TDP

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  • in reply to: Sodium range in neonatal TPN #48751

    TDP
    Keymaster

    Good points, Thanks for sharing.

    in reply to: Ketogenic TPN #48489

    TDP
    Keymaster

    To my knowledge, ketogenic nutrition support terminology either parenteral nutrition or enteral feedings concept is applied to patients with intractable seizure and some cases in inborn error of metabolism like carbohydrate disorder metabolism and characterized by high fat, low carbohydrate, and maintenance protein contents.
    The goal of nutrition support in cancer patients is to minimize wasting but not for ideally nutrition repletion and gaining weight.
    Also, The goal of nutrition support in patient with cancer (adult) maintenance support which is between 23- 25 KCla/kg/day. not anabolic support as theoretically high calories providing may feed cancer cells as stated in some studies.
    I advise you to monitor other parameters like prealbumin or transferrin with CRP (if patient is not under any kind of stress) if you don’t see increasing in patient weight in order to if the patient got benefit from PN


    TDP
    Keymaster

    Hello,
    The practice of holding PN during blood transfusion is to avoid fluid load in short time that may affect cardiopulmonary system.
    The average of blood transfusion is between 1 to 4 hrs depending on the number of units. except platelets that may take just less than one hour. In case of blood transfusion,, you have taper PN rate by half for at least one hour depends on the dextrose concentration in PN.( no need if patient receiving peripheral PN).
    Also, you may recommend finger-stick at the mid of blood transfusion.
    Regarding IV lipids, you may advise the nurse to begin IV lipids after blood transfusion is completed.

    My thoughts are as follows:

    1. Make sure not to infuse Lipid and PN through the same line as Blood; Using the same line of PN and Blood is an absolute contraindication and might cause Blood Dyscrasias.
    2. There is no absolute contraindication of infusing blood at the same time as PN and Lipids using different lumen unless if the patient is fluid overloaded as mentioned by Hamdy
    3. Most patients can tolerate the low infusion rate of lipid same time with Blood transfusion; we don’t favour discontinuation and manipulation of lipid
    4. If the patient is at risk of fluid overload, then hold PN as mentioned by Hamdy; hold lipid and resume after blood transfusion
    5. If you know the time of blood transfusion in advance, try to start lipid after completion of blood transfusion. So you avoid holding and restarting.
    in reply to: 55-year-old woman with a 4-year history of hypertension (HTN) #48473

    TDP
    Keymaster

    Add losartan 50 mg/day and maintain both hydrochlorothiazide and metoprolol.
    This patient has stage 2 HTN despite receiving two agents at normal doses. Therefore, adding losartan 50 mg/day to her existing therapy is the best option (Answer 4 is correct). The continuation of hydrochlorothiazide and metoprolol may be debated based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) versus American Heart Association (AHA) versus Canadian Hypertension Education Program (CHEP) recommendations. Nonetheless, published guidelines must be individualized to meet patient care needs on a case-by-case basis. She does not have coronary artery disease (CAD), CAD risk equivalent, diabetes mellitus, or chronic kidney disease (CKD); however, based on her angina and her father’s past MI, she is considered at risk of CAD.

    Although she is tolerating both therapies well, she requires additional blood pressure control. Pharmacists should remember that about 80% of the blood pressure–lowering effects of an antihypertensive agent are seen with half-standard doses, and this patient is being treated with typical doses for each agent.

    Increasing hydrochlorothiazide to 100 mg/day (Answer 1) is incorrect because it would not be expected to provide the necessary reductions in blood pressure and would likely increase her risk of metabolic adverse effects. The AHA recommendations to use low doses of thiazide diuretics apply to this patient. Increasing metoprolol tartrate to 100 mg two times/day (Answer 2) is incorrect because this dose is unlikely to be tolerated by the patient given her current pulse rate. It is also unlikely that an increase in metoprolol would provide the necessary reductions in her blood pressure. Discontinuing metoprolol and initiating losartan 50mg/day (Answer 3) is incorrect. The exchange of metoprolol 100 mg/day for losartan 50 mg/day is not expected to provide adequate target blood pressure–lowering effects.

    Although AHA does not recommend the use of metoprolol as first-line therapy for primary CAD prevention, the use of two-drug therapy for this patient is unlikely to meet goals and she probably requires three-drug therapy. It is also important to assess her for causes of resistant HTN.

    in reply to: Body weight considerations for TPN in obese patients #48468

    TDP
    Keymaster

    Hope that answered your question.

    in reply to: Body weight considerations for TPN in obese patients #48463

    TDP
    Keymaster

    The common practice for calories and protein requirements calculation in obese patients is using actual weight for calories and Ideal body weight for protein.
    This practice is followed by ASPEN
    The recommendation for calories and protein for stable adult obese patients:

    View post on imgur.com

    Calories Amino Acids Fat
    Grade I obesity 15-20 Kcal/Kg (ABW)/day 2 gm/kg (IBW)/day 0.3-0.5 gm/kg (IBW)/day

    Grade II Obesity 10-15 kcal/kg (ABW)/day 2 gm/kg(IBW)/day No need for the first week, start with small dose 0.3-0.5 gm/kg (IBW)/day if patient is still NPO in order to prevent EFAD

    Grade III Obesity 10-15Kcal/Kg (ABW)/day >2 gm up to 2.5 gm/kg/day NO need for the first week, start with small dose 0.3-0.5 gm/kg (IBW)/day to prevent EFAD

    Some clinicians use Adjusted body weight for calories requirements. If so, you may add up to 20% additional to the above numbers for calories.

    Also, close attention must be paid to other micronutrient deficiencies like vitamins and trace elements. They may need mega doses and off course to monitor those levels and adjust accordingly like fat soluble vitamins, vitamin B1 and B12, selenium, zinc, and copper.

    For calories, you have the other option of using IBW and the range will be 20-22 kcal/kg. I tried both ways ( IBW and ABW) and all will end by the same numbers.

    There are different schools: we use Adjusted Body Weight (AjBW) for any patient who is 20% above IBW. (some references state 30%)

    Estimate Ideal body weight in (kg)

    Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.

    Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.

    AjBW = IBW + 0.4( ABW* – IBW)

    *ABW is Actual Body Weight

    in reply to: Mepredine #48456

    TDP
    Keymaster

    Hello,

    short answer is neurotoxicity.

    Normeperidine (an active metabolite and CNS stimulant) may accumulate and precipitate anxiety, tremors, or seizures; risk increases with preexisting CNS or renal dysfunction, prolonged use (>48 hours), and cumulative dose (>600 mg/24 hours in adults). Oral meperidine should not be used since first-pass metabolism decreases efficacy while increasing normeperidine concentrations (APS 2016). Note: Naloxone does not reverse, and may even worsen, neurotoxicity.


    TDP
    Keymaster

    We are considering the initiation of a new pharmacy-led sterile compounding service at our hospital.

    1. If you have the budget, use it all ASAP or you will lose it.
    2. Build the Clean Room as per available resources. Make sure you have the right space for the available workload> be strategic so no extension/construction for next 20 years.
    3. Leave a space for future technologies i.e. Robots of the future, IV Workflow needs extra electric and network sockets, other compounding devices, etc.
    4. Make sure the contractor has healthcare experience and knows a bit about USP 797
    5. Horizontal LAFH ONLY for ordinary drugs (not vertical)

    Due to limited resources at this time and as a first step, we narrowed down the types of medications to be prepared in a hood to antimicrobials (antibiotics, antivirals, and antifungals), nutrition (total parenteral nutrition, and pediatric electrolyte solutions), ophthalmic products, +/- monoclonal antibodies. We then determined the overall daily number of preparations requiring sterile compounding as well as the number of hours needed to complete those preparations.

    1. Good strategy, although I feel it is important to give priority for non-antimicrobial agents since these drugs protect themselves naturally. Just theoretical judgement.
    2. Work on standardization of doses then invest on batches- batches- batches

    One of our main concerns is the fact that the current pharmacy operating hours are limited to 11 working hours on week days, 8 hours on Saturdays, and 3 hours on Sundays and holidays. This schedule, if maintained as such, prevents the pharmacy department from being able to cater for new orders requiring sterile compounding during pharmacy off-hours. The solution that we thought of would be to extend pharmacy operating hours to 24 hours.

    1. Great thoughts by Naveed & Nawal as shown in previous replies
    2. JCIA will mercy you if the nurses are well trained under pharmacy supervision in using aseptic technique (strict when needed especially in immunocompromised patients) when mixing/transferring parenteral drugs outside the duty hours.
    3. Make sure there is a dedicated mixing Bench at the nursing medication room and away from traffic and bed side… I don’t favour LAFW hood in nursing units.
    4. Have a pharmacist on call to answer nursing queries

     

    in reply to: STARTING PARENTERAL NUTRITION FROM A-Z #49178

    TDP
    Keymaster

    Hello,
    It’s better to make a separate topic for your question.

    in reply to: STARTING PARENTERAL NUTRITION FROM A-Z #49146

    TDP
    Keymaster

    Related topic FYI

    Laminar Flow Cleaning

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