Critical Care: Nutrition Support

Question 1

List three inappropriate ways to estimate nutrition needs in critically ill patients

Answer 1

1. Albumin
2. Prealbumin
3. Nitrogen balance

Question 2

List two superiors ways to estimate nutrition needs in critically ill patients

Answer 2

1. Indirect calorimetry

2. Predictive equations

Question 3

What is the Respiratory Quotient (RQ)

Answer 3

A measurement provided by indirect calorimetry. It indicates substrate metabolism and allows modification of macronutrient delivery

Question 4

What is the normal range of RQ?

Answer 4

0.67-1.3

Question 5

If the patient is only metabolizing fats, what is their RQ?

Answer 5

RQ 0.7 indicates primary fat oxidation

Question 6

If the patient is only metabolizing proteins, what is their RQ?

Answer 6

RQ 0.8 indicates primary protein oxidation

Question 7

If the patient is only metabolizing carbohydrates, what is their RQ?

Answer 7

RQ 1 indicates primary carbohydrate oxidation

Question 8

What does an RQ less than 0.67 indicate?

Answer 8

Outside range; question test validity

Question 9

What does an RQ 0.7 indicate?

Answer 9

1. Primary fat oxidation
2. Systemic inflammatory response syndrome
3. Metabolic alkalosis
4. Ethanol oxidation

Question 10

What does an RQ 0.8 indicate?

Answer 10

Primary protein oxidation

Question 11

what does an RQ 0.82-0.85 indicate?

Answer 11

Normal “mixed” substrate oxidation

Question 12

What does an RQ 0.9-1.0 indicate?

Answer 12

1. Primary carbohydrate oxidation

2. Metabolic acidosis

Question 13

What does an RQ 1.0-1.3 indicate?

Answer 13

1. Lipogenesis (overfeeding)
2. Hyperventilation
3. System “leak”

Question 14

List 5 predictive equations for critically ill patients

Answer 14

1. Harris-benedict
2. Penn State and modified Penn State
3. Ireton-Jones
4. Mifflin
5. Swinamer

Question 15

Some guidelines recommend a ___ kcal/kg actual body weight target, but this approach may be too simplistic for most critically ill patients

Answer 15

25 kcal/kg

Question 16

Describe benefit of permissive underfeeding in critically ill patients

Answer 16

One study showed that giving 60-70% of target calories and 90-100% of protein needs showed a significant reduction in hospital mortality for critically ill patients

Question 17

What is the recommendation for critically ill obese patients?

Answer 17

It is recommended that patients with obesity (BMI greater than 30 kg/m2) can be fed at 60-70% of target energy requirements or 11-14 kcal/kg actual body weight per day. Protein should be delivered in the range of 2-2.5 g/kg ideal body weight per day.

Question 18

What are the SSC recommendations for hypocaloric feeding?

Answer 18

The SSC recommends avoiding mandatory full caloric feeding in the first week, but suggets low-dose feeding (up to 500 kcal per day) advancing only as tolerated.

Question 19

The stress response in critical illness increases _____, which cannot be fully suppressed by exogenous _____.

Answer 19

1. Gluconeogenesis

2. Exogenous glucose

Question 20

Protein intake of ___ g/kg of actual body weight is recommended in most critically ill patients

Answer 20

1.2-2 g/kg actual body weight

Question 21

Critically ill patients on continuous renal replacement therapy may need up to ___ g/kg per day of protein

Answer 21

2.5 g/kg

Question 22

Describe protein needs in patients with acute kidney injury who are not receiving renal replacement

Answer 22

Protein restriction is generally not recommended

Question 23

Patients

with extensive burn injury may need up to ___ g/kg per day of protein

Answer 23

3 g/kg per day

Question 24

Use of an enteral nutrition protocol must have guidance on initiation, _____ and _____

Answer 24

1. Initiation
2. Advancement
3. Interruptions

Question 25

EN can be delivered safely to patients receiving ___ vasopressors

Answer 25

Low-dose vasopressors

Question 26

Delivery of EN directly into the small bowel instead of gastric may be associated with a reduction in ____

Answer 26

Pneumonia

Question 27

In units where small bowel access is readily available, routine use of _____ is recommended

Answer 27

Routien use of small bowel feeding

Question 28

If small bowel access is not readily available, then small bowel feedings should only be considered for patients at high risk of ____ to EN

Answer 28

1. High risk of intolerance to EN
2. High risk for regurgitation and aspiration
3. Repeatedly demonstrated intolerance of gastric feeds

Question 29

List four factors making someone high risk of intolerance to EN

Answer 29

1. Inotropes
2. Continous infusion of sedatives
3. Paralytic agents
4. High nasogastric drainage

Question 30

What is a risk factor for regurgitation and aspiration

Answer 30

Nursed in supine position (face up)

Question 31

Describe evidence for gastric residual volumes in critically ill patients

Answer 31

No data indicating that interruption of gastric feeding for a specific residual volume prevents morbidity (aspiration pneumonia) in critically ill patients

Question 32

Describe guideline recommendation for gastric residual volumes in critically ill patients

Answer 32

The guidelines do not recommend routine checking of residual volume to assess aspriation risk

Question 33

List two appropriate circumstances to check gastric residual volumes

Answer 33

1. If there is concern for tolerance

2. Assess gastric motility, especially in patients with recent bowel surgery

Question 34

A residual volume of ___ is recommended as a point where intervention should occur

Answer 34

250-500 mL

Question 35

Prokinetic agents such as _____ may be given to decrease residuals and enhance gastric motility

Answer 35

1. Metoclopramide

2. Erythromycin

Question 36

IV catheters intended for PN ______

Answer 36

Should not be used for any other purpose

Question 37

Blood glucose measurements should be taken at least every ____ hours for patients receiving PN during ____ and _____

Answer 37

1. Every 4-6 hours

2. Initiation and Changes in carbohydrate content

Question 38

Describe recommendation for supplemental antioxidants and immmunomodulation nutrition

Answer 38

Supplemental antioxidants and immunomodulating micronutrients (vitamin E, selenium, fish oils, arginine, glutamine, zinc) are not recommended for general critically ill patients.