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PDAT3 > 10 - Special Populations, Nutrition > Flashcards

10 - Special Populations, Nutrition Flashcards

1
Q

Parenteral Nutrition
for Special Populations - DIABETES

A
  • *< 150 gm Glucose_ = _1.5 mg/kg/min**
  • HALF of normal 3*
  • *Insulin in TPN** or seperate infusion
  • *10-50% of insulin ADHERES TO BAG** –> need to adjust
  • *START with 2/3 of previous needs**

LA SQ Insulin Glargine

Monitor BG >q6hr
provide correction bolus w/ SA insulin PRN

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2
Q

ENTERAL Nutrition
for Special Populations - DIABETES

A

Select formula that limits carbs to:
<50% of total Calories

HIGH FIBER formulations –> less BG elevation

CONTINUOUS DELIVERY
of enteral feedings vs bolus feedings

Start w/ 25% of estimated needs
& monitor BG q6 hours

Advaance q1-2 days as tolerated

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3
Q

Goal of Nutritional Support
for Special Populations - RENAL DISEASE

A

Provide adequate PROTEIN
without causing azotemia / uremia

Insulin lasts LONGER in renal pts –> GLUCOSE monitoring

Correct & Maintain:
Normal Fluid / Electrolyte / A-B balance

Macro & Micro - nutrient requirements vary with:
TYPE of renal disease (AKI / CKD)
TYPE of renal replacement therapy:
Hemodialysis / peritoneal dialysis / CVVHD

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4
Q

Glucose Considerations
HYPERGlycemia
for Special Populations - RENAL DISEASE

A

HYPERGlycemia
Peripheral Insulin RESISTANCE
in AKI –> INCREASED levels of glucagon / GH / catecholamines

Initiate glucose at LOWER AMOUNT
titrate up slowly

Treatment similar to DIABETES patients

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5
Q

Glucose Considerations
HypoGlycemia
for Special Populations - RENAL DISEASE

A

HypoGlycemia

decreased Glucagon Reserve

decrease in insulin renal elimination

  • *CAPD** = continuous dextrose dialysis
  • may result in* loss of carbs due to absorption in dialysis fluid
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6
Q

Protein Considerations
for Special Populations - RENAL DISEASE

A

AZOTEMIA occurs without renal replacement
IF - standard protein amounts are provided

Goal is to MAINTAIN a POSITIVE nitrogen Balance

GI Bleeding / overfeeding of protein –> BUN elevations

AKI is associated w/ marked protein catabolism / urea accumulation

HEMODIALYSIS
loss of 6-8 g protein per treatment

CVVHD
loss of 10-12g per 24 hours

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7
Q

Protein Requirements
for NON-DIALYZED
for Special Populations - RENAL DISEASE

A

0.6 - 1.0 g/kg/d

Use
Actual Body Weight

unless OBESE –> use IBW

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8
Q

Protein Requirements
for Intermittent Hemodialysis / CAPD
for Special Populations - RENAL DISEASE

A

1.2 - 1.4 g/kg/d

Use
Actual Body Weight

unless OBESE –> use IBW

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9
Q

Protein Requirements
for Continuous Renal Replacement Therapy = CRRT
for Special Populations - RENAL DISEASE

A

1.8 - 2.5 g/kg/d

Use
Actual Body Weight

unless OBESE –> use IBW

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10
Q

Protein Source
for Special Populations - RENAL DISEASE

A

A mixture of:
Essential AAs + Non-Essential AAs
recommended for pts w/ renal failure

TRAVISOL = standard

Renal specialty formulas are available
but NO BENEFIT over standard
Aminosyn RF // NephrAmine

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11
Q

Fat Considerations
for Special Populations - RENAL DISEASE

A

PRO = Volume Sparing
OUTWEIGHS ANY CONS
Fat is 9cal/gram –> less volume for more energy

Cons
Need to closely monitor:
TG’s**&**PHOS levels

500 mL IVLE –> 7.4 mM phos
1/2 of AKI pts have decreased hepatic lipoprotein lipase –> Elevated TG’s

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12
Q

Water Considerations
for Special Populations - RENAL DISEASE

A

AKI - Oliguric Renal Failure
Restrict to 1500mL/day of water

AKI - non-aliguric renal failure
depends on urine output

CKD - dilutional HypoNatremia
Restrict to 1500 mL/day of water

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13
Q

Sodium Considerations
for Special Populations - RENAL DISEASE

A

AKI - Oliguric Renal Failure

  • LESS* sodium, start @
  • *0.5 mEq/kg/d**
  • AKI - non-aliguric renal failure*
  • may have increased sodium loss*

CKD - dilutional HypoNatremia
start at lower end of standard amount
1 mEq/kg/d

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14
Q

OTHER Electrolyte Considerations
for Special Populations - RENAL DISEASE

A
  • *Potassium & Magnesium**
  • DO NOT SUPPLEMENT UNTIL STABLE*
  • decreased excretion in BOTH AKI / CKD*
  • *Phosphate**
  • *usually NOT required**, not excreted in AKI or CKD

Acid - Base
MAXIMIZE ACETATE in TPN solutions
CKD frequently have metabolic ACIDOSIS

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15
Q

Vitamin Considerations
for Special Populations - RENAL DISEASE

A

NORMAL DOSE
in AKI & CKD +/- renal replacement

Might need some Additional Supplementation if needed:
CKD has some DECREASED Vitamin D activation

Folic Acid / Pyridoxine / Vit C
most commonly REMOVED during dialysis

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16
Q

Trace Element Considerations
for Special Populations - RENAL DISEASE

A

SELENIUM
eliminated in urine

  • DECREASE* Dose to 1/2 for MOST renal Patients
  • *30mcg**
  • EXCEPT FOR*
  • *CRRT** - use standard dose = 60mcg
17
Q

Goals of Nutritional Support
for Special Populations - HEPATIC DISEASE

A

Provide Adequate PROTEIN w/o causing or worsening:
Complications of Cirrhosis
HE(hepatic encephalopathy) =High protein
Ascites = High Protein + Fluids

Over come impaired abs & digestion of nutrients

Improve immune response –> minimize infectious disease related complications of cirrhosis

Support pt until xplant

18
Q

Glucose Considerations
for Special Populations - HEPATIC DISEASE

A

Glucose infusions typically cause HYPERglycemia
in pts w/ hepatic disease
–> initiate glucose as described in DIABETIC PATIENTS

  • *Glucagon + Insulin** metabolized by liver
  • *elevation in both** seen in cirrhosis

Cirrhotic patients –> MAY develop peripheral Insulin resistance

19
Q

Protein Considerations
for Special Populations - HEPATIC DISEASE

A
  • *Protein INTOLERANCE common**
  • *AAA –> encephalopathy**
  • *BCAA** –> catabolized for energy in peripheral muscle
  • *BCAA specialy formula** = 35% vs 16%
  • *MAY HAVE BENEFIT** in patients with HE
20
Q

Protein Requirements for
Compensated Cirrhosis w/ no symptoms of encephalopathy
for Special Populations - HEPATIC DISEASE

A

1 - 1.2 g/kg/day

Use
Actual Body Weight

unless OBESE –> use IBW

21
Q

Protein Requirements for
Mild = Grade 1-2 Encephalopathy
for Special Populations - HEPATIC DISEASE

A

0.5 g/kg/day

start there, slowly advance to target

Use
Actual Body Weight

unless OBESE –> use IBW

22
Q

Protein Requirements for
SEVERE = Grade 3-4 Encephalopathy // Significant Ascites
for Special Populations - HEPATIC DISEASE

A

<0.5 g/kg/day

(20 grams)
Start there –> slowly advance to target
Use
Actual Body Weight

unless OBESE –> use IBW

23
Q

Fat Considerations
for Special Populations - HEPATIC DISEASE

A
  • *ESLD** associated w/
  • *Lipid Intolerance & HYPER-TG’s**

Monitor TG’s frequently

  • Oral fat intake** should be *_decreased_ in patients with
  • *streatorrhea** = fatty stools / diarrhea
24
Q

Water & Sodium Considerations
for Special Populations - HEPATIC DISEASE

A

Restrictions required due to
EDEMA & ASCITES

Water
HYPERvolemic HypoTonic HypoNateremia
restrict to 1500 mL/day

Sodium Restriction
Ideally no more than <90 mEq/day
start @ 0.5 - 1.0 mEq/kg/day

25
Q

OTHER ELECTROLYTES
for Special Populations - HEPATIC DISEASE

A

Poor oral intake / impaired absorption / diuretic use / diarrhea:
VVVV
HypoKalemia

HypoPhosphatemia
refeeding –> INCREASE requirements

HypoMagnesemia

26
Q

Vitamin Considerations
for Special Populations - HEPATIC DISEASE

A

Initially NORMAL # of Vitamins

Add if needed:
Vitamin A + D deficiency
due to decreased FAT absorption

Folic Acid + Thiamine
due to alcoholism

27
Q

Trace Elements
for Special Populations - HEPATIC DISEASE

A

Initially normal

ZINC deficiency
common due to steatorrhea

28
Q

Goal of Nutritional Support
for Special Populations - CRITICAL ILLNESS

A

Maintain & Modulate immune response:

  • *EARLY ENTERAL NUTRITION**
  • not parental, may need but NO*

Typically associated with
Catabolic Stress State
Cortisol / Catecholamines / Glucagon / GH

Preserve lean body mass

BCAA NOT PROVEN to show advantage vs std products

29
Q

When to Initiate Nutritional Support
ENTERAL FEEDINGS
​for Special Populations - CRITICAL ILLNESS

A

85-90% of critically ill patients can be
fed through ENTERAL tubes
Start within 24-48 hours (EARLY)

NRS 2002 > 5
provide >80% of estimated needs within 48-72 hours

In other patients w/ gut feeding:
500 kcal/day is acceptable

30
Q

When to Initiate Nutritional Support
PARENTERAL NUTRITION
​for Special Populations - CRITICAL ILLNESS

A

WITHHOLD PN first 7 days

UNLESS
NRS 2002 > 5
or
patient is severely malnourished

31
Q

Goal of Nutritional Support
for Special Populations - OBESITY

A

Depends on SEVERITY of Illness
Concomintant disease state severity / amplitude of obesity

if RENAL or HEPATIC dysfunction
VVV
Estimate calories per PENN STATE or MSJ & PROTEIN base

  • if not:*
  • *HIGH PROTEIN + HypoCaloric Feeding**
32
Q

Caloric Needs
for Special Populations - OBESITY

A

USE ACTUAL BODY WEIGHT

33
Q

Why do we need
HIGH PROTEIN + HypoCaloric
for OBESE
for Special Populations - OBESITY

A

POSITIVE NITROGEN BALANCE

Benefit:
AVOID risk of Overfeeding
avoid HYPERglycemia / infection / fluid overloat
LIMIT pathologic processes that occur in stress
Modestly REDUCE weight

34
Q

PROTEIN Needs for
Morbidly OBESE = BMI >40
for Special Populations - OBESITY

A

Provide 65-70% of target energy requirements

Calories:
11-14 kcal/kg (ABW)

Protein:
_>_2.5 g/kg/day
(IDEAL BODY WEIGHT)

35
Q

PROTEIN Needs for
OBESE = BMI 30-40
for Special Populations - OBESITY

A

Provide 65-70% of target energy requirements

Calories:
11-14 kcal/kg (ABW)

Protein:
_>_2 g/kg/day
(IDEAL BODY WEIGHT)

PDAT3 (23 decks)

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