Critical Care Flashcards
Do infants or adults have a higher caloric reserve?
adults
Do infants or adults have a higher metabolic rate?
infants
Do infants or adults have a higher growth rate?
infants
Do infants or adults have higher demands during illness?
infants
How much do infants grow in weight by 4-6 months?
doubles
How much do infants grow in weight by 12 months?
triples
How much do infants grow in length by 12 months?
50%
What is the typical newborn weight?
2.5 to 4 kg
What age is classified as preschool?
2 to 6 years old
What age is classified as middle childhood?
7 to 10 years old
What age is classified as adolescence?
11 to 18 years old
Which growth chart is used for patients < 2 years of age?
WHO
Which growth chart is used for patients 2 to 20 years of age?
CDC
How much of a neonate’s basal energy expenditure is used by their brain?
~50%
What classifies as failure to thrive (growth faltering)?
-fall of 2 major percentiles
-weight < 3rd to 5th percentile
What is the caloric density of breastmilk?
20 kcal/oz
What are the AAP recommendations for breastfeeding if there are no contraindications?
-exclusive breastfeeding for first 6 months
-optimally continue for at least 1 year
-may extend beyond 1 year if desired
How long does WHO recommend breastfeeding for?
up to 2 years
What are contraindications for breastfeeding?
-active, untreated maternal TB
-HIV positive
-human T-cell lymphotropic virus (type I and II)
-ebola infection (suspected or confirmed)
-untreated brucellosis
-use of illicit drugs
-drugs
What drugs can harm the infant directly?
-immunosuppressants
-chemotherapy
-radioactive agents
What drugs can reduce milk production?
-ergots
-decongestants
Is low or high oral bioavailability of a medication that the mother takes more likely to be absorbed by the infant?
high
What PK characteristics of a drug increases absorption into the breastmilk?
-non-ionized
-small molecular weight
-low protein binding
-high lipid solubility
-long half-life
-low volume of distribution
How often will healthy infants feed on average per day?
6 to 9 times per day
How often should a newborn be feeding each day?
every 2 to 4 hours
How much should a newborn be feeding each time?
~2 oz per feed
How often should a 2 to 4-month-old infant be feeding each day?
5 to 8 times per day
How much should a 2 to 4-month-old infant be feeding each time?
3 to 6 oz per feed
How often should a 6 to 8-month-old infant be feeding each day?
3 to 5 times per day
How much should a 6 to 8-month-old infant be feeding each time?
6 to 8 oz per feed
How much should a 12-month-old infant be feeding each day?
3 to 5 times per day
How much should a 12-month-old infant be feeding each time?
~8 oz per feed
Who does the CDC recommend cholecalciferol supplementation to?
all breastfeeding infants
What is the conversion for cholecalciferol between international units (IU) and mcg?
400 IU = 10 mcg
What is the dosing recommendation of cholecalciferol for premature neonates < 1.5 kg?
200 IU QD
What is the dosing recommendation of cholecalciferol for premature neonates > 1.5 kg?
200 to 400 IU QD
What is the dosing recommendation of cholecalciferol for partially or fully breastfed term infants?
400 IU QD
What is the dosing recommendation of cholecalciferol for formula fed infants?
200 to 400 IU QD until receiving 1000 mL/day of formula
Who is iron supplementation indicated for?
-premature neonates
-iron-deficient term infants
What is the dosing recommendation of elemental iron for premature neonates?
2 mg/kg/day
What is the dosing recommendation of elemental iron for term infants?
3 mg/kg/day
What is the common ferrous sulfate concentration?
75 mg/mL
What is the common elemental iron concentration of ferrous sulfate?
15 mg/mL
What is the conversion between zinc sulfate and elemental zinc?
44 mg of zinc sulfate = 10 mg of elemental zinc
What patients may require zinc supplementation?
-premature infants
-prolonged exclusive breastfeeding after > 6 months of age
-parenteral nutrition
-IBD/intestinal failure
-vegan or vegetarian diets
-generalized malnutrition
What are the fluid requirements for a patient weighing <10 kg according to the Holliday-Segar Method?
100 mL/kg
What are the fluid requirements for a patient weighing 10 to 20 kg according to the Holliday-Segar Method?
1000 mL + 50 mL/kg for every kg >10 kg
What are the fluid requirements for a patient weighing >20 kg according to the Holliday-Segar Method?
1500 mL + 20 mL/kg for every kg >20 kg
What is the IBW equation for males?
50 kg + 2.3 x inches over 60”
What is the IBW equation for females?
45.5 kg + 2.3 x inches over 60”
What is the equation for NBW?
IBW + 0.25 (weight - IBW)
When should NBW be used instead of ABW?
ABW ≥130% of IBW
What are the risk factors for malnutrition?
-UBW
-involuntary weight loss >10% within 6 months
-NPO > 10 days
-gut malfunction
-mechanical ventilation
-increased metabolic needs
-alcohol/substance abuse
-protracted nutrient losses
What is categorized as UBW?
20% below IBW
What score on the NUTRIC scale is classified as low risk for malnutrition?
0 to 5
What score on the NUTRIC scale is classified as low risk for malnutrition without IL-6?
0 to 4
What score on the NUTRIC scale is classified as high risk for malnutrition?
6 to 10
What score on the NUTRIC scale is classified as high risk for malnutrition without IL-6?
5 to 9
What is the normal serum concentration of transthyretin (prealbumin)?
15 to 40 mg/dL
What other lab value needs to be assessed with prealbumin to determine malnutrition?
C-reactive protein (CRP)
If prealbumin decreases and CRP increases, what does this indicate?
inflammation
If prealbumin decreases and CRP is normal, what does this indicate?
malnutrition
What is marasmus?
protein-calorie malnutrition
What is kwashiorkor?
protein malnutrition
What is the ideal goal of nitrogen balance?
3 to 5 grams
What is the nitrogen balance formula?
(nitrogen in) - (nitrogen out)
What is the nitrogen in formula?
24-hour protein intake (g) / 6.25
What is the nitrogen out formula?
24-hour UUN + 4 g
What is the recommended daily caloric intake of non-stressed or non-depleted patients?
20 to 25 kcal/kg/day
What is the recommended daily caloric intake of trauma/stress/surgery, critically ill, or major burn patients?
25 to 30 kcal/kg/day
What is the recommended daily caloric intake of obese patients with a BMI of 30 to 50?
11 to 14 kcal/kg/day
What body weight should be used to estimate caloric intake of obese patients with a BMI of 30 to 50?
ABW
What is the recommended daily caloric intake of obese patients with a BMI >50?
22 to 25 kcal/kg/day
What body weight should be used to estimate caloric intake of obese patients with a BMI of >50?
IBW
What is the formula for total energy expenditure (TEE)?
resting energy expenditure (REE) x 1.2
What is the goal for the respiratory quotient (RQ)?
0.85 to 0.95
What does an RQ >0.95 indicate?
overfeeding
What does an RQ <0.85 indicate?
underfeeding
What does an overfed patient need more of?
carbohydrates
What does an underfed patient need more of?
proteins
What is the recommended daily protein intake for maintenance?
0.8 to 1 gm/kg/day
What is the recommended daily protein intake for floor patients?
1 to 1.5 gm/kg/day
What is the recommended daily protein intake for ICU, trauma, surgery, or burn patients?
1.5 to 2 gm/kg/day
What is the recommended daily protein intake for obese patients with a BMI >30?
2 gm/kg/day
What is the recommended daily protein intake for obese patients with a BMI ≥40?
2.5 gm/kg/day
What body weight should be used for obese patients when calculating daily protein intake?
IBW
What is the standard non-protein calorie distribution of dextrose to fat?
70/30
When can a non-protein calorie distribution of 100/0 be used?
-sepsis
-bloodstream infections
What are the indications for parenteral nutrition?
-anticipated NPO >7 days
-small bowel or colonic ileus
-extensive small bowel resection
-malabsorptive states
-intractable vomiting/diarrhea
-enterocutaneous fistulas
-IBD
-hyperemesis gravidum
What solutions are not tolerated via a peripheral vein for parenteral nutrition?
dextrose and amino acid solutions
What should the total osmolarity of a solution be for peripheral parenteral nutrition?
<900 mOsm/L
Where can central venous catheter (CVC) insertion sites be?
-subclavian (SC)
-internal jugular (IJ)
-femoral
How many kilocalories is 1 gram of protein?
4 kcal
How many kilocalories is 1 gram of dextrose?
3.4 kcal
How many kilocalories is 1 gram of lipid?
10 kcal
What two ingredients in intralipid 10% need to be checked for allergies?
-glycerin 2.25%
-egg yolk phospholipid 1.2%
What does SMOFlipid consist of?
-soybean oil 30%
-medium-chain triglycerides 30%
-olive oil 25%
-fish oil 15%
What is the maximum lipid intake for adults?
2.5 gm/kg/day
How many kilocalories per milliliter does propofol contain?
1.1 kcal/mL
At what CrCl can electrolytes not be administered in a standard parenteral formula?
<50
How should parenteral nutrition be initiated?
start at ~25% of goal and achieve final rate within 24 hours
How often should BG be checked when initiating parenteral nutrition?
Q4-6H and before each increase in rate of PN
What should you do if the BG >200?
continue PN at same rate for 4 hours and recheck BG
What should you do if the BG >200 after rechecking?
initiate insulin therapy
How should parenteral nutrition be discontinued?
decrease rate by 50% Q2H until rate <50 mL/hr, then D/C
What medication can be added to parenteral nutrition?
famotidine
What type of insulin can be added to parenteral nutrition?
regular insulin
What is the common dosing regimen for regular insulin added to parenteral nutrition?
0.1 units/gm of dextrose
What is the common dosing regimen for regular insulin added to parenteral nutrition if BG >150 mg/dL?
0.15 units/gm of dextrose
What is the common dosing regimen for regular insulin added to parenteral nutrition if BG >300 mg/dL?
do not initiate until BG <200 mg/dL
What is the maximum amount of regular insulin that can be added to parenteral nutrition?
0.3 units/gm of dextrose
What is the recommended daily volume of maintenance IV fluids?
30 to 40 mL/kg/day
How many mEq/L are in NS?
154 mEq/L
How much potassium should a patient be started on?
0.5 to 1 mEq/kg
How much calcium should a patient be started on if serum calcium is normal?
10 mEq/day
How much magnesium should a patient be started on if serum magnesium is normal?
8 mEq/day
How much phosphorus should a patient be started on?
0.3 mMol/kg
How many mEq is 1 mMol of phosphorus?
1.4 mEq
What are the positive ions?
-sodium
-potassium
What are the negative ions?
-chloride
-acetate
-phosphorus
How do you calculate how much chloride AND acetate should be given to a patient?
sodium (mEq) + potassium (mEq) - phosphorus (mEq)
What is the ratio of chloride to acetate?
2:1
How many mL of multivitamin should be added to a patient’s parenteral nutrition?
10 mL
How many mL of multi-trace elements should be added to a patient’s parenteral nutrition?
1 mL
What are the mechanical complications of parenteral nutrition?
-clotting of line
-displacement
What are the infectious complications of parenteral nutrition?
-catheter-related sepsis
-solution contamination
-bacterial translocation
What are the metabolic complications of parenteral nutrition?
-electrolyte imbalances
-fluid imbalance
-hyper- and hypoglycemia
-liver function abnormalities
What are the baseline monitoring parameters for parenteral nutrition?
-CMP (magnesium, phosphorus, calcium)
-hepatic function panel
-prealbumin/CRP
-PT/INR
What are the daily monitoring parameters for parenteral nutrition?
-vital signs
-intake/output (stools)
-CMP (electrolytes, glucose, BUN/SCr)
-feeding tube placement and patency
What are the twice weekly monitoring parameters for parenteral nutrition?
-weight
-CBC (magnesium, phosphorus, calcium)
-prealbumin/CRP
What are the weekly monitoring parameters for parenteral nutrition?
-albumin, transferring, nitrogen balance
-LFTs
-TGs
-PT/INR
-RQ
What are the key clinical findings of refeeding syndrome?
-hypophosphatemia
-hypomagnesemia
-hypokalemia
What should the carbohydrates amount be limited to on day 1 of initiating parenteral nutrition for a patient with refeeding syndrome?
100 to 150 gm
What should the fluids amount be limited to on day 1 of initiating parenteral nutrition for a patient with refeeding syndrome?
800 mL/day
What should the caloric intake be limited to on day 1 of initiating parenteral nutrition for a patient with refeeding syndrome?
50% of total caloric needs
What complication of parenteral nutrition can be prevented?
essential fatty acid deficiency
What are contraindications for enteral nutrition?
-mechanical obstruction
-non-mechanical obstruction (ileus)
-intractable vomiting
-severe malabsorption
-severe GI hemmorrhage
-fistulas
What are GI complications of enteral nutrition?
-high gastric residuals
-aspiration
-nausea/vomiting or decreased motility
-abdominal distention
-diarrhea
-constipation
What are metabolic complications of enteral nutrition?
-hyper- or hypoglycemia
-overhydration/dehydration
-electrolyte imbalances
What are mechanical complications of enteral nutrition?
-clogging of feeding tube
-tube malposition
-rhinitis
-sinusitis
What are medication-related complications of enteral nutrition?
-clogged feeding tubes
-drug-tube feed interactions
What dosage form of medication is preferred for enteral feeding tubes?
liquid
How can oral dosage forms be used for enteral feeding tubes?
crush tablet to fine powder (or empty capsule contents) and mix in water
What medications should not be crushed for enteral feeding tubes?
SR or EC formulations
Should medications be administered separately or together for enteral feeding tubes?
separately
What should be done between administration of each medication through enteral feeding tubes?
flush feeding tube with water
How much water should hypertonic medications or those irritating to the gastric mucosa be diluted in before administration through enteral feeding tubes?
≥30 mL
