Critical Care Nutrition (part 3) Flashcards
Cause of acute kidney injury in the ICU:
Acute tubular necrosis
What are risk factors for acute tubular necrosis:
-Decreased renal perfusion
-Nephrotoxic medications
-Sepsis or systemic inflammatory response syndrome
Treatment options for acute tubular necrosis:
-No dialysis
-Intermittent hemodialysis
-Continuous renal replacement therapy (CRRT)
One example of continuous renal replacement therapy is ____ ____ ____
Continuous venovenous hemodialysis
Continuous venovenous hemodialysis removed ___, ___, and ____ products
Water, electrolytes, and waste
Protein loss is an issue with continuous venovenous hemodialysis; people lose about ___-___ g of protein per day
10-15
People can also absorb ___-___% of dextrose from dialysate
35-45%
Energy needs for someone with acute kidney injury:
25-30 kcal/kg
Protein needs for someone with acute kidney injury who is not on dialysis:
1.2-2 g/kg
Protein needs for someone with acute kidney injury who is having frequent intermittent hemodialysis:
1.0-1.5 g/kg
Protein needs for someone with acute kidney injury who is on continuous venovenous hemodialysis:
1.5-2.5 g/kg
For non-obese patients, we should use ____/____ to calculate kcal and protein needs
UBW/EDW
For critically ill patients with obesity, we should use ____ to calculate kcal and protein needs
IBW
Fluid needs for someone with acute kidney injury in critical illness:
Replace output + 500 mL
Fluid ____ is not usually necessary on continuous renal replacement therapy
Restriction
____ and ____ are usually well-cleared with continuous venovenous hemodialysis, so an electrolyte restriction is not necessary
Potassium and phosphate
Electrolytes (potassium and phosphate) may need to be restricted with ____
Hemodialysis
If someone with acute kidney injury is on enteral nutrition, use a ___-___ enteral formula that meets ICU recommendations for protein and kcal
Non-renal
If someone with acute kidney injury has significant electrolyte abnormalities, consider a ____ ____ enteral nutrition formula
Renal failure
Systemic inflammatory response syndrome causes widespread inflammation resulting from…
-Infection
-Severe acute pancreatitis
-Ischemia
-Burns
-Major trauma
-Hemorrhagic shock
Systemic inflammatory response syndrome causes the release of…
-Cytokines
-Proteolytic enzymes
-Toxic oxygen species
Cytokines increase ____ ____
Capillary permeability
____ and ____ can occur with systemic inflammatory response syndrome, which can lead to organ damage and multi-organ dysfunction syndrome
Hypotension and hypoperfusion
What are two hypotheses for the development of systemic inflammatory response syndrome?
-Excessive production of pro-inflammatory cytokines
-Disruption of gut barrier function, leading to bacterial translocation
Primary multiple organ dysfunction syndrome is caused by direct ___ ___
Organ injury
Secondary multiple organ dysfunction syndrome is caused by ____/____ in other organs (SIRS)
Inflammation/infection
Multiple organ dysfunction syndrome causes failure what organs?
-Lungs
-Kidney
-Liver
-Intestines
MNT for systemic inflammatory response and multiple organ dysfunction syndrome:
-Increased kcal and protein to meet increased metabolic demands (however, avoid overfeeding and use indirect calorimetry if possible)
-Early enteral nutrition (unless hemodynamically unstable)
-If prolonged small bowel ileus, initiate parenteral nutrition
____ is another name for hemodynamic instability
Shock
Shock is treated with high doses of…
-Epinephrine
-Norepinephrine
-Dopamine
-Dobutamine
If someone is in shock, we should withhold ____ ____
Enteral nutrition
Hyperglycemia in the ICU is a large concern; we should promote blood glucose control between ____-____ mg/dL
140-180
In order to help avoid hyperglycemia, we should avoid ____
Overfeeding
____ ____ are an acute form of peptic ulcer that accompanies severe illness, trauma, or neural injury
Stress ulcers
Stress ulcers can manifest in the stomach and duodenum and cause significant ____
Bleeding
Stress ulcers are caused by ____ ____
Gastric ischemia
A curling stress ulcer results from ____ and a cushing stress ulcer results from ____
Burns; TBI
Prevention/treatment for stress ulcers:
Medications to reduce gastric acid production
MNT for stress ulcers:
Early, continuous enteral nutrition may decrease risk
What should be included in a nutrition assessment for a critically ill patient?
-Many traditional parameters may not be available
-Not recommended: albumin, prealbumin
-NFPE is critical
-Food-medication interactions (in the context of acute illness/injury)
-Nitrogen balance
Nitrogen balance is used to assess ____ ___ and also to determine ____ ____
Protein status and protein needs
Formula for determining nitrogen balance:
Nitrogen balance= (protein intake/6.25) - (UUN + 4)
The goal for healing is a positive nitrogen balance between ___ and ____
+2 to +4
The goal for nitrogen balance in someone who is critically ill is _____ (0)
Equilibrium
A negative nitrogen balance would indicate…
-Inadequate protein intake
-Increased protein needs
-Excessive loss of protein
Nitrogen balance cannot be accurately calculated in patients with ____ disease or excessive ____ ____
Renal; exudative losses
The goal for critically ill patients is to provide adequate nutrition in order to…
-Slow the loss of LBM
-Heal wounds
-Fight infection
We should avoid overfeeding in order to prevent…
-Hyperglycemia
-Excessive CO2 production
-Lipogenesis
____ ____ is the gold standard for calculating energy requirements
Indirect calorimetry
Indirect calorimetry estimates energy expenditure by measurement of ____ consumption and ____ production over a given period of time
O2; CO2
Indirect calorimetry uses the ____ formula to estimate energy expenditure from gas exchange data
Weir
Candidates for indirect calorimetry include patients with…
-Obesity
-Cachexia
-TBI; SCI
-Burns
-Failure to wear from ventilator
-Delayed wound healing
-Amputations
Required conditions for indirect calorimetry:
-Fasting (at least 7 hours) or receiving continuous feeding
-After a 30-minute resting period
-Relaxed and not moving
-Thermoneutral environment
What are some clinical situations that decrease the validity of indirect calorimetry?
-Air leak
-Physical agitation
-Unstable body temperature
-Unstable pH
-ECMO
What equation can predict energy needs for critically ill patients?
Penn State 2010 equation
The Modified Penn State 2010 equation can be used for…
Critically ill patients with obesity who are over 60 years
We can predict energy needs for critically ill patients with ____-____ kcal/kg estimated dry weight
20-30
A ____, ___ ____ diet can be used for critically ill patients with obesity to promote steady-state weight loss while preventing the loss of lean body mass
Hypocaloric, high protein
A hypocaloric, high-protein diet may possibly reduce ____
Complications
For hypocaloric, high-protein feeding, we should provide ____-____% of energy requirements measured by indirect calorimetry
65-70
Energy needs for someone with a BMI of 30-50 who is getting a hypocaloric, high protein diet are ____-____ kcal/kg actual body weight
11-14
If indirect calorimetry cannot be used for someone getting hypocaloric, energy needs for someone with a BMI of over 50 are ____-____ kcal/kg ideal body weight
22-25
If someone with a BMI between 30-39.9 is on hypocaloric, high-protein feeding, their protein needs are:
2.0 g/kg IBW
If someone with a BMI 40 or more is on hypocaloric, high-protein feeding, their protein needs are:
2.5 g/kg IBW
Protein requirements for non-obese patients in the ICU:
1.2-2 g/kg
Fluid needs in the ICU should be individualized using ___ and ____-based guidelines
Age and weight
The goal of fluid needs is to maintain adequate ____ _____
Urine output
When determining fluid needs, consider ____ and ____ ____ of fluid
Losses and additional sources
Oral nutrition in the ICU may be delayed by…
-Inability to chew or swallow
-Altered mental status
-Mechanical ventilation
-Weakness
-Anorexia
-GI distress
-Sedation
For nutrition support in the ICU, ____ nutrition is preferred to ____ nutrition
Enteral; parenteral
If parenteral nutrition is ordered, confirm the _____
Indication
Nutrition cannot abolish the hypermetabolism and catabolism, but may slow the loss of _____
Protein
Without exogenous protein intake, there is decreased…
-Wound healing
-Immune function
Without exogenous protein intake, there is increased risk of…
-Infections
-Pressure injuries
-Respiratory insufficiency
Enteral nutrition should be started within ___-___ hours of admission to the ICU and advanced toward goal kcal during the next 48-72 hours
24-48
If someone is on enteral nutrition, we should elevate head of bed ___-___ degrees to prevent aspiration
30-45
We should recommend small bowel enteral feeding for…
-Delayed gastric emptying
-Supine position
-NG suction
-High aspiration risk
In the ICU, it is common to use ___ ___, ____ enteral nutrition formulas
High protein, polymeric
We may consider use of immune-modulating formulas for patients with…
-TBI
-Major surgery
-Severe trauma
Immune-modulating formulas are not recommended for patients with severe ____
Sepsis
We can consider the use of a mixed fiber-containing formula if a patient has persistent _____
Diarrhea
We should avoid both soluble and insoluble fiber for patients at high risk for…
-Bowel ischemia
-Severe dysmotility
When determining energy needs, we need to consider additional kcal sources such as…
-Dextrose in IVF: 3.4 kcal/g
-Propofol (Divprivan): 1.1 kcal/mL
-Clevidipine: 2 kcal/mL
-CVVHD
-Multiple sources of nutrition
What should be monitored in those in the ICU?
-Changes in medical status
-Biochemical data: glucose, electrolytes, BUN, Cr, TG, LTF’s, ABG’s, CBC
-Weight changes
-NFPE
-GI status
-Nitrogen balance
-Fluid status
-All sources of kcal
-TF: tolerance, total volume received
-PN tolerance
-Readiness to transition to another mode of feeding
