Angela's Nutrition Flashcards
Most sensitive test for malnutrition?
albumin
Pre-albumin for short term, albumin for long term
CRP is acute phase reactant and can help determine if hypoalbuminemia is due to inflammatoy process or malnutrition
Anergy secondary to malnutrition is mediated through what cells?
T cells
What elements are increased in tumor lysis syndrome?
1.Potassium
2.Phosphorus
3.Hyper - uremic (Uric Acid)
Which element is decreased in tumor lysis syndrome?
1.calcium
Which electrolyte abnormality is least consistent with tumor lysis syndrome?
1.Hypercalcemia: ANSWER
Wrong choices:
hyperphosphatemia, hyperuricemia, hyponatremia, hypokalemia (I think they meant hyperkalemia…)
electrolyte abnormalities with TLS: high K, low Ca, high Phos, high uric acid
Which element is most increased with massive transfusion?
Potassium
(Two common electrolyte abnormalities that occur in MTP are hypocalcemia, caused by the preservative citrate and hyperkalemia.)
Which element is most decreased with massive transfusion?
calcium
(Two common electrolyte abnormalities that occur in MTP are hypocalcemia, caused by the preservative citrate and hyperkalemia)
What are benefits of enteral feeds compared to TPN?
Trophic to small gut, decreases infection
more physiological, simpler, cheaper and less complicated
what non essential aa is essential in patients with critical illness?
Glutamine
Think glutAMINE for amino acid
(Glutamine is the most abundant free amino acid in the body; essential for maintaining intestinal integrity and function, sustaining the immune system’s response, and maintaining antioxidative balance)
What is an essential fatty acid in critical illness?
Linoleic acid
Lino - chocolino - fat
What causes cholestasis associated with TPN ?
excessive carbohydrate calories
What is the most common TPN metabolic abnormality?
hyperglycemia
What equation is used to calculate basal energy expenditure?
Harris-Benedict
666 + (9.6 * kg) + (1.7 * cm) - (4.7 * yr)
kg - weight, cm - height
Harris Benedict which is used to calculate basal energy expenditure is most dependent on weight, height, or age?
WEIGHT
What is the most common ELECTROLYTE abnormality with TPN?
hypophosphatemia
Where is iron absorbed?
Duodenum
What is a cofactor required for iron absorption?
Vitamin C
Night blindness, weakened immunity, diarrhea, alopecia are common when deficient in what nutrient?
Zinc
Where is folate absorbed?
Duodenum
What trace element is needed for creation of RBCs?
Copper
Post op hyponatremia is secondary to what physiologic changes?
Increased ADH and free water retention
What is the most common cause of hyperkalemia?
Renal failure; lab error
What are EKG manifestations of hyperK?
Peaked T waves
flat P waves
prolonged QRS
(all the above)
What is the best acute treatment for hyperK with EKG changes?
Glucose, insulin, and calcium
(all the above)
What is the best continued treatment for hyperK (depletes stores)?
Kayexalate (polystyrene sulfonate), saline diuresis, dialysis
(all the above)
Calculate fena
Duplicate
(Urine Na x Plasma Cr/
Plasma Na x Urine Cr) x 100
Pre-renal: <1%
Intrinsic: >2%
Post-renal: >1%
What electrolyte abnormality is common with malignant hyperthermia?
hyperkalemia - due to muscle break down and rhabdomyolysis
A patient presents with stage 3B SCCC presents w ureteral obstruction K>7, Cr 9, peaked T waves. Best initial step?
glucose/insulin, dialysis, kaexylate, stent, lasix
(not calcium gluconate) <— MLH I think this is wrong
Per UTD: K>6.5 w EKG changes = hyperK emergency —> IV Ca, insulin, glucose FIRST. Also K removal: HD, kayexylate, diuretics)
what is the most common cause of hypokalemia?
vomiting, diarrhea, NG suction, malnutrition, alkalosis,
Also diuretics, hypomag, insulin
what vitamin requires Magnesium for absorption?
vitamin D
(Slide into your DMs)
What patients are prone to become hypermagnesemic?
Patients with renal failure or acidosis
What EKG changes are present in patients who are hyperMg?
widened PR and QRS
Long QT
What is the treatment for hypermagnesemia?
IV calcium
(JS) UTD says IV calcium only if severe/symptomatic. Otherwise just fluids and loop diuretics
Which patients are prone to become hypomagnesemic?
Duplicate
patients on cisplatin, diuretics (loop and thiazide), digoxin, pts taking aminoglycosides, and w radiation enteritis
Radiation enteritis can result in brachycardia in some patients secondary to loss of what electrolyte?
Magnesium
What are symptoms of low magnesium?
similar to hypocalcemia: weakness, tetany, QT prolongation
what is the most reversible cisplatin toxicity?
hypomagnesium
Where is calcium absorbed?
duodenum
What forms does calcium circulate in?
45% ionized
40% protein bound
15% bound tightly to other ions
What are common causes of hypercalcemia in cancer patients?
lytic bony lesions, secretion of PTH-like peptide, thiazide diuretics
What are symptoms of hypercalcemia?
Duplicate
short QT, weakness, confusion, nausea/vomiting
Stones bones groans psych overtones
MILD: Ca <12 asx or non-specific constipation, fatigue, depression.
MODERATE: 12-14 polyuria, polydipsia (b/c can’t concentrate urine), dehydration, anorexia, nausea, m. weakness, sensorium changes.
SEVERE: Ca >14 progression of sx seen in moderate
What are treatment options for HYPERcalcemia?
Duplicate
Mild-moderate: minimal or no sx (mild - albumin-corrected calcium <12 mg/dL / mod - 12-14)
No treatment other than adequate PO hydration. Avoid:
●Thiazide diuretics
●Lithium carbonate
●Volume depletion
●Prolonged bed rest or inactivity
●A high-calcium diet (>1000 mg/day), Calcium supplements
●Vitamin D supplements in excess of 800 international units/day
●Multivitamins containing calcium
Moderate-severe: albumin-corrected calcium >14 mg/dL
- Volume expansion with isotonic saline
- Calcitonin
- bisphosphonate (zolendronic acid) or denosumab
What is the most common EKG finding with hypercalcemia?
shortened QT interval
What are causes of hypocalcemia in cancer patients?
malnutrition, hypomagnesemia, tumor lysis syndrome
** also: Platinum chemotherapy, particularly cisplatin, is commonly associated with electrolyte imbalances, including hypomagnesemia, hypokalemia, hypophosphatemia, hypocalcemia and hyponatremia.
What are clinical signs of hypocalcemia?
Duplicate
1 = tetany;
Chvostek’s sign, prolonged QT and ST, hyperreflexia.
hallmark of acute hypocalcemia is tetany, which is characterized by neuromuscular irritability. Range from perioral numbness, paresthesias of the hands and feet, muscle cramps to severe (carpopedal spasm, laryngospasm, and focal or generalized seizures, which must be distinguished from the generalized tonic muscle contractions that occur in severe tetany)
Others: fatigue, hyperirritability, anxiety, and depression, hypotension, papilledema, psychological sx
What is the most common electrolyte abnormality with TPN?
hypophosphatemia
What are the symptoms of hypophosphatemia?
weakness, mental status changes, hypertonia
Where is phosphorus stored?
bone
What hormone mediates the release of phosphorus?
PTH
What are common causes of metabolic acidosis?
GI loss
ketoacidosis
aspirin
Tylenol
methanol ingestion
renal tubular acidosis
which metabolic acidosis have a gap?
1.Lactic acidosis
2.ASA
3.Tylenol
4.DKA
Which metabolic acidosis DO NOT have a gap?
USED PART
Urinary diversion
Small bowel fistula
Excess chloride
Diarrhea
Pancreatic fistula
Addison, acetazolamide
Renal tubular acidosis
Tenofovir, topiramate
what is the expected change in pH associated with change of 10 pCO2?
0.08
What are causes of high anion gap acidosis?
(Duplicate)
DKA
lactic acidosis (sepsis)
ASA
ESRD
MUDPILES: Methanol, Uric acid (aka uremia/ARF), DKA, Paraldehyade/phenformin, Iron/INH, Lactic acidosis, Ethylene glycol, Salicylates
which patient will likely have a non-gap acidosis?
renal tubular acidosis and a patient with a transverse colon conduit (in another answer; hyperchloremic acidosis)
which is least likely to produce acidosis?
vomiting, diarrhea, fistula
Vomiting - causes metabolic alkalosis
Diarrhea - hyperchloremic acidosis
Fistula - metabolic acidosis
How to avoid hypo phosphatemia on TPN?
Add 10-15 mEq to each liter of TPN
UTD: 20-40 mmol/day
What are malnutrition labs?
- Albumin <3.5
- Transferrin <150
- Absolute lymphocyte count <1500
- Loss of reactivity to 4 of 5 androgens
- Loss >10% ideal body weight or 10 lbs unintentionally in 2 months
*In the text book: this list is the major signs of protein depletion in hospitalized patients.
Fat requirements for TPN?
absolute minimum requirement is 4% of total calories
Maximum is 60% of total calories
*Per Angela: usually after protein and carb calories have been calculated fat accounts for far less than 60% but usually >4%)
CHO requirement for TPN?
half of the total caloric requirement
Textbook definition of severe malnutrition?
Duplicate
> 10% weight loss over 2 to 3 months of desired body weight
or history of inadequate oral intake longer than 7 days
*added from nutritional chapter
Ideal Body Weight Formula
IBW= 100 lbs for 5ft + 5lb/inch if greater 5 ft
example: 5ft 4 in would have IBW 120bs
What is the general rule for daily nutritional requirements (parenteral or enteral)?
1.Use current weight for total calorie requirements
2.Use IBW for protein requirements
Why do we care about assessment of nitrogen?
assessment of nitrogen balance is the most useful clinical tool for determining the effectiveness of nutritional therapy. Because the goal of nutrition therapy is getting an anabolic state or reduction of nitrogen losses, we have to know the nitrogen balance. Difference between nitrogen intake and nitrogen excretion.
*from the textbook so nitrogen question makes sense
What is the nitrogen balance equation?
- 24 hr UUN = gm Nitrogen in urine/24 hours
- (UUN) x 6.25 gm prot/gm N = gm protein in urine/24 hrs
- N balance = (gm protein/6.25) – (UUN +4)
- Goal N balance = + 4 – 6 grams/day
*24 hour urinary urea nitrogen assay = (UUN)
1 gm nitrogen is how much gm protein?
1 gm nitrogen = 6.25 gm protein
Daily requirement of nitrogen/kg/day?
0.3 gm nitrogen/kg/day
1 gm CHO to kcal?
1 gm CHO is 3.4 kcal
1 gram protein to kcal?
1 gm protein is 4 kcal
most common complication associated with feeding tube?
(textbook question but I think its a good question to be asked)
Diarrhea
(assessed/treated the following ways: exclude infectious diarrhea, decrease rate of infusion, enteral formula changed to isomolar formula, medication to decrease intestinal motility, decreased level of enteral support and give peripheral parenteral support until better)
Most common catheter related complications for temporary and permanent central venous catheters?
subclavian venous thrombosis (#1), pneumothorax (#2)
How many kcal/kg/day and protein/kg/day for:
Obese person?
Normal/Lean person?
Severe illness/malnutrition?
Obese: 15 and 25 kcal/kg, 1g/kg/day
Normal/Lean – 35 kcal/kg/day, 1.0 gm protein/kg/day (to 1.5)
Severe Illness/Malnutrition – 45 kcal/kg/day, 1.5 gm protein/kg/day
how many kcal is 1 gram fat?
1 gram fat = 9 kcal
(remember, triglyceride are part of your lipid panel, biochem there are 3 chains!)
