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CNSC, Parenteral Nutrition Exam Questions and Answers
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CNSC, Parenteral Nutrition Exam Questions and Answers
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CNSC, parenteral nutritionA patient on long-term parenteral nutrition begins to experience Parkinson-like symptoms. Which trace
element toxicity is most likely to present with these symptoms?
1: Manganese
2: Copper
3: Zinc
4: Selenium - Answer -1: Manganese
Manganese is an essential trace element routinely added to long-term parenteral nutrition (PN)
solutions. Though manganese deficiency is exceedingly rare, toxicity is well documented in these
patients. Excess manganese accumulates in the brain leading to Parkinson disease-like symptoms such
as tremor, involuntary movements and rigidity. Patients with abnormal liver function are at an increased
risk for toxicity due to manganese being primarily excreted via bile. Manganese contamination of PN
solutions can also occur during manufacturing and delivery of PN solutions. Despite this increased risk,
there is limited evidence to support manganese-free PN solutions in patients without symptoms of
toxicity or impaired liver function. Current recommendations for long-term PN patients are to serially
monitor liver function as well as signs and symptoms of manganese toxicity.
The adverse effects of lipid injectable emulsion (ILE) administration in adult PN prescription is best
prevented by
1: supplementing with L-carnitine.
2: avoiding infusion rates >0.05 grams/kg/hour.
,3: using Alternative ILEs.
4: ILE free PN solutions. - Answer -3: using Alternative ILEs.
Liver dysfunction results from a complex set of risk factors present in patients receiving PN, called PN
associated liver disease (PNALD). Recommended dosage for all types of ILE are 1-2g/kg/day, not to
exceed 2.5g/kg/day. L-carnitine deficiency exacerbates lipid abnormalities but existing evidence has not
confirmed that supplementation corrects hypertriglyceridemia. Alternative ILEs may preserve liver
function and prevent hypertriglyceridemia due to their lower content of Soybean Oil/phytosterols.
Phytosterols are structurally similar to cholesterol, and may interfere with bile synthesis and transport.
This effect, in addition to high concentrations of peroxidation-sensitive PUFAs in plant-based ILE could
lead to free radical damage of liver cells. Lipid free PN Rx can cause EFAD within 2 weeks in acutely ill
patients. Although physical evident of deficiency may not be noticed, biochemical deficiencies can be
suspected by elevated AST, ALT and confirmed by triene: tetraene ratio.
An adult critically ill patient with small bowel obstruction is started on PN. He will not receive any
vitamins in PN due to parenteral multiple vitamins product shortage. Which of the following vitamins
are recommended to be added individually to PN?
1: Thiamine
2: Thiamine, folic acid, Pyridoxine, vitamin C
3: D, A, E and thiamine
4: 10 ml of pediatric intravenous multivitamin - Answer -2: Thiamine, folic acid, Pyridoxine, vitamin C
ASPEN has recommended to not consider using pediatric intravenous multivitamins for adults.
Additionally, pediatric intravenous multivitamins should not be used when there is a shortage. Try and
supplement vitamins enterally if possible. Special considerations to water soluble vitamins - thiamin, B6,
folic acid and vitamin C which may need to given individually on daily basis. Thiamin supplementation is
indicated if patients receive carbohydrates and are at risk for thiamine deficiency (which can happen in
patients on PN who do not receive vitamins for 3-4 weeks).
References:
2021 Parenteral Nutrition Multivitamin Product Shortage Considerations. Updated January 18, 2021.
Available at: https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Product_Shortages/
2021_Parenteral_Nutrition_Multivitamin_Product_Shortage_Considerations/
, A pregnant patient is admitted with hyperemesis gravidarum (HG). Which of the following is a clinical
indication for PN use?
1: Vomiting NOT controlled with supportive care within 48 hours
2: Intolerance to EN trial and supportive care measures
3: Patient refusal of EN tube placement
4: Fluid and electrolyte imbalances - Answer -2: Intolerance to EN trial and supportive care measures
Hyperemesis gravidarum (HG) is a severe form of pregnancy-induced nausea and vomiting. Due to the
likelihood that the patient's nutritional intake has been poor for several weeks due to vomiting, EN or
PN may be required. Early treatment options would include antiemetic use, and oral intake would
temporarily be avoided. Initiation of an EN trial for HG would be appropriate if the patient is still unable
to take oral feedings after 24-48 hours of supportive therapy, as listed above. If the EN trial fails due to
exacerbated nausea, vomiting, diarrhea, significant gastric residuals, or tube displacement and is
associated with clinically significant weight loss (greater than 5% of body weight), it is appropriate to
begin PN.
References:
Mogensen, Kris M.; and Erick, Miriam. "Pregnancy and Lactation." The ASPEN Adult Nutrition Support
Core Curriculum. 3rd ed. Silver Spring: American Society for Parenteral and Enteral Nutrition, 2017. 397-
417. Print.
Rapid intravenous infusion of potassium phosphate may result in
1: thrombophlebitis.
2: hypermagnesemia.
3: metabolic acidosis.
4: rhabdomyolysis. - Answer -1: thrombophlebitis.
The leading complication with peripheral intravenous infusion is thrombophlebitis (an inflammation at
the cannulation vein) with hallmark signs of pain, erythema, tenderness or a palpable cord. The risk of
thrombophlebitis increases by day 4. Infusion rates of phosphate should not exceed 7 mmol/hr because
faster rates can cause thrombophlebitis and soft tissue calcium-phosphate deposition. When
considering the diluent (dextrose vs saline), dextrose solutions may worsen the hypokalemia by
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