Critical Care Guidelines Flashcards
1
Q
Target population for critical care guidelines?
A
- Adults >18 y
- Critical illness, >2-3 LOS in MICU or SICU
- Organ failure (pulmonary, renal, liver)
2
Q
Which illnesses are often indicated for critical care guidelines?
A
- Acute pancreatitis
- Surgical subsets trauma, TBI)
- Sepsis
- Post-op major Sx.
- Chronic critically ill
- Critically ill obese
3
Q
What is the definition of nutrition therapy?
A
Refers to provision of either EN or PN
4
Q
Definition of standard therapy?
A
Refers to the provision of IV fluids and advancement to oral diet (No EN or PN)
5
Q
MICU?
A
-Medical Intensive Care Unit
6
Q
SICU?
A
-Surgical Intensive Care Unit
7
Q
If there is a planned surgery, we will likely nourish via ______, but there is often not enough time to intervene in acute cases
A
ERAS
8
Q
Who should be screened for nutrition risk?
A
- All patients admitted to the ICU for whom volitional intake is anticipated to be insufficient
- Use NRS-2002 or NUTRIC score with IL-6
9
Q
NRS-2002 “at-risk” score?
A
3
10
Q
NRS-2002 “at high-risk” score? What is this indicative of?
A
5
-May be candidates for early EN feeding
11
Q
What is recommended to help assess nutritional assessment?
A
- All co-morbid conditions
- Function of GI tracts
- Risk of aspiration
- Ultrasound may be used to assess body composition at bedside
12
Q
What is not recommended to help asses nutritional assessment?
A
- Use of serum proteins (hepatic re-prioritization)
- Cytokines and CRP
- Anthropometry not reliable
- CT too costly for body comp.
- Muscle function (not validated)
13
Q
What is the bottom line of nutritional assessment in the ICU?
A
-Many patients are unconscious, not mobile or cannot comprehend - therefore nutritional assessment is very difficult in the ICU
14
Q
How should we evaluate nutritional progression in ICY?
A
Evaluate weekly towards optimization of energy and protein
15
Q
Protein in general ICU patient?
A
1.2-2 g/kg/day
16
Q
Many patients in ICU may be assessed with IC, what are some variables which may affect the accuracy of IC?
A
- Air leaks. chest-tubes, supplemental O2
- CRRT
- Anesthesia
- Physical therapy
- Excessive movement
17
Q
CRRT?
A
- Continuous renal replacement therapy (dialysis)
- Causes a hemodynamic shift
- Causes losses of proteins within the dialysate, which should otherwise be accounted for in the calorimetry
18
Q
Anesthesia?
A
Will lower the energy expenditure
19
Q
Physical therapy?
A
Although not 24/7, can have some impact on energy level which is not considered when using the IC
20
Q
Excessive movement?
A
-Some ICU patients have spasms, random muscle contractions or other random movements which are not accounted for within the IC
21
Q
(T/F) Penn-state, Ireton-Jone and Swinamerare are no more accurate than Harris-Benedict or MFSJ
A
T
22
Q
Which weight should be used in the ICU?
A
- Dry-weight (non-edema)
- Usual body weight
- Try 25-30 kcal.kg in the non-obese
23
Q
What are the issues with accurate BW in the ICU?
A
- Shifts in body fluids will cause inaccurate weight.
- Issues with volume resuscitation, edema, anasarca
24
Q
What is anasarca?
A
Generalized edema
25
Rationale for using EN?
- Maintain gut integrity
- Modulate stress and systemic response
- Attenuate disease severity
- Delivery of immune-modulating agents if possible
- Effective stress ulcer prophylaxis
26
Is immune-modulating agents warranted in the ICU?
-Unlikely
27
Quality of evidence for early EN?
Low
28
When should early EN be initiated?
- When NRS 2002 >5
| - Within 24-48 critically ill patient who is unable to maintain volitional intake
29
Why is there low evidence suggesting preference for EN over PN in the ICU?
- Practical and safe
- Reduces infectious morbidity
- Reduces ICU LOS by ~1 day **
- Evaluate GI contractility (i.e. bowel sounds)
30
Are overt signs of GI contractility required prior to the initiation of EN?
No
| Do not delay the nutrition support
31
______ favoured over gastric in terms of nutrition efficiency and reduced risk of pneumonia
Small bowel
32
Why is it generally acceptable to place EN in the stomach in the ICU patient?
- Easier to place and access
- May decrease time and initiation of EN
- Ensure to refer to institutional protocols
33
In the setting of hemodynamic compromise or instability, what is the protocol regarding EN?
- Should be withheld until the patient is fully resuscitated and/or stable
- Caution re-initiation in patients undergoing withdrawal of vasopressor support
34
When do we withhold EN therapy?
- Hypotensive (Mean arterial BP <50 mm hg)
- Initiation of catecholamines or vasopressors
- Increased needs of catecholamine to maintain hemodynamic stability
35
What are signs of intolerance which may be indicative of early signs of gut ischemia?
- Abdominal distention
- Increased GRVs
- Decreased passage of stool, flatus
- Hypoactive bowel sounds
- Acidosis or base deficit
36
Patients with _____ who cannot maintain ____ do not require specialized nutrition therapy over the first week of hospitalization in the ICU.
- NRS2002 <3
| - volitional intake
37
Why are ICU patients with NRS2002 <3 not candidates for specialized nutrition support? Is this definitive?
- Risk of EN likely exceeds benefit
| - No, reassess daily (metabolic state, disease severity, expected LOS) may warrant EN
38
Which case would most likely benefit from EN?
- MVA accident causing TBI
- Abdominal Sx following MVA
- TBI
- Brain injury and head injury are usually some of the most metabolically demanding conditions
- Some abdo Sx will have patients on CF, FF and soft foods within a week of Sx.
39
What is appropriate for patients with acute resp. distress or acute lung injury, when they have a duration of mechanical ventilation >72 h?
Trophic or full nutrition via EN
40
Which feeds require RD intervention?
Trophic feeds
41
Which feeds do not require RD intervention?
Volume feeds
42
What are trophic feeds?
- 25% of energy needs
- Will get "something" into the GI tract, and will reap benefits of early EN
- Lower incidence of GI intolerance vs full EN
- Initiate soon if indicated
43
Rate of trophic feeds?
10-20 ml/h
OR
10-20 kcal.hr
and up to 500 kcal/day
44
What is the goal of establishing nutrition support in ICU patients?
-Provide >80% of estimated or calculated goal energy and protein within 48-72 h to achieve clinical benefits
45
When is lowest mortality reached? What is the minimum EN needed to be considered "beneficial"?
- When >80% of E and P needs met
| - Even >10 kcal/kg/day is beneficial
46
Why early EN?
- Maintain gut barrier function (burn, bone marrow transplants)
- Faster cognitive function restoration (TBI)
- Reduce mortality
47
We typically use 1.2-2.0 g/kg/day of protein, caveat in sepsis?
1.5-2.0 g/kg/day
48
We typically use 1.2-2.0 g/kg/day of protein, caveat in renal replacement?
2-2.5 g/kg/day due to dialysate
49
We typically use 1.2-2.0 g/kg/day of protein, caveat in obesity?
2 g/kg/day of IBW
50
When is protein higher
In burn or multi-trauma patients
51
In Non-Protein Calorie:Nitrogen and Nitrogen balance often warranted in ICU?
No
52
(T/F) In the ICU, protein intake is more highly related to positive outcomes than provision of energy
T
53
Break down of lean mass/day in unfed stressed patient?
250 g
54
Break down of lean mass/day in unfed septic patient?
150 g
55
How can we monitor for tolerance/
- Physical exam
- Passage of stool
- Radiology
- Abdo distention
56
What is GI tolerance defined by?
- Vomiting
- Abdominal distention
- High NG output, high GRV
- Diarrhea
57
Why should we minimize NPO orders of Dx tests?
- Limit propagation of ileus
| - Prevent inadequate nutrient delivery
58
____ of ICU patients ever reach target energy intake during ICU stay
<50%
59
Avoid holding EN when GRV ____ in absence of other signs of intolerance
<500 ml
60
What does not correlate with incidences of pneumonia, regurgitation or aspiration?
GRV
| --> Still used at the MUHC
61
Why design and implement feeding protocols?
To increase % of goal energy
62
How should rates be adjusted with an EN protocol?
-Adjust rates towards achieving intakes based on symptoms
63
What are two strategies in EN protocol which could be considered?
- Volume based feeding protocol
| - Top-down multi-strategy protocol (Volume-based + pro-kinetic agents, post-pyloric tubes ect).
64
What is volume based feeding?
Protocol
designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common
fixed hourly rate-based feeding (RBF) method
65
Risks for aspiration?
- Inability to protect airway
- Presence of nasoenteric device
- Mechanical ventilation
- >70/yo, reduced consciousness
- GERD
66
Which type of feeds can increase the risk of aspiration?
Bolus feeding
| -Consider switching to continuous feeds
67
What is the goal in reducing aspiration risk?
-Reduce pneumonia
68
What is the typical culprit of pneumonia?
-Not from tube feeding, but from saliva secretions, oral hygiene and medications
69
Recommendations for patients at high-risk of aspiration?
- Post-pyloric fees
- Continous fees
- Prokinetic agent
- Nursing directives
70
What are nursing directives which may reduce the risk of aspiration?
- HOB elevated at 30-45 degrees
| - Use of chlorhexidine mouthwash 2x daily
71
What is not recommended for patients at risk of aspiration?
- Do not use food colouring
| - Glucose oxidase strips to detect glucose in tracheal secretions are not valid
72
Should EN be automatically stopped if dirrhea
-No, and rather investigate cause (i.e. FODMAPS, medications)
73
What are two culprits of diarrhea which may be present within the EN formulation?
- FODMAP contains polyols (sugar alcohol)
| - Inulin in fiber formulas
74
Recommendations when selecting EN formula in ICU patients?
- Standard polymeric formula
| - No specialty, anti-inflammatory or mixed fiber formula is recommended
75
When may immune modulated formulas be indicated in the ICU?
- Not in the MICU
| - Sometimes in the SICU for peri-operative or TBI
76
Components of immune-modulating formulas?
- Arginine
- EPA, DHA
- Glutamine
- Nucleic acids
77
Which patients are En formulas with anti-inflammatory lipid profiles recommended for?
- Acute resp. distress
| - Acute lung injury
78
Should mixed fiber formula be used to promote bowel regularity or prevent diarrhea?
No
| However, may be used if persistant diarrhea
79
What can be considered for those with persistant diarrhea with suspected malabsorption or lack of response to fiber?
Small peptide formulation
80
Avoid both ___& ____ formulas in high risk for bowel ischemia or severe dysmotility
Soluble & insoluble fiber
81
What kind of fiber may be considered for use in all hemodynamically stable patients on standard formulations? What is the recommended amount?
- Fermented soluble fiber additive (FOS, inulin)
| - 10-20g/24 h as adjunctive therapy if there is evidence of diarrhea
82
Probiotics in ICU? MICU?
- Safe in ICU
| - No recommendation in MICU
83
Antioxidant vitamins and minerals in ICU patients?
-May be warranted, and safe, on critically ill patients who need specialized nutrition therapy
84
Pertinent vitamins and minerals?
-Vit E, C, selenium, inc, copper in birns, trauma, mech. ventilation
85
Why is evidece low for vit/min supplementation?
- EN formulary itself is often enough to provide enough vit/min
- Therefore, supplementation above the amount is likely not warranted
86
Should glutamine be added to EN?
No
87
What is the rationale behind the addition of glutamine to EN?
-Possible trophic effects in GI but no systemic antioxidant effects, and lacks outcome benefits
88
When should exclusive PN be withheld if volitional intake is inadequate and early EN is not feasible? For how long?
- When NRS <3
| - For the first 7 days
89
When should exclusive PN be initiated? In what time frame?
- When NRS >3, or malnourished
| - As soon as possible
90
When should we use EN in conjunction with PN?
- If EN is unable to meet >60% of goals after 7-10 days
| - Due to not tolerated EN
91
Hypo-caloric PN and adequate protein?
<20 kcal/kg/day or 80% of EEE
- >1.2 g/kg/day
- Over first week in the ICY
92
Which IVFE should be withheld in ICU?
-Soybean oil lipids
93
If concerned for EFAD, what IVFE should be admnistered?
If no allergy to fish, try SMOFlipid 100g/week divided into 2 doses/week
94
Is there an advantage between standardized commerically available PN vs manually compounded?
No
95
What is the glucose target range for the ICU?
- 150-180 mg/dL
- <10 mmol/L
- -> Re-call that we are in a "fed" state
96
When should be discontinue PN?
-When EN is now providing >60% of target energy
97
Guidelines for pulmonary failure?
- No need for high fat, low CHO as they will be ventilated
- Consider energy-dense EN in acute resp. failue
- Monitor serum phosphate
98
Guidelines for acute kidney injury?
- 25-30 kcal/kg and 1.2-2.0 g/kg/day ABW
| - Use regular formula unless evidence of electrolyte abnormalities
99
In acute kidney injury, when should protein intake be maximum of 2.5 g/kg/day?
If receiving hemodialysis or CRRT
100
Guideline with hepatic failure?
- Use dry weight or usual weight, often has edema, portal HTN
- Preferentially use EN in acute and/or chronic liver failure
101
Should protein be restricted in hepatic failure? Which EN formulation should be selected?
- No, use 1.1-2 g/kg/day (standard)
| - Use standard EN formulation
102
In what context is there no evidence of BCAA formulation in hepatic patients with encephalopathy?
-When they are already receiving 1st line therapy with antibiotics and lactulose
103
Guidelines in trauma patients?
Once hemodynamically stable:
- Initiate early EN feeding (24-48h)
- High pro polymeric EN formula OR
- Immune-modulating formulations with arginine and FO to be considered in severe trauma
104
Guidelines in TBI?
Initiate early EN feeding within 24-48 hours once hemodynamically stable
105
Guidelines in septic shock?
-early EN within 24-48 hours once hemodynamically stable
106
When should a combination of E and PN not be used in the early phase, regardless of nutritional risk?
Septic and septic shock patients
107
Is selenium, zinc and antioxidant supplementation recommended in septic or septic shock patients?
No
108
EN feeds during initial phase of sepsis?
- Trophic feeds (10-20kcal/h or up to 500 kcal/day)
| - No immune-modulating formulas
109
When can we advance EN feeds in sepsis?
-After trophic feeds, advance 24-48 h to reach >80% of target within the first week
110
Protein in sepsis?
1.2-3 g/kg/dayy
111
When a patient is titrated-up, are we likely to feed?
No, not hemodynamically stable
| -Remain NPO
112
What do vasopressins and cathecholamines do?
Will maintain the patients mean arterial pressure, meaning that the patient is not hemodynamically stable
-Keep NPO and do not feed
113
If patient is stabilized by catecholamine and vasopressins, and the patient has been an NPO order for a few days, how should they be progresses?
- Go to trophic feeds as long as BP is maintained
| - When MAP > 60 mmHG, start on trophic feeds at 10 ml/h
114
After the discharging of catecholamine and vasopressins, should we progress trophic feeds?
- Start volume feeds at a target goal rate determined by dietitian (if RD not present)
- If RD present, likely to slowly progress trophic feeds (NOT double)
115
How to calculate nutrition adequacne?
(Actual volume)/(target volume) x 100
116
In the case that a patient is hemodynamically stable, but the RD is not present to assess the patient, which protocol will be in place?
-Volume based feeds
