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CC Flashcards

1
Q

Acute phase response biochemistry

A

Acute phase response:
* Low albumin
* High CRP
* High WBC
* Deranged LFTS
* Us + Es

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2
Q

Define intubation

A

Intubation: placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to administer certain drugs.

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3
Q

Define extubation

A

Extubation: removing an endotracheal tube

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4
Q

Define artificial ventilation

A

Artificial ventilation: process of simulating normal breathing in a patient who is anaesthetised or unable to breathe for themselves

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5
Q

Define weaning

A

Weaning: gradual decrease in ventilatory support

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6
Q

Define tracheostomy

A

Tracheostomy: procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening.

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7
Q

Factors indicative of metabolic stress

A

Factors indicative of metabolic stress
Lab data
* High temperature
* High WBC
* High CRP
* High serum urea (difficult to interpret)
* Low haemoglobin
* Low serum albumin
Clinical indicators
* Anorexia
* Fatigue
* Reduced physical activity

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8
Q

Terminology that describes critical care

A

Terminiology that describes critical care
* Critical Care Department
* Adult Intensive Care Unit
* Critical Care Unit
* Intensive Care Unit
* High Dependency Unit (more stable/possibly step down but not fit enough to be on ward)

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9
Q

Reasons for being in critical care

A

Reasons for being in critical care (not exclusive)
* RTA
* Advanced respiratory support
* Complex surgery
* Severe heart attack
* AKI requiring RRT
* Severe pancreatitis
* Sepsis
* Sedation: head injury, epilepsy, cardiac arrest
* Vasopressers: treatment of low blood pressure unresponsive to fluid resuscitation on the ward
* Severe burns (unstable)
* Resuscitation and stabilisation
* Physiological optimisation to prevent MOF
* Facilitate complex surgery
* Support failing organs
* Recognise futility of treatment
* Provide organ support to maintain normal physiology
* Sepsis: Provide vasopressors to maintain organ perfusion & improve BP as antibiotic treatment and immune system combat infection

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10
Q

MOF

A

MOF = Multi Organ Failure

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11
Q

CVC

A

CVC = Central Venous Cathether

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12
Q

PENN STATE W MIFFLIN Equation: Women

A

PENN STATE W MIFFLIN Equation: Women
MIFFLIN: (10 x wt) + (6.25 x ht) - (5 x age) -161
PSU: (MIFFLIN x 0.96) + (Tmax x 167) + (Vm x 31) - 6212

Where,
Wt=kg
Ht= cm
Tmax= Max body temp in 24h
Vm= ventilator l/minute

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13
Q

PENN STATE W MIFFLIN Equation: Men

A

PENN STATE W MIFFLIN Equation: Men
MIFFLIN: (10 x wt) + (6.25 x ht) - (5 x age) +5
PSU: (MIFFLIN x 0.96) + (Tmax x 167) + (Vm x 31) - 6212

Where,
Wt=kg
Ht= cm
Tmax= Max body temp in 24h
Vm= ventilator l/minute

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14
Q

Ebb phase

A

Ebb pase
* “HOURS”
* 0-24 h following trauma/injury
* “Untreated SHOCK”
* Body attempting to recover from acute injury/trauma
* Reduction in metabolic activity
* Reduction in oxygen consumption
* Reduced body temperature
* Energy reserves mobilized BUT reduced ability to utilize reserves
* Reduction in REE: hypometabolic state
* Conservation of fluids & electrolytes due to hormones
* Haemodynamic compensation: e.g. vasoconstriction & tissue blood flow shunting: redirection of cardiac output to essential/injured tissues

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15
Q

Ebb phase nutrition specific considerations

A

Ebb phase nutrition specific considerations
* Minimal-no nutrition advised
* Energy reserves mobilized BUT reduced ability to utilize reserves
* Reduction in REE: hypometabolic state
* Protein losses increase 4 fold (Furst, 2005)
* Critical care patients weight can increase by 10-20% due to fluid shifts (Lowell et al., 1990)

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16
Q

Flow phase

A

Flow phase
* “DAYS”
* 24-48H +
* “CATABOLIC” phase
* Phase length depends on severity & treatment of trauma/injury
* Hypermetabolism: Increased REE
* Hypercatabolism

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17
Q

Which hormones cause conservation of fluid & electrolytes in the EBB PHASE?

A

Hormones that cause conservation of fluid & electrolytes in the EBB PHASE
* Vasopressin (Anti-diuretic hormone): may have glycogen mobilizing effect too
* Renin
* Angiotensin
* Aldosterone

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18
Q

Flow phase nutrition specific considerations

A

Flow phase nutrition specific considerations
* “DAYS”
* 24-48H +
* “CATABOLIC” phase: increase in energy production & consumption
* Phase length depends on severity & treatment of trauma/injury
* Hypermetabolism: Increased REE
* Hypercatabolism: Increased nitrogen losses
* Protein mobilisation caused by: increased catecholamines, glucagon & cortisol
* Increased glucose intolerance: caused by catecholamines
* Aim: prevent further nitrogen losses
* Increase in dietary pro: can reduce but NOT reverse accelerated loss of body protein due to anabolic resistance
* Excess non-protein calories may have adverse effects (Wolfe, 2017)
* “Less is more” : avoid overfeeding
* Muscle, glycogen, lipid mobilised to increase glucose availability

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19
Q

How much LBM can critically ill patients lose per day? (Puthucheary et al., 2013)

A

Critically ill patients can lose up to 2% of their LBM per day (Puthucheary et al., 2013)

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20
Q

How many kcal/ml is there in Propofol?

A

There is 1.1kcal/ml in Propofol.

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21
Q

Anabolic phase/Recovery phase nutritional considerations

A

Anabolic phase/Recovery phase
* “ WEEKS or MONTHS” after catabolic phase
* Appetite increases
* Transfer to positive nitrogen balance
* Improvement in nutritional status possible: ANABOLIC
* Aim: increase muscle mass via increased protein intake & exercise
* Aim: Weight gain
* Increase protein

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21
Q

What happens during the metabolic response to critical illness?

A

What happens during the metabolic response to critical illness:
* Early acute phase: EBB “SHOCK”
* Late acute phase: FLOW “CATABOLIC”
* Late phase: RECOVERY/REHAB/ANABOLIC
* Disrupted HOMEOSTASIS
* Adaptive stress response to critical illness

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21
Q

Build up of kcal:
* 0-24h
* Day 1-4
* Post Acute ICU phase >Day 5
* Post ICU phase
* Post Hospital Discharge

A

Build up of kcal:
* 0-24h: no nutrition
* Day 1-4: go slow. Day 1: 25%, Day 2: 50%, Day 3: 75%, Day 4: 100% of target
* Post Acute ICU phase >Day 5: 70% of predictive equations or 100% of indirect calorimetry
* Post ICU phase: 125% of predictive equations/indirect calorimetry or 30kcal/kg/day
* Post Hospital Discharge:150% of predictive equations/indirect calorimetry or 35 kcal/kg/day
(protocol is in place if patient adm on weekend)

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21
Q

Build up of kcal: 0-24H

A

Build up of kcal: 0-24H
* 0-24h: no nutrition

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22
Q

Build up of kcal: Day 1-4

A

Build up of kcal: Day 1-4:
* Go slow
* Day 1: 25%
* Day 2: 50%
* Day 3: 75%
* Day 4: 100% of target
(protocol is in place if patient adm on weekend)

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22
Q

Build up of kcal: Post Acute ICU phase >Day 5

A

Build up of kcal: Post Acute ICU phase >Day 5:
* 70% of predictive equations
or
* 100% of indirect calorimetry

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22
Q

Build up of kcal: Post ICU phase

A

Build up of kcal: Post ICU phase:
* 125% of predictive equations/indirect calorimetry
or
* 30kcal/kg/day

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23
Q

Build up of kcal: Post Hospital Discharge

A

Build up of kcal: Post Hospital Discharge:
* 150% of predictive equations/indirect calorimetry
or
* 35 kcal/kg/day

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24
Q

During the flow phase, is the glucose generated by muscle, glycogen and liver mobilisation suppressed by feeding or IV glucose?

A

No. During the flow phase, the glucose generated by muscle, glycogen and liver mobilisation is NOT suppressed by feeding or IV glucose (Oshima et al., 206)

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25
Q

During the flow phase, what might simultaneous delivery of excess non-protein kcal do?

A

During the flow phase, simultaneous deivery of excess non-protein kcal may have little benefit & cause adverse effects (Wolfe, 2017)

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26
Q

Anabolic phase/Recovery phase

A

Anabolic phase/Recovery phase
* Reduced metabolic rate
* Fluid status returns to normal
* Increased appetite

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27
Q

How much glucose does Dextrose 5% have per litre?

A

Dextrose 5%: 50g of glucose/L

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28
Q

How much kcal does Dextrose 5% have per litre?

A

Dextrose 5% contains 200kcal

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29
Q

What are catecholamines?

A

Catecholamines:
* A type of neurohormone.
* Catecholamines are important in stress responses.

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30
Q

Catecholamines, glucagon and cortisol increase during which response?

A

Catecholamines, glucagon and cortisol increase during the FLOW PHASE.

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31
Q

What do increased catecholamines do during the FLOW PHASE?

A

Increased catecholamines causes hyperglycaemia and insulin resistance during the FLOW PHASE

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32
Q

What does increased: Cytokines, Catecholamines, Glucagon & Cortisol do during the FLOW PHASE?

A

Increased cytokines, catecholamines, glucagon and cortisol increases PROTEIN MOBILISATION during the FLOW PHASE.

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33
Q

Increased catecholamines cause ?, ? & ? during the FLOW PHASE

A

Increased catecholamines cause HYPERGLYCAEMIA, GLUCOSE INTOLERANCE & INSULIN RESISTANCE during the FLOW PHASE

34
Q

Increased cytokines drives ? during the FLOW PHASE

A

Increased cytokines drive LEAN TISSUE BREAKDOWN during the FLOW PHASE

35
Q

How long does the EBB PHASE last?

A
  • The EBB PHASE lasts ~24H (some sources say up to 48H)
  • “HOURS”
36
Q

How long does the FLOW PHASE last?

A
  • The FLOW PHASE lasts 24-48H or MORE
  • “DAYS”
37
Q

How long does the ANABOLIC/RECOVERY PHASE last?

A

The ANABOLIC/RECOVERY PHASE lasts WEEKS/MONTHS after the FLOW (CATABOLIC) PHASE)

38
Q

During the FLOW PHASE muscle breakdown is also needed for the generation of which proteins?

A

During the FLOW PHASE, muscle breakdown is also needed for the generation of ACUTE PHASE PROTEINS (e.g. CRP)

39
Q

What is the dietetic aim during the FLOW PHASE?

A

Dietetic aim during the FLOW PHASE:
Energy balance to slow down UNAVOIDABLE muscle/tissue breakdown

40
Q

What is the dietetic aim during the ANABOLIC/RECOVERY PHASE?

A

Dietetic aim during the ANABOLIC/RECOVERY PHASE:
* Restore muscle mass (exercise also needed, PHYSIO in hospital)
* Gain weight
* Weight loss could be goal if obese/overweight

41
Q

A reduction in CRP could indicate that an individual is entering which phase?

A

A reduction in CRP (still above reference ranges) could indicate that an individual is entering the FLOW PHASE

42
Q

Which malnutrition screening tools are appropriate for use in Critical Care?

A

Critical Care MALNUTRITION Screening Tools:
* NUTrition Risk In The Critically Ill (NUTRIC) score (Heyland et al., 2015)
* PENG suggest: NRS-2002

43
Q

Pros and Cons of the NUTRIC score screening tool

A

Pros and Cons of the NUTRIC score screening tool
Pros
* Specifically developed & validated for use in critically ill patients
* Helps to identify which patients more likely to benefit from optimal amounts of macronutrients when mortality is considered
* Could be used to guide decisisions for aggressive nutritional support BUT prospective data is lacking
Cons
* Long & complex to use: not practical to complete at bedside due to complexity of the severity of illness scoring required
* Measures clinical parameters more than nutritional
*

44
Q

Pros and Cons of the NRS-2002 screening tool

A

Pros and Cons of the NRS-2002 screening tool
Pros
Cons
* May not be as suitable as NUTRIC Score. Coruja et al.: NUTRIC Score identified ~50% of patients in the ICU at high risk of malnutrition whereas NRS-2002 only identified ~35%.

45
Q

Barriers to obtaining anthropometric measures in Critical Care

A

Barriers to obtaining anthropometric measures in Critical Care
* Patients might be unable to provide medical/ diet/ anthropometric histories
* Patients may not have medical documentation
* Weight may fluctuate dramatically. CC patients weight can increase by 10-20% in the first 24H.
* CC patients are usually immobile
* CC patients may not be weighed due to haemodynamic instability/ unstable injuries.
* Alternate measures: Ulna, MUAC: not validated for use in CC. Should be used as a guide only
* Traction, casts & braces: provide logistic difficulties: need to be accounted for in resultant measurements.
* Adjusting body wt in amputees: add additional scope for errors.

46
Q

Is the MUST tool suitable for use in Critical Care?

A

No, the MUST tool is not suitable for use in Critical Care.

47
Q

Stiles et al.

A
48
Q

What is haemodynamic instability?

A

Haemodynamic instability is an insufficient blood flow in the body.

49
Q

What is haemodynamic instability caused by?

A

Haemodynamic instability may be caused by (not exclusive):
* heart disease
* high or low blood pressure
* heart failure
* peripheral artery disease
* issues with the heart valves

50
Q

What is Gastric Residual Volume?

A

Gastric Residual Volume (GRV) is the amount of liquid drained from a stomach following administration of enteral feed

51
Q

Considerations following ICU stay

A

Considerations following ICU stay
* ICU acquired weakness

52
Q

What is ICU acquired weakness?

A

ICU-acquired weakness (ICUAW) is ‘clinically detected weakness in critically ill patients in whom there is no plausible aetiology other than critical illness’

53
Q

Which type of diet should be recommended in those that can eat orally during the recovery phase?

A

A high energy high protein diet should be recommended to those that can eat during the recovery phase to aid regaining muscle/weight loss.

54
Q

Why would I choose to use the Penn State University equation instead of the Ireton-Jones equation to estimate energy requirements in CC?

A

I would choose to use the Penn State University equation instead of Ireton-Jones to estimate energy requirements in CC because:
PSU: More sensitive to metabolic status: REE, temperature & ventilator
PSU: Higher accuracy than Ireton-Jones
PSU: Utilizes MIFFLIN ST JEOR: which includes parameters: age, sex, ht, wt.
I-J: Overestimates in non-obese, underestimates in obese.

55
Q

What is a limitation of the PSU equation?

A

According to Frankenfield, the PSU equation is less sensitive in underweight CC/ICU patients (58% accuracy).

56
Q

When might Ireton-Jones be preferred over PSU?

A

Ireton-Jones may be preferred over PSU for burns or trauma patients as it was developed for this population.

57
Q

What are the components of the Global Leadership Initiative on Malnutriton (GLIM criteria)?

A

Components of the GLIM criteria:
1. Screening of malnutrition (with validated tool)
2. Diagnostic assessment: Phenotypic & aetologic
3. Diagnosis: =/> 1: Phenotypic & 1 Aetologic
4. Grading of malnutrition severity: based on phenotypic criterion

58
Q

What could a calf circumference measurement be affected by?

A

A calf circumference measurement could be affected by oedema.
A Japanese study found that the presence of oedema increased a calf circumference by 2cm.

59
Q

What has been suggested as an alternative to weight estimation in CC?

A

It has been suggested that a fibula measurement could be utilized instead of visual weight estimation in critical care. Although differences between ethnicities would need to be accounted for (Asian population)

60
Q

Calf circumference limitations

A

Calf circumference limitations:
* Doesn’t give indication of muscle strength/quality.
* Could be measuring oedema as well as muscle
* Could be measuring fat
* May not be suitable in those with extreme BMIs (underweight or overweight), but adjustments have been suggested

61
Q

Hand grip strength is an indication of ? ? not ? ?

A

Hand grip strength is an indication of muscle function not dietetic treatment

62
Q

What is BMI adjusted low calf circumference associated with? (Brazilian study)

A

In a Brazilian study: BMI adjusted low calf circumference is associated with longer hospital stay. Although CC patients were not included in this study.

63
Q

When is use of ideal body weight indicated?

A

Use of ideal body weight is indicated in extreme BMIs (underweight or overweight).

64
Q

Why is ideal body weight suggested in obese patients?

A

Ideal body weight is suggested in obese patients because use of their actual body weight may lead to overestimation of nutritional requirements (Pinnock, 2022)

65
Q

What are limitations of the use of IBW?

A

IBW limitations:
* All IBW formulae predict a single-target body weight as a linear function of height but it the height-weight relationship is complex:
* Weight is affected by: fat mass, muscle mass, presence of oedema/ascites
* No single body weight that applies across all
demographics such as sex, ethnicity and age (Peterson et al., 2016).
* Nor is there a single body weight that applies to all comorbidities and causes of mortality (Peterson et al., 2016).

66
Q
A

All IBW formulae predict a single-target body weight as a linear function of height

67
Q

What could body weight be affected by?

A

Body weight could be affected by:
* Body volume,
* muscle mass,
* fat mass,
* presence of oedema/ ascites

68
Q

Which formulae is available for the calcuation of IBW?

A

Formulae for IBW calcuation:
* Hamwi Formula
* Devine Index
* Robinson Formula
* Miller Formula
* Hammond formula
* Lemmens Formula: 22 x ht squared
* Deitel and Greenstein

69
Q

Considerations for appropriate IBW

A

Considerations for appropriate IBW:
* Age: BMI: >25 or 27-32 kg/m2 might be beneficial (Kisac et al., 2022)
* Chronic disease risk increases above 25 kg/m2
* Ethnicity
* Sex

70
Q

Suggested ranges for IBW

A

Suggested ranges for IBW:
* Body mass index (BMI) of 18.5-24.9kg/m2 (normal range)
* Weight equivalent of 25kg/m2: commonly used by dietitians but no evidence to support this.
* Clinical judgement should be used.
*

71
Q

Mens Sarcopenia Grip Strength Cut Off

A

Men Sarcopenia Grip Strength Cut Off:<27kg

72
Q

Womens Sarcopenia Grip Strength Cut Off

A

Womens Sarcopenia Grip Strength Cut Off:<16kg

73
Q

What is anamesis?

A

Anamesis:
the taking of a patient’s personal medical history

74
Q

What is an emerging tool for muscle mass measurements in CC/ICU?

A

Emerging tool for muscle mass measurements in CC:
ultrasound

75
Q

What is low muscle mass associated with?

A

Low muscle mass is associated with:
* Impaired immune function
* Impaired strength/ ability to perform daily tasks
* Increased morbidity
* Frailty
* Increased length of hospital stay
* Poor QOL

76
Q

Muscle mass is affected by ?, ?, ?

A

Muscle mass is affected by:
* Ethnicity (higher amount in African descendants)
* Sex (higher amount in men than women)
* Age (higher amount in younger adults)

77
Q

Characteristics of Lambell et al. (2022) ultrasound study/
What did Lambell et al., find about ultrasound use in Critical Care/ICU?

A

Characteristics of Lambell et al. (2022) ultrasound study:
* 50 participants
* ICU setting
* Pilot cross sectional study
* Australia
* Participants mostly: normal, overweight, obese
* Imbalance of male and female (more males than females)
* More <65y than >65y

What Lambell et al. (2022) found about ultrasound use in CC/ICU:
* Ultrasound could indicate muscle mass in ICU
* Ultrasound is comparable to CT scan
* Traumatic injury was the most common reason for missing ultrasound data

78
Q

Biochemistry considerations in CC/ICU

A

Biochemistry considerations in CC/ICU:
* Acute phase/metabolic stress: WBC, CRP, Alb, Haemoglobin
* Hydration: Urea + Electrolytes
* Kidney function: Urea + Electrolytes
* Liver function tests: AST, ALT
* Sepsis: Lactate
* Refeeding bloods: Mg, PO4, K
* Electrolytes: PO4, Adj Ca, Mg.
* Trends & baseline (especially in renal patients)
* Specific biochemical tests related to patients condition/diagnosis

79
Q

Dangers of overfeeding

A
80
Q

Dangers of underfeeding

A
81
Q

Drugs/medications that may impact nutrition in CC/ICU

A

Drugs/medications that may impact nutrition in CC/ICU
* Opioid analgesics/sedatives e.g.: morphine, fenatyl
* Propofol (1% & 2%)
* Neuromuscular blocking agents e.g.: atracurium, rocuronium
* Inotropes & vasopressors e.g.: noradrenaline, adrenaline, dobutamine, vasopressin
* Intravenous fluids e.g. crystalloids, colloids
* Prokinetics e.g.: Metoclorpamide, erythromycin
* Phenytoin/roframpicin/ciprofloxacin
* Stress ulcer prophylaxis e.g. lansoprazole, omeprazole, ranitidine
* Citrate & glucose-based dialysis solutions
* Diuretics e.g. furosemide, spironolactone
* Laxatives e.g. senna, lacutlose
* Anti-diarrhoeal e.g. codeine phosphare, loperamide
* Antimicrobials e.g. metronidazole, tazocin, genamicin
* Sliding scale insulin

82
Q

How do opioid analgesics/sedatives affect nutrition?

A

Opioid analgesics/sedatives affect nutrition by:
* Reducing gut motility
* Reduced gut motility leads to delayed gastric emptying which can cause constipation, nausea & vomiting

83
Q

How does Propofol affect nutrition?

A

Propofol affects nutrition by:
* Providing an additional source of energy (as lipid)
* 1.1kcal/ml
* Risk of fat overload and hyperlipidaemia

84
Q

What is propofol?

A

Propofol is an intravenous anaesthetic agent used for induction and maintenance of general anaesthesia

85
Q

How do PPIs & stress ulcer prophylaxis affect nutrition?

A

PPIs & stress ulcer prophylaxis affect nutrition by:
* Alteration of gastric pH
* Alteration of gastric pH can affect pH reading for NG placement

86
Q

How does sliding scale insulin affect nutrition?

A

Sliding scale insulin can affect nutrition by increasing the risk of hypoglycaemia with interruptions to feeding

87
Q

Which drugs (if adm enterally) need to be given during a break when enterally feeding to allow for absorption?

A

Phenytoin, rifampicin, ciprofloxacin need to be given during a break if given enterally to allow for their absorption

88
Q

Critiques of HCHP/ HEHP diet (check placement presentation)

A
89
Q
A

CCD (14 decks)

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