Critical Care Nutrition (part 1) Flashcards by perjunke fibers

The metabolic stress response is a ____, ____ response to acute injury or disease

Hypermetabolic, catabolic

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The metabolic stress response can be caused by…

-Trauma
-Surgery
-Burns
-Infection
-Sepsis

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The magnitude of the metabolic stress response correlates with the _____ of the injury

Severity

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Metabolic alterations begin at the time of injury and persists until ____ is complete

Healing

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What are the three phases of the metabolic stress response?

-Ebb phase (2-48 hours after injury)
-Flow phase
-Adaptive response

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What might be seen in the ebb phase of the metabolic stress response?

-Decreased BP, cardiac output, O2 consumption, and metabolic rate
-Hypovolemia, tissue hypoxia, and shock
-Decreased insulin and increased glucagon secretion

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The flow phase begins as the patient becomes _____ ____

Hemodynamically stable

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What might be seen in the flow phase of the metabolic stress response?

-Increased release of catecholamines, glucagon, and cortisol-> increased substrates for wound healing
-Increased cardiac output and O2 consumption
-Increased metabolic rate and protein catabolism
-Increased release of the cytokines
-Increased positive acute-phase protein synthesis for inflammation, wound healing, and coagulation
-Decreased synthesis of negative acute-phase proteins

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What are positive acute-phase proteins?

-C-reactive protein
-Ceruloplasmin
-Fibronectin
-Ferritin

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What are negative acute-phase proteins?

-Albumin
-Transferrin
-Prealbumin

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The flow phase lasts for several ____ or longer

Weeks

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What happens during the adaptive response phase of the metabolic stress response?

-Hormonal response gradually diminishes
-Metabolic rate normalizes
-Anabolism predominates (anabolism can only occur in the presence of adequate nutrition)

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Tissue injury causes increased levels of ____ ____

Counterregulatory hormones

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What are three counterregulatory hormones?

-Glucagon
-Cortisol
-Catecholamines

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Role of glucagon:

-Hepatic glycogenolysis
-Gluconeogensis

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Roles of cortisol:

-Skeletal muscle catabolism to provide amino acids for hepatic gluconeogenesis and positive acute phase protein synthesis
-Glycogenolysis
-Increased lipolysis

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Roles of catecholamines:

-Glycogenolysis
-Gluconeogenesis
-Lipolysis
-Decrease in insulin release
-Causes temporary insulin resistance

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Aldosterone is also released in the hormonal response to stress; it causes…

-Increased Na reabsorption by the kidneys

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Anti-diuretic hormone is also released, which leads to…

-Increased water reabsorption by the kidneys

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Examples of cytokines:

-Interleukin-1
-Interleukin-6
-TNF

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Cytokines are ____ proteins

Proinflammatory

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Cytokines are released by macrophages, T helper cells, and mast cells in response to…

-Tissue damage
-Infection
-Inflammation

Cytokines stimulate…

-Muscle catabolism
-Gluconeogenesis
-Hepatic amino acid uptake
-Positive acute phase protein synthesis

A release of cytokines may lead to ____

Anorexia

Release of interleukin-1 leads to decreased serum levels of ____ and ____

Zinc and iron

What are the effects of the metabolic response to stress on carbohydrate metabolism?

-Glycogen stores are depleted quickly -Increased glucose production and epinephrine's inhibition of insulin release-> hyperglycemia (AKA "stress diabetes")

What are the effects of the metabolic response to stress on protein metabolism?

-Lean body mass catabolism (BCAA are oxidized as a source of energy for muscles; provides amino acids for positive acute phase protein synthesis) -Rapid loss of lean body mass causes negative nitrogen balance

Muscle wasting occurs due to...

-Effect of catabolic hormones -Imbalance between energy intake and energy needs -Physical immobilization

What are the effects of the metabolic response to stress on lipid metabolism?

-Increased lipolysis of triglyceride stores due to increased levels of counterregulatory hormones -Increased circulation of FFA -Increased beta-oxidation -Less ketosis than seen in starvation

What are the net effects of the hormonal and cell-mediated response to stress?

-Hypercatabolic state -Greater availability of substrates for metabolically active tissues -Negative nitrogen balance -Increased blood volume and edema

In contrast to the metabolic response to stress, starvation causes...

-Decreased REE -No increase in counter-regulatory hormones -Ketosis -Decreased gluconeogenesis (protein is spared and fat is the primary fuel used)

Consequences of burns:

-Pain -Loss of water and nutrients via wound -Infection -Hypermetabolism and catabolism with large protein losses

What should be included in the nutrient assessment for burn patients?

-Diet history -Weight-> consider fluid status; use dry weight to calculate BMI -Comorbidities -Food-medication interactions -Biochemical assessment -NFPE -Monitor wound healing

In the first 24-48 hours, someone with burns will need ___ and ___ replacement

Fluid and electrolyte

The volume of fluid needed for those with burns is based on...

-Age -Weight -Total body surface area burned

After resuscitation, someone should get maintenance hydration, plus extra fluid to replace ____

Losses

In someone with burns getting hydration, we should monitor...

-Weight -Physical signs -Serum Na -Serum osmolality -Intake and output records

____ needs for someone with burns often exceeds that of any other injury

Energy

Energy needs increase with the ____ of the burn

Size

REE can almost ____ for severely burned patients

Double

____ ____ in someone with severe burns may not be feasible

Weight gain

There are many predictive equations for energy needs for those with burns available, but most have been found to _____ needs

Overestimate

The best way to determine energy needs for patients with burns is ____ ____

Indirect calorimetry

Protein needs in patients with burns are elevated due to...

-Gluconeogenesis -Wound healing -Losses via wounds and urine

Protein needs for someone with burns:

1.5-2.0 g/kg

We should provide ___-___% of kcal from protein for those with burns

20-25%

We may consider the use of supplemental ____ in those with burns

Arginine

Those with burns have ____ micronutrient needs

Increased

We should prescribe a ____ with minerals to those with burns

Multivitamin

We should recommend ____-____ mg/d of vitamin C

500-1000

We should recommend ____ mg of ZnSO4 (50 mg of elemental zinc)

220

We should also monitor ____ in those with burns

Electrolytes

Most patients with <___% total body surface area burned can meet their needs with an oral diet (high kcal and protein diet with oral nutrition supplements)

Those with a poor appetite or >20% total body surface area burned may require ____ ____ with high protein, high kcal formula

Tube feeding