NFS 444 Lecture Notes - Lecture 20: Short Bowel Syndrome, Glucose, Cachexia

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6 Feb 2017
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NFS 444 EXAM 2 Study Guide Outline (Pharmacy)
I. Enteral Nutrition
1. Feeding tube and medications
Medications
o Forms that can be admin
IR oral tablets crush to fine powder and mix with water
Hard gelatin capsules
Soft gelatin capsules
Liquid forms
Preferred method of admin
AE
o Osmolarity of many > 300 mOsm/kg
o Many liquids contain sorbitol
o Forms that cannot be admin
Enteric coated
Sublingual or buccal
SR
Syrups
2. Calculations: Kcals/Pro/Free H20
1. Calculate total volume provided
2. To calc the amount of fluid provided
- consider the amount of free water each formula contains
- 1.0 cal/cc = 85%
- 1.5 cal/cc = 78%
- 2.0 cal/cc = 70%
*calc daily mls of formula multiply each % by total mls
3. Guest Lecture
FOS (type of fiber)
MCT (used with fat malabsorption)
structured lipids (blend of MCTs and LCTs)
HMB (decreases muscle breakdown)
EPA, & GLA ( fatty acids in Oxepa that help decrease inflammation in
patients with ARDS)
II.Parenteral Nutrition
1. Indications/ Contraindications for use
Indications
Contraindications
Non-functioning GI tract ( ex. Severe
malabsorption, short bowel syndrome,
intractable vomiting, diarrhea)
Bowel rest (severe pancreatitis)
Severe malnutrition or catabolism and pt is
unable to eat for > 5 days
Treatment < 5 days without severe
malnutrition
Functioning GI tract
Inability to gain venous access
Prognosis that does not warrant aggressive
nutrition support
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2. Osmolarity = sum of below
a. Amino acids: g x 10
b. Dextrose: g x 5
c. Electrolytes: mEq x 2
d. Lipid x 1.5
3. Recommendations for kcals
a. Carbs 40-80% kcals dextrose
i. 5-10% dextrose max via peripheral access
ii. max rate = 7 mg/kg/min
b. 2-4% of kcals, max 35%
4. Guidelines for transition to oral feedings
a. Assess ability to take enteral/oral diet
b. Decrease PN to 75% of needs
c. Add EN to make up 25-40% of needs
d. PN decrease as EN/Oral increases
e. Try to decrease PN and increase EN/Oral by 25% increments or 50/50 PN/EN then 25%
PN (or stop) and 75-100% EN/Oral
5. CALCULATIONS!:
a. given % and volume - calculate grams of dex, aa, lipids & kcals
%/100 = g/vol
b. need to know dextrose/a.a/lipid- kcals per gram
Dexrose 3.4 kcal/gram
Protein 4 kcal/gram
Lipid 9 kcal/gram
c. Lipid solutions 10%, 20% = kcals per ml
Lipid 10% - 1.1 kcal/ml
Lipid 20% - 2.0 kcal/ml
d. maximum dextrose amounts and how to calculate g/kg, mg/kg/min
max: 7 mg/kg/min
7 mg/kg/min x 1440 min/day x kg = mg/day
* convert mg to g
* g x 3.4 = kcals/day
e. conversion between mg to mEq for Na
mg = mEq x 23
mEq = mg/23
5. Stability issues
a. Increase temp dissociation of electrolytes
b. IVFE higher pH
i. Ca-Phos solubility lower pH
c. Light and oxygen exposure
d. Order of mixing
i. Dextrose, aa, water first
ii. Vitamins last use within 24 H
iii. If TNA is mixed, add lipids just prior to vitmains
iv. NEVER add dextrose and IVFE directly to eachother
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6. Peripheral vs. Central TPN
Peripheral
Central
Short term access only (<14 days)
Catheter tip outside central vessles
Access via cephalic, basilica or brachial veins
Short or long term access
Catheter tip reaches the vena cava
Access via subclavian, jugular, femoral,
cephalic, and basiliac veins
PICC lines
7. Understand how to write order
a. Estimate Kcal, pro, fluid needs
b. Estimare kcal of fat/ g of fat
c. Calc ml of lipids
d. Find remaining fluids
e. Find % aa in remaining fluids
f. Find remaining kcals
g. Find grams dextrose from remaining kcals
h. Find % dextrose
8. Standard TPN order standard amount of electrolytes
a. 40 mEq/L NaCl
b. 20 mEq/L NaAc
c. 20 mEq/L KCl
d. 20 mEq/L KPhos
e. 5 mEq/L CaGlu
f. 8 mEq/L MagSO4
g. 10 ml/day Adult MVI
h. 3 ml/day MTE-5
9. How to compound TPN; will particular order fit in certain volume?
a. TPN compounded using 10%, 15% amino acid, 70% dextrose, and 20% lipids
b. TPN Rx must be compounded using standard base solutions
c. This can be an issue if the pt is on fluid restriction
d. Find minimum value to compound PN Rx
i. Find mls of each required component (aa, dex, lipids)
e. Add mls
f. See if less than fluid restriction
g. If no… reduce dextrose or use higher % AA base if available
Recommend review “Parenteral Nutrition Formula Calculations and Monitoring Protocols” Slides
III. Nutritional Care for Patients with HIV/Cancer
1. Characteristics of cancer cachexia
a. Weight loss
b. Anorexia
c. Disproportionate loss of BCM
2. Neutropenic diets: avoid:
a. Fresh fruits + veggies (banannas, oranges ok)
b. Undercooked meats
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