18 - Critically Ill Flashcards
Critically ill is assoc w state of…
catabolic stress characterized by
- systemic inflammation
- multipl-orgn dysfnctn
- prolonged hospitalitn
- disproportnt mortality
nutrition support aids in
- metab response to stress
- prevent oxidative cellular injury
- decr exaggerated immune response
- reduce infectious morbidity
- reduve ventilator dependency
- decr protein catabolism
disruption in homeostasis elicits a…
body wide stress response
- characterized by hormonal + inflammatory/metab changes for healing
- ebb + flow
ebb + flow phase of stress response
1 initial shock/ebb
2 catabolic flow
3 anabolic flow
initial shock or ebb
hemodynamic instability
-24-48 hr
initial shock or ebb characteristics
- shock
- hypo vol
- low perfusn
- low CO, O consumption, temp
- high HR, gluc, acute phase proteins
- activated immune systm
initial shock or ebb Tx
- restore blood flow to organs
- maintain oxygenation
- stop bleed
- replace fluids
Catabolic Flow
metabolic instability + catabolism
- 3-10 days
- spike in circulatory hormones (fight/flight)
- promotes breakdown of stored nutrients (glycogen>glucose, muscle>amino acids, fat>fatty acids)
Catabolic Flow
characteristics
- insulin resistance
- high CO, O consumptn, temp, BMR, total body protein catabolism
- length of phase depends on severity or whether complications develop*
positive/negative nitrogen balance
+ protein synth
- protein catabolism/breakdwn
Catabolic Flow
Nutrition goals
- fluid/electro balance
- minimize body protein catabolism
- meet caloric protein
- micronutrient needs
Anabolic Flow Phase
characteristic + nutrition needs
- [+] nitrogen balance> protein synth
- needs calories, protein, nutrients for anabolism
hormone response includes….
- catecholamines, glucagon, + cortisol»> release stored macros to meet incr demands, hyperglycemia,
- excess cortisol is damaging when prolonged»> inhibits protein synth even when intake is high, promotes insulin resistance, suppress immune response
- aldosterone + antidiuretic> maintain blood volume
acute phase response
quick inflammatory response to destroy infectious agents, prevent further damage, promote healing
inflammation causes increase in positive acute proteins such as… and decrease in negative acute proteins such as…
- c-reactive protein
- albumin, prealbumin, transferrin
cytokines
- more than 100 types of proteins involved in immune response
- responsible for regulating acute-phase proteins
- produce changs in other cells that cause accelerated catabolism> anorexia, fever, lethargy, wt loss
prolonged or exaggerated inflammatory response is compensated by…
- increasing the ANTIinflammatory response to counter
- disproportionate shift towards ANTIinflammtn can lead to endothelial damage, organ failure, immune suppression, metab abnormalities, + loss of body mass
- weakened immune system is unable to destroy pathogens> immunocompromised
sepsis
abnormal systemic host response to infection
- causes life-threatening organ dysfunction
- primary cause of death fr infectn
septic shock
underlying circulatory + cellular metabolism abnormalities are severe enough to substantially incr risk f death
why is there malnutrition w inflammatory response?
hypermetabolism + catabolism quickly deplete protein stores
nutrition support
via enteral tubes or parenteral catheters
an oral intake that meets __% of client’s needs from days 3-7 is considered adequate
70%
if enteral feed is indicated, it should be initiated as soon as…
fluid resuscitation is complete + client is hemodynamically stable
-preferably w/in 24-48 hr
polymeric enteral formula
intact macros
-1-1.5 cal/mL
enteral formula for obese
low-caloric density formula
- reduced nonprotein calorie-to-nitrogen ratio
- less cals fr fat + carb than protein
enteral formula for surgical ICU, or severe trauma
immune-modulating formula that provides arginine, fish oil, glutamine
disease specific formula
no benefit for critically ill
weight based calories
BMI<30: 25-30 cal/kg
BMI 30-50: 11-14 cal/kg
BMI>50: 22-25 cal/kg
protein intake based on BMI
<30: 1.2-2 g/kg
30-40: 2 g/kg
>40: 2.5 g/kg
** higher amounts may be needed for certain illnesses like burns
supplemental enteral glutamine
not recommended to be added
-no benefits
supplemental vitamins + minerals
antioxidant vit (E + C) trace minerals (selenium, zinc, copper)
esp w burns, trauma, + pt that needs mechanical ventilation
formula for clients with persistent diarrhea
fiber containing formula
or semi-elemental formula
or soluble fiber supplement
indirect calorimetry
analysis of O2 + CO2 of inspired + expired air
- gold standard for determining cal needs
- not done routinely bc limited availability + costly
how often should calorie calculation should be reevaluated?
more than once a week
how to avoid overfeeding
early full EN + PN should not be given to critically ill
-should be achieved w/in 3-7 days
- unless severely malnourished or high nutrition risk, then advance to goal quickly over 24-48 hr
- –monitor for refeeding syndrome
monitor malnourished clients such as …… for refeeding syndrome
- alcoholic
- chronic undernutrition
- morbid obesity w massive wt loss
- prolonged fasting
- long-term use of simple IV hydratn
- cardiac/cancer cachexia
sudden availability of carb stimulates…
- insulin secretion
- incr need for thiamin + minerals involved in carb metab
thiamin deficiency can cause..
acidosis, hyper vent, neurologic impairments
initial provision of ___% of calculated cals is reasonable in msot young or well nourished clients
100-70%
extubation care
- oral intake is commonly inadequate right after bc pain, anorexia, GI upset, etc
- monitor oral intake closely
- small frequent high cal + protein
- nutrient dense
- oral or EN supplements may be needed
protein is for..
- replace lean body mass lost fr catabolic phase
- restore blood vol + plasma proteins
- replace loss fr immobility
- meet incr need for tissue replare
- resistance to infection
calories is for…
- spare protein
- restore norm wt
vitamin c is for
- capillary formation
- tissue synth
- wound healing thru collagen formation
- antibody formation
thiamin, niacin, riboflavin is for
increased metab rate
folic acid + B12 is for
- cell prolif> tissue synth
- maturation of RBC
- impaired folic acid synth or impaired b12 absorptn fr some abx
vit A is for
- immune functn
- protein synth
- cell differentiatn
- epithelial cells
vit K is for
- blood clotting
- impaired intestinal synth bc abc
zinc is for
- protein synth
- wound heal
- norm lymph + phagocyte response
