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Advanced MNT 2 > Critical Care Part 3 > Flashcards

Critical Care Part 3 Flashcards

1
Q

Causes of AKI in Critically Ill Patients

A

Acute tubular necrosis (ATN)

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2
Q

Risk factors for ATN

A

Decreased renal perfusion
Nephrotoxic medications
Sepsis or SIRS

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3
Q

Treatment Options for AKI in the ICU

A

No dialysis
Intermittent Hemodialysis (IHD)
Continuous Renal Replacement Therapy (CRRT)

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4
Q

Continuous Renal Replacement Therapy (CRRT) involves
________________

A

CVVHD – Continuous Venovenous Hemodialysis

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5
Q

CVVHD – Continuous Venovenous Hemodialysis

Removes _____, ____, & _____
Protein loss is an issue: ~_____ g of aa/d
Can have ______% absorption of dextrose from dialysate

A

water, electrolytes, & waste products
10-15
35-45

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6
Q

Nutritional Needs for Critically Ill Patients with AKI

Energy: ________

Protein:
If frequent IHD: _______ g/kg
CVVHD: ________ g/kg

Use _______ to calculate kcal & protein needs
For critically ill patients with obesity=> use ____

A

25-30 kcal/kg

1.2-2.0 g/kg non-dialyzed
1.0-1.5 g/kg
CVVHD: 1.5-2.5 g/kg

UBW/EDW
IBW

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7
Q

Nutritional Needs for AKI in Critical Illness

Fluid
_________ (calculation)
If _____ and _______, restrict fluid to ____ L/day
Restriction usually not necessary on ____

Electrolytes
____, _____ usually well cleared with CVVHD
May need to restrict with ____

A

Replace output + 500 ml
anuric
not on CRRT
1-1.2
CRRT

K+
PO4
HD

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8
Q

For patients on CRRT, typically use a _______ enteral formula that meets ICU recommendations for protein & kcal

However, if significant electrolyte abnormalities develop or patient is receiving IHD, consider a __________

A

non-renal
renal failure formula

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9
Q

Additional Concerns in the ICU

A

shock
hyperglycemia
stress ulcers

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10
Q

shock in ICU

patients have ______________
Treated with _____, _____, _____, and _____
do not give ______

A

Hemodynamically instability

high dose epinephrine, norepinephrine, dopamine, dobutamine

EN

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11
Q

Hyperglycemia in ICU

Caused by _____, _____, _____

Should Promote ______: between ______ mg/dL

Avoid ________

A

metabolic response to stress
medications
overfeeding

RBG control: between 140-180 mg/dL

Avoid overfeeding

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12
Q

stress ulcers in ICU are ____ form of ______ that accompanies severe illness, trauma, or neural injury

Multiple sites of ulceration in ____ and _____
Can cause significant _____

Caused by=> __________
Curling vs. Cushing ulcer

A

Acute
peptic ulcer

stomach & duodenum
bleeding

gastric ischemia

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13
Q

Curling ulcer come from ____ Cushing ulcers come from ______

A

burns
brain

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14
Q

Prevention & Treatment of Stress Ulcers
Meds?
MNT?

A

Medications used to reduce gastric acid production

MNT=>Early continuous EN may decrease risk

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15
Q

Nutrition assessment in ICU

Many traditional parameters may not be available
Not recommended: _____, ______
______ is critical

Biochemical assessment
Food-drug interactions
Assess for malnutrition (in context of _______)

A

albumin
prealbumin
NFPE

acute illness/injury

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16
Q

Used to assess protein status and also to determine protein needs of patients in ICU

A

Nitrogen Balance

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17
Q

Nitrogen Balance equation ?
What is goal for healing ?
What is the goal for critical illness?

A

(protein intake/6.25) – (UUN + 4)
+2 to +4
0 (positive is not rlly possible)

18
Q

Negative nitrogen balance can indicate ____________, __________, or __________

Cannot be accurately calculated in patients with ______ or ______

A

inadequate intake of protein
increased needs
excessive losses of protein

renal disease
excessive exudative losses

19
Q

You are assessing an ICU patient with a small bowel ileus & ARDS. The patient is NPO and receiving 3-in-1 TPN of 1.5L 220 g dextrose, 88 g AA, with 50 g of 30% lipid.
UUN is: 16 g/d

Calculate the patient’s nitrogen balance & the patient’s protein needs to achieve nitrogen balance

A

88/6.25 – (16 + 4) = -5.9

5.9 g N x 6.25 = 37 g of add. pro needed
37 g + 88 g = 125 g protein/day

20
Q

Goals for nutritional needs in ICU

Provide adequate nutrition to slow loss of ____, ____, ____

Avoid overfeeding to prevent
_____, ____, and ____

A

LBM
heal wounds
fight infection

Hyperglycemia
Excessive CO2 production
Lipogenesis=> fatty liver

21
Q

Energy Requirements

___________ is the Gold standard
Estimates energy expenditure by measurement of _____________ over a given period of time

Uses the _________ to estimate energy expenditure from gas exchange data
[(3.94 x VO2 L/min) + (1.11 x VCO2 L/min)] x 1440

A

Indirect calorimetry (IC)
O2 consumption & CO2 production

Weir formula

22
Q

Candidates for IC

A

Patients with:
obesity
cachexia
TBI; SCI
burns
failure to wean from ventilator
delayed wound healing
amputations

23
Q

Required Conditions for IC

Measurement taken:
______ or _______
After a __________ period
Relaxed & not moving
_______ environment

A

Fasting (at least 7 hours)
receiving continuous feeding

30-minute resting

Thermoneutral

24
Q

Clinical Situations Which Decrease Validity of IC Results

A

Air leak*****
Physical agitation
Unstable body temperature
Unstable pH
ECMO

25
Q

Equation Used for critically ill, mechanically-ventilated, patients

A

Penn State 2010 Equation

26
Q

Penn State Equation uses…
____ calculated using the ________ equation
_____________________
& ____________

A

RMR
Mifflin-St. Jeor

maximum temperature (Tmax) in degrees Celsius

minute ventilation (VE) in liters per min

27
Q

For patients with _____ who are >____yo
Use the Modified Penn State 2010 equation
RMR = Mifflin(0.71) + Tmax(85) + VE (64) - 3085

A

obesity
>60 yo

28
Q

kcal/kg for ICU patients

A

20-30 kcal/kg estimated dry weight

29
Q

_____, ____ Feeding should be used for Patients with Obesity in ICU.
Why? (3)

A

Hypocaloric, High Protein

Promote steady weight loss
preventing loss of LBM
may possibly reduce complications

30
Q

Energy for ICU patients with obesity

Provide _____% of energy requirements as measured by IC
OR
_____ kcal/kg ______ wt for those with a BMI ____
_____ kcal/kg _____ for those with BMI____

A

65-70

11-14
actual
30-50

22-25
IBW
>50

31
Q

Protein for obese patients in ICU

BMI _______: __________
BMI ____ (Class III Obesity): up to _______

A

30-39.9
2.0 g/kg IBW

> 40
2.5 g/kg IBW

32
Q

Protein for Non-obese patients in ICU
______ g/kg

A

1.2-2.0

33
Q

Fluid: individualized
Use age & weight-based guidelines

Goal: maintain adequate ______
Consider losses
Consider additional sources of fluid

A

urine output

34
Q

Oral nutrition may be delayed by=> _______ (7)

For nutrition support: ___ preferred
____ - confirm indication when ordered

A

inability to chew or swallow
altered mental status
mechanical ventilation
weakness
anorexia
GI distress
sedation

EN
PN

35
Q

Nutrition cannot abolish the hypermetabolism & catabolism but may ____________

Without exogenous protein:
Decreased: ______ and _____
Increased: ______, ______, and _____

A

slow the loss of protein

wound healing
immune function

risk of infections
pressure injury
respiratory insufficiency

36
Q

EN should be started within _____ hrs of admission to ICU and advanced toward goal kcal during the next _____ hrs

Rx ________ to prevent aspiration

Gastric vs. small bowel feeding
Recommend small bowel feeding for=> _______ (4)

A

24-48
48-72

30-45° HOB elevation

delayed gastric emptying
supine position
NG suction
high aspiration risk

37
Q

Enteral Nutrition Formulas Often use _______, _____

May consider use of _________ for patients with TBI, major surgery, & severe trauma
- Not recommended for patients with _____

A

high protein, polymeric

immune-modulating formulas
severe sepsis

38
Q

Consider use of a ________ formula if persistent diarrhea

Avoid both soluble & insoluble fiber for patients at high risk for:
_______ and _____

A

soluble fiber-containing

Bowel ischemia
Severe dysmotility

39
Q

Consider additional kcal sources

Dextrose in IVF: ____ kcal/g

Propofol (Diprivan) used for ______:
____ kcal/mL from ____

Clevidipine used in ICU for ____
: ____ kcal/mL from ____

CVVHD _____

Multiple sources of nutrition

A

3.4

sedation
1.1
from fat

lowering BP
2
fat (safflower emulsion)

3.4 kcal/g bc dextrose

40
Q

The following are important and can change, so ______

Changes in medical status
Biochemical data: glucose, electrolytes, BUN, Cr, TG, LFT’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

A

Monitor patients

Advanced MNT 2 (17 decks)

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