Condition Specific Nutrition Flashcards
Which of the following immunomodulating nutrients may be harmful in patients with severe sepsis?
1: Arginine
2: Glutamine
3: Nucleic acids
4: Omega-3 fatty acids
Arginine is a major substrate for nitric oxide production. Under normal conditions, small quantities of nitric oxide have a beneficial effect on immune function and tissue oxygenation. Thus, arginine is considered an “immune-enhancing” agent. However, nitric oxide can also be detrimental by leading to coagulation abnormalities and altered hemodynamic status. In this case, arginine could be considered harmful. Because of these effects, there is still much debate over the value of arginine in nutrition support for critically ill patients.
References:
Btaiche IF, Marik PE, Ochoa J, et al. Nutrition in critical illness, including immunonutrition. In: Merritt R, ed. The A.S.P.E.N. Nutrition Support Practice Manual. 2nd ed. Silver Spring, MD: A.S.P.E.N.; 2005:263-270.
Which of the following best describes enteral glutamine supplementation in the critically ill?
1: Enteral glutamine is preferred over parenteral glutamine
2: Supplementation of enteral glutamine to glutamine containing immune-modulating formulations improves morbidity and mortality statistics
3: Approximately 20-40 g glutamine/day should be administered to all critically ill patients
4: The addition of enteral glutamine to a non-glutamine enteral nutrition regimen has shown to reduce the length of stay in some ICU patients
- The addition of enteral glutamine to a non-glutamine enteral nutrition regimen has shown to reduce the length of stay in some ICU patients
The metabolic demand for glutamine can exceed the capacity of skeletal muscle to release it during critical illness such as burn trauma, or mixed ICU illness. Glutamine powder, mixed with water, should be given in 2 or 3 divided doses to provide 0.3-0.5g/kg/day in critically ill patients. Enteral glutamine should not be added to immune-modulating enteral formulas containing glutamine.
References:
McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient JPEN 2009;33:277-316.
In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in
1: metabolic acidosis.
2: metabolic alkalosis.
3: respiratory acidosis.
4: respiratory alkalosis.
The increased metabolism of glucose (oxidation and lipogenesis) increases CO2 production. This may result in increased blood pCO2 if pulmonary insufficiency is significant. According to the Henderson-Hasselbach equation, this will result in a decrease in pH. If compensatory retention and increase in bicarbonate ion occur, the pH may not change. This is a condition of respiratory acidosis. The increased CO2 production is greatest when overfeeding occurs (2 x BEE). Lipogenesis, the synthesis of fat from glucose, produces 6 to 8 times more CO2 than the oxidative process (energy production).
References:
Cresci GA, Gottschlich MM, Mayes T, Mueller C. Trauma, Surgery and Burns. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD; A.S.P.E.N.; 2007:455-476.
For a patient requiring nutrition support therapy, which of the following may be necessary for a patient with acute kidney injury (AKI) receiving continuous renal replacement therapy (CRRT)?
1: Low potassium
2: Increased phosphorus
3: Low protein
4: Increased fluid
4: Increased fluid
CRRT can remove upwards of 20 liters of volume per day. This massive volume removal can result in severe hypokalemia and hypophosphatemia if potassium and phosphorus are restricted. As such, the nutrition support regimen should be generous in potassium and phosphorus. Protein requirements can be as high as 2.5 grams per kilogram per day depending on comorbidities and other acute conditions. A nutrition support regimen need not be restricted in fluid for patients receiving CRRT. However, increased fluid provision from nutrition support is not necessary.
References:
Mascarenhas, MR, Divito D, McClave SA. Pancreatic disease. In Merritt R, ed. The A.S.P.E.N. Nutrition Support Practice Manual, 2nd ed. Silver Spring, MD; A.S.P.E.N.;2005; 211-230.
Which of the following has NOT been shown to delay weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease who are receiving enteral nutrition?
1: Refeeding syndrome
2: Tube feeding syndrome
3: Underfeeding
4: Overfeeding
Adequate nutrition and balanced hydration is necessary for successful weaning from mechanical ventilation. Both overfeeding and underfeeding have been associated with prolonged ventilator dependence. Refeeding syndrome is characterized by a serum depletion of phosphorus, magnesium, and potassium as a result of aggressively refeeding malnourished patients. The hypophosphatemia associated with refeeding syndrome can intensify respiratory dysfunction and diaphragmatic weakness, leading to difficulty in ventilator weaning. Tube feeding syndrome is the development of azotemia, hypernatremia and dehydration related to the use of high protein tube feedings and inadequate fluid provisions. Fluid overload and not fluid depletion is most often implicated in difficulty weaning from mechanical ventilation.
References:
A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN. 2002;26(1 suppl):1SA-138SA.
What is the recommended dietary protein intake in acutely ill patients receiving continuous renal replacement therapy (CRRT)?
1: 0.5-0.8 g/kg per day
2: 1.2-1.5 g/kg per day
3: 1.5-2 g/kg per day
4: 2.5-3 g/kg per day
3: 1.5-2 g/kg per day
The delivery of adequate protein to acutely ill patients requiring dialysis is critical secondary to hypercatabolism, obligatory use of protein as a preferred fuel source during the stress response, and the likelihood of significant protein losses in CRRT effluent. In general, centrally-infused protein losses into CRRT effluent range from 10-17% and should be taken into consideration when determining protein requirements. Consensus in the literature for daily protein delivery in patients undergoing CRRT is 1.5-2 g protein/kg per day. While doses as high as 2.5g protein/kg per day have been advocated to promote positive nitrogen balance, disadvantages of high-protein delivery may include the exacerbation of uremia, increased demand on hepatic and renal function, and increased costs.
References:
Wolk R, Moore E, Foulks C. Renal Disease. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD; A.S.P.E.N.; 2007:575-598.
Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for
1: hyperkalemia.
2: azotemia.
3: hypermagnesium.
4: hypoglycemia.
Loop diuretics are known to cause electrolyte abnormalities as a result of increased urine output. Specific disturbances include excess potassium and magnesium excretion which can result in hypokalemia and hypomagnesemia. Patients are not known to become hypoglycemic. Azotemia can occur related to volume depletion.
References:
Wolk R, Moore E, Foulks C. Renal Disease. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD; A.S.P.E.N.; 2007:575-598.
Hypoglycemia, requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease?
1: Hepatic steatosis
2: Well-compensated cirrhosis
3: Decompensated cirrhosis
4: Fulminant hepatic failure
Hypoglycemia is seen in the majority of patients with fulminant hepatic failure and may result from impaired glycogenolysis, glycogenesis, gluconeogenesis and hyperinsulinemia requiring aggressive glucose administration. Patients are usually in a hypercatabolic state with increased in energy expenditure and can become malnourished rapidly.
References:
Wolk R, Moore E, Foulks C. Renal Disease. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD; A.S.P.E.N.; 2007:575-598.
Which of the following best describes the treatment of diarrhea in inflammatory bowel disease?
1: Cholestyramine is effective treatment for steatorrhea
2: Patients with diarrhea should be treated with prebiotics
3: Antidiarrheal agents can contribute to toxic megacolon
4: Pharmacological therapy is withheld until diarrhea exceeds 1 L/day
Antidiarrheals should not be given to patients with inflammatory bowel disease until the possibility of an infectious etiology of the diarrhea has been ruled out. Otherwise, there is a risk of developing toxic megacolon that can result in mortality and morbidity. Cholestyramine, used to treat bile salt malabsorption, can be used with antidiarrheal agents for patients who have undergone extensive bowel resection. There are no definite guidelines on when treatment for diarrhea should begin. However, stool output greater than 500 mL/day for 2 consecutive days should be evaluated with intervention started to reduce the risk of volume depletion and electrolyte deficiencies. There is currently a growing interest in the role of prebiotics and probiotics in the management of patients with inflammatory bowel disease. However, there are no evidence-based recommendations for using prebiotics and probiotics as standard therapy with diarrhea.
References:
Roberts S, Mattox T. Cancer. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD: A.S.P.E.N.; 2007:649-675.
A patient with chronic heart failure on high-dose furosemide is started on enteral nutrition for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms?
1: Thiamin
2: Vitamin B12
3: Folate
4: Riboflavin
Furosemide and digoxin may decrease thiamin uptake by cardiac cells in patients with heart failure. Thiamin deficiency in the form of wet beriberi is characterized by an enlarged heart, nonspecific electrolyte alterations, profound vasodilation, and peripheral neuritis. Symptoms of heart failure secondary to wet beriberi have been shown to improve fairly rapidly in response to thiamin supplementation in tablet or injection form.
References:
Parrish CR, Krenitsky J, Willcutts K, et al. Gastrointestinal Disease. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach - The Adult Patient. Silver Spring, MD: A.S.P.E.N.; 2007:508-539.
Persistent hyperglycemia in patients with type 2 diabetes can result in the development of
1: cholestasis.
2: lipotoxicity.
3: hepatic steatosis.
4: macorcytic anemia.
- Lipotoxicity
Chronically elevated glucose levels in patients with type 2 diabetes adversely affect insulin secretion. Glucotoxicity and lipotoxicity are closely interrelated in the sense that lipotoxicity does not exist without chronic hyperglycemia and chronically elevated fatty acid levels do not harm B-cell function as long as blood glucose levels are normal. Macrocytic anemia is caused by the deficiency of folic acid and/or vitamin B12.
References:
A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN. 2002;26(1 suppl):1SA-138SA.
Human immunodeficiency virus (HIV) associated lipodystrophy syndrome is
1: visceral fat loss.
2: not observed in patients on highly active antiretroviral therapy (HAART).
3: observed in patients with a greater than 7 year history of HIV.
4: seen mostly in patients younger than 40 years old.
HIV-associated lipodystrophy syndrome is manifested by increased peripheral subcutaneous fat loss. Patients taking HARRT can demonstrate lipodystrophy. A risk factor of developing lipodystrophy is age; particularly in patients older than 40 years old. An additional risk factor is 7 or more years since the diagnoses of HIV.
References:
Cimbalik C, Paauw JD, & Davis AT. Pregnancy and Lactation. In: Gottschlich MM ed. The ASPEN Nutrition Support Core Curriculum: A case-based approach – the adult patient. ASPEN 2007:383-404.
