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Clinical Nutrition 2 > Critical Care Guidelines > Flashcards

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)
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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
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3
Q

What is the definition of nutrition therapy?

A

Refers to provision of either EN or PN

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4
Q

Definition of standard therapy?

A

Refers to the provision of IV fluids and advancement to oral diet (No EN or PN)

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5
Q

MICU?

A

-Medical Intensive Care Unit

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6
Q

SICU?

A

-Surgical Intensive Care Unit

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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

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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
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9
Q

NRS-2002 “at-risk” score?

A

3

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10
Q

NRS-2002 “at high-risk” score? What is this indicative of?

A

5

-May be candidates for early EN feeding

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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
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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)
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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

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14
Q

How should we evaluate nutritional progression in ICY?

A

Evaluate weekly towards optimization of energy and protein

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15
Q

Protein in general ICU patient?

A

1.2-2 g/kg/day

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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
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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
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18
Q

Anesthesia?

A

Will lower the energy expenditure

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19
Q

Physical therapy?

A

Although not 24/7, can have some impact on energy level which is not considered when using the IC

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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

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21
Q

(T/F) Penn-state, Ireton-Jone and Swinamerare are no more accurate than Harris-Benedict or MFSJ

A

T

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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
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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

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24
Q

What is anasarca?

A

Generalized edema

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25
Q

Rationale for using EN?

A
  • Maintain gut integrity
  • Modulate stress and systemic response
  • Attenuate disease severity
  • Delivery of immune-modulating agents if possible
  • Effective stress ulcer prophylaxis
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26
Q

Is immune-modulating agents warranted in the ICU?

A

-Unlikely

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27
Q

Quality of evidence for early EN?

A

Low

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28
Q

When should early EN be initiated?

A
  • When NRS 2002 >5

- Within 24-48 critically ill patient who is unable to maintain volitional intake

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29
Q

Why is there low evidence suggesting preference for EN over PN in the ICU?

A
  • Practical and safe
  • Reduces infectious morbidity
  • Reduces ICU LOS by ~1 day **
  • Evaluate GI contractility (i.e. bowel sounds)
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30
Q

Are overt signs of GI contractility required prior to the initiation of EN?

A

No

Do not delay the nutrition support

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31
Q

______ favoured over gastric in terms of nutrition efficiency and reduced risk of pneumonia

A

Small bowel

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32
Q

Why is it generally acceptable to place EN in the stomach in the ICU patient?

A
  • Easier to place and access
  • May decrease time and initiation of EN
  • Ensure to refer to institutional protocols
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33
Q

In the setting of hemodynamic compromise or instability, what is the protocol regarding EN?

A
  • Should be withheld until the patient is fully resuscitated and/or stable
  • Caution re-initiation in patients undergoing withdrawal of vasopressor support
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34
Q

When do we withhold EN therapy?

A
  • Hypotensive (Mean arterial BP <50 mm hg)
  • Initiation of catecholamines or vasopressors
  • Increased needs of catecholamine to maintain hemodynamic stability
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35
Q

What are signs of intolerance which may be indicative of early signs of gut ischemia?

A
  • Abdominal distention
  • Increased GRVs
  • Decreased passage of stool, flatus
  • Hypoactive bowel sounds
  • Acidosis or base deficit
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36
Q

Patients with _____ who cannot maintain ____ do not require specialized nutrition therapy over the first week of hospitalization in the ICU.

A
  • NRS2002 <3

- volitional intake

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37
Q

Why are ICU patients with NRS2002 <3 not candidates for specialized nutrition support? Is this definitive?

A
  • Risk of EN likely exceeds benefit

- No, reassess daily (metabolic state, disease severity, expected LOS) may warrant EN

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38
Q

Which case would most likely benefit from EN?

  • MVA accident causing TBI
  • Abdominal Sx following MVA
A
  • 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.
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39
Q

What is appropriate for patients with acute resp. distress or acute lung injury, when they have a duration of mechanical ventilation >72 h?

A

Trophic or full nutrition via EN

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40
Q

Which feeds require RD intervention?

A

Trophic feeds

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41
Q

Which feeds do not require RD intervention?

A

Volume feeds

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42
Q

What are trophic feeds?

A
  • 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
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43
Q

Rate of trophic feeds?

A

10-20 ml/h
OR
10-20 kcal.hr
and up to 500 kcal/day

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44
Q

What is the goal of establishing nutrition support in ICU patients?

A

-Provide >80% of estimated or calculated goal energy and protein within 48-72 h to achieve clinical benefits

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45
Q

When is lowest mortality reached? What is the minimum EN needed to be considered “beneficial”?

A
  • When >80% of E and P needs met

- Even >10 kcal/kg/day is beneficial

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46
Q

Why early EN?

A
  • Maintain gut barrier function (burn, bone marrow transplants)
  • Faster cognitive function restoration (TBI)
  • Reduce mortality
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47
Q

We typically use 1.2-2.0 g/kg/day of protein, caveat in sepsis?

A

1.5-2.0 g/kg/day

48
Q

We typically use 1.2-2.0 g/kg/day of protein, caveat in renal replacement?

A

2-2.5 g/kg/day due to dialysate

49
Q

We typically use 1.2-2.0 g/kg/day of protein, caveat in obesity?

A

2 g/kg/day of IBW

50
Q

When is protein higher

A

In burn or multi-trauma patients

51
Q

In Non-Protein Calorie:Nitrogen and Nitrogen balance often warranted in ICU?

A

No

52
Q

(T/F) In the ICU, protein intake is more highly related to positive outcomes than provision of energy

A

T

53
Q

Break down of lean mass/day in unfed stressed patient?

A

250 g

54
Q

Break down of lean mass/day in unfed septic patient?

A

150 g

55
Q

How can we monitor for tolerance/

A
  • Physical exam
  • Passage of stool
  • Radiology
  • Abdo distention
56
Q

What is GI tolerance defined by?

A
  • Vomiting
  • Abdominal distention
  • High NG output, high GRV
  • Diarrhea
57
Q

Why should we minimize NPO orders of Dx tests?

A
  • Limit propagation of ileus

- Prevent inadequate nutrient delivery

58
Q

____ of ICU patients ever reach target energy intake during ICU stay

A

<50%

59
Q

Avoid holding EN when GRV ____ in absence of other signs of intolerance

A

<500 ml

60
Q

What does not correlate with incidences of pneumonia, regurgitation or aspiration?

A

GRV

–> Still used at the MUHC

61
Q

Why design and implement feeding protocols?

A

To increase % of goal energy

62
Q

How should rates be adjusted with an EN protocol?

A

-Adjust rates towards achieving intakes based on symptoms

63
Q

What are two strategies in EN protocol which could be considered?

A
  • Volume based feeding protocol

- Top-down multi-strategy protocol (Volume-based + pro-kinetic agents, post-pyloric tubes ect).

64
Q

What is volume based feeding?

A

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
Q

Risks for aspiration?

A
  • Inability to protect airway
  • Presence of nasoenteric device
  • Mechanical ventilation
  • > 70/yo, reduced consciousness
  • GERD
66
Q

Which type of feeds can increase the risk of aspiration?

A

Bolus feeding

-Consider switching to continuous feeds

67
Q

What is the goal in reducing aspiration risk?

A

-Reduce pneumonia

68
Q

What is the typical culprit of pneumonia?

A

-Not from tube feeding, but from saliva secretions, oral hygiene and medications

69
Q

Recommendations for patients at high-risk of aspiration?

A
  • Post-pyloric fees
  • Continous fees
  • Prokinetic agent
  • Nursing directives
70
Q

What are nursing directives which may reduce the risk of aspiration?

A
  • HOB elevated at 30-45 degrees

- Use of chlorhexidine mouthwash 2x daily

71
Q

What is not recommended for patients at risk of aspiration?

A
  • Do not use food colouring

- Glucose oxidase strips to detect glucose in tracheal secretions are not valid

72
Q

Should EN be automatically stopped if dirrhea

A

-No, and rather investigate cause (i.e. FODMAPS, medications)

73
Q

What are two culprits of diarrhea which may be present within the EN formulation?

A
  • FODMAP contains polyols (sugar alcohol)

- Inulin in fiber formulas

74
Q

Recommendations when selecting EN formula in ICU patients?

A
  • Standard polymeric formula

- No specialty, anti-inflammatory or mixed fiber formula is recommended

75
Q

When may immune modulated formulas be indicated in the ICU?

A
  • Not in the MICU

- Sometimes in the SICU for peri-operative or TBI

76
Q

Components of immune-modulating formulas?

A
  • Arginine
  • EPA, DHA
  • Glutamine
  • Nucleic acids
77
Q

Which patients are En formulas with anti-inflammatory lipid profiles recommended for?

A
  • Acute resp. distress

- Acute lung injury

78
Q

Should mixed fiber formula be used to promote bowel regularity or prevent diarrhea?

A

No

However, may be used if persistant diarrhea

79
Q

What can be considered for those with persistant diarrhea with suspected malabsorption or lack of response to fiber?

A

Small peptide formulation

80
Q

Avoid both ___& ____ formulas in high risk for bowel ischemia or severe dysmotility

A

Soluble & insoluble fiber

81
Q

What kind of fiber may be considered for use in all hemodynamically stable patients on standard formulations? What is the recommended amount?

A
  • Fermented soluble fiber additive (FOS, inulin)

- 10-20g/24 h as adjunctive therapy if there is evidence of diarrhea

82
Q

Probiotics in ICU? MICU?

A
  • Safe in ICU

- No recommendation in MICU

83
Q

Antioxidant vitamins and minerals in ICU patients?

A

-May be warranted, and safe, on critically ill patients who need specialized nutrition therapy

84
Q

Pertinent vitamins and minerals?

A

-Vit E, C, selenium, inc, copper in birns, trauma, mech. ventilation

85
Q

Why is evidece low for vit/min supplementation?

A
  • EN formulary itself is often enough to provide enough vit/min
  • Therefore, supplementation above the amount is likely not warranted
86
Q

Should glutamine be added to EN?

A

No

87
Q

What is the rationale behind the addition of glutamine to EN?

A

-Possible trophic effects in GI but no systemic antioxidant effects, and lacks outcome benefits

88
Q

When should exclusive PN be withheld if volitional intake is inadequate and early EN is not feasible? For how long?

A
  • When NRS <3

- For the first 7 days

89
Q

When should exclusive PN be initiated? In what time frame?

A
  • When NRS >3, or malnourished

- As soon as possible

90
Q

When should we use EN in conjunction with PN?

A
  • If EN is unable to meet >60% of goals after 7-10 days

- Due to not tolerated EN

91
Q

Hypo-caloric PN and adequate protein?

A

<20 kcal/kg/day or 80% of EEE

  • > 1.2 g/kg/day
  • Over first week in the ICY
92
Q

Which IVFE should be withheld in ICU?

A

-Soybean oil lipids

93
Q

If concerned for EFAD, what IVFE should be admnistered?

A

If no allergy to fish, try SMOFlipid 100g/week divided into 2 doses/week

94
Q

Is there an advantage between standardized commerically available PN vs manually compounded?

A

No

95
Q

What is the glucose target range for the ICU?

A
  • 150-180 mg/dL
  • <10 mmol/L
  • -> Re-call that we are in a “fed” state
96
Q

When should be discontinue PN?

A

-When EN is now providing >60% of target energy

97
Q

Guidelines for pulmonary failure?

A
  • No need for high fat, low CHO as they will be ventilated
  • Consider energy-dense EN in acute resp. failue
  • Monitor serum phosphate
98
Q

Guidelines for acute kidney injury?

A
  • 25-30 kcal/kg and 1.2-2.0 g/kg/day ABW

- Use regular formula unless evidence of electrolyte abnormalities

99
Q

In acute kidney injury, when should protein intake be maximum of 2.5 g/kg/day?

A

If receiving hemodialysis or CRRT

100
Q

Guideline with hepatic failure?

A
  • Use dry weight or usual weight, often has edema, portal HTN
  • Preferentially use EN in acute and/or chronic liver failure
101
Q

Should protein be restricted in hepatic failure? Which EN formulation should be selected?

A
  • No, use 1.1-2 g/kg/day (standard)

- Use standard EN formulation

102
Q

In what context is there no evidence of BCAA formulation in hepatic patients with encephalopathy?

A

-When they are already receiving 1st line therapy with antibiotics and lactulose

103
Q

Guidelines in trauma patients?

A

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
Q

Guidelines in TBI?

A

Initiate early EN feeding within 24-48 hours once hemodynamically stable

105
Q

Guidelines in septic shock?

A

-early EN within 24-48 hours once hemodynamically stable

106
Q

When should a combination of E and PN not be used in the early phase, regardless of nutritional risk?

A

Septic and septic shock patients

107
Q

Is selenium, zinc and antioxidant supplementation recommended in septic or septic shock patients?

A

No

108
Q

EN feeds during initial phase of sepsis?

A
  • Trophic feeds (10-20kcal/h or up to 500 kcal/day)

- No immune-modulating formulas

109
Q

When can we advance EN feeds in sepsis?

A

-After trophic feeds, advance 24-48 h to reach >80% of target within the first week

110
Q

Protein in sepsis?

A

1.2-3 g/kg/dayy

111
Q

When a patient is titrated-up, are we likely to feed?

A

No, not hemodynamically stable

-Remain NPO

112
Q

What do vasopressins and cathecholamines do?

A

Will maintain the patients mean arterial pressure, meaning that the patient is not hemodynamically stable
-Keep NPO and do not feed

113
Q

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?

A
  • Go to trophic feeds as long as BP is maintained

- When MAP > 60 mmHG, start on trophic feeds at 10 ml/h

114
Q

After the discharging of catecholamine and vasopressins, should we progress trophic feeds?

A
  • 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
Q

How to calculate nutrition adequacne?

A

(Actual volume)/(target volume) x 100

116
Q

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?

A

-Volume based feeds

Clinical Nutrition 2 (21 decks)

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