presence of at least a dozen minerals as contaminants
What is the recommended method for reducing the risk of thromboembolic complications in patients with central venous catheters?
All of the above
What is the recommended approach to addressing mineral contamination in PN components?
Purchasing products that accurately describe levels of contamination
What is the purpose of the GRADE format in the development of PN guidelines?
To provide a framework for evaluating the strength of evidence
Which of the following is a characteristic of PN admixtures in the absence of drug additives?
Pharmaceutically complex
What is the recommended infusion time for IVFE in neonates and infants?
Continuous infusion up to 3 g/kg per day
What is the primary limitation of including non-nutrient medication in PN admixtures?
Lack of data on physicochemical compatibility and stability
What is the primary concern with using polyethylene catheters?
Fibrin accumulation
What is the recommended method for reducing the risk of microbial contamination in IVFE?
Providing IVFE as part of a TNA
What is the primary concern with repackaging IVFE into smaller patient-specific volumes?
All of the above
What percentage of goal energy may be required to prevent increases in intestinal permeability and systemic infection in burn and bone marrow transplant patients?
50%–65%
What is the correlation between the percentage of goal energy delivered and mortality in high-risk ICU patients with NUTRIC scores ≥6?
Direct correlation
What is the recommended range of protein requirements for critically ill patients?
1.2–2.0 g/kg/d
What is the association between protein provision and mortality in mechanically ventilated patients?
Inverse association
What is the limitation of using nitrogen balance or NPC:N in determining protein requirements in the ICU?
It is of limited value
What is the benefit of providing sufficient preoperative nutrition therapy in high-risk surgery patients?
Reduced risk of nosocomial infections
What is the quality of evidence for the recommendation of providing sufficient protein in critically ill patients?
Very Low
What is the effect of providing sufficient protein and energy targets on mortality in critically ill patients?
50% decrease in mortality
What is the association between protein provision and mortality in a mixed MICU/SICU?
Stepwise decrease in mortality with increased protein provision
What is the limitation of small RCTs in determining the effect of protein provision on mortality in critically ill patients?
They show no difference in mortality
What is the primary purpose of providing enteral nutrition (EN) to critically ill patients?
All of the above
What is the recommended approach for critically ill patients who require nutrition support therapy?
Use EN over PN
What is the significance of GI contractility in initiating EN in critically ill patients?
GI contractility is not required prior to initiating EN
What is the preferred level of infusion of EN in critically ill patients at high risk for aspiration?
Diverted lower in the GI tract
What is the outcome effect of EN compared to PN in critically ill patients?
Reduced infectious morbidity and ICU length of stay
What is the primary reason for GI dysfunction in ICU patients?
All of the above
What is the benefit of initiating EN in critically ill patients within the initial 36–48 hours of admission to the ICU?
Feasibility and safety of EN
What is the definition of GI intolerance in ICU patients?
Vomiting, bowel dilatation, diarrhea, GI bleeding, or high gastric residual volumes
What is the role of the gut in EN therapy?
All of the above
What is the primary benefit of using EN over PN in critically ill patients?
Improved patient outcomes
What is the primary consideration when deciding the level of infusion within the GI tract?
Ease and feasibility of placing small bowel enteral access devices
What was the result of the largest multicenter RCT comparing gastric versus small bowel EN in critically ill patients?
No difference in clinical outcomes between groups
What is the estimated improvement in nutrient delivery with small bowel feedings?
11.06%; 95% CI, 5.82–16.30%
When should EN be withheld in adult critically ill patients?
During periods of hemodynamic instability
What is a rare complication associated with EN?
Ischemic bowel
What is the benefit of early EN in patients treated with multiple vasopressors?
Lower OR of hospital mortality
What is the purpose of trophic feeds in low- to moderate-risk patients?
Both a and b
What is the recommended goal for achieving the clinical benefit of EN over the first week of hospitalization?
80% of estimated or calculated goal energy and protein within 48–72 hours
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).
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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