Critical Care Part 3 Flashcards
Causes of AKI in Critically Ill Patients
Acute tubular necrosis (ATN)
Risk factors for ATN
Decreased renal perfusion
Nephrotoxic medications
Sepsis or SIRS
Treatment Options for AKI in the ICU
No dialysis
Intermittent Hemodialysis (IHD)
Continuous Renal Replacement Therapy (CRRT)
Continuous Renal Replacement Therapy (CRRT) involves
________________
CVVHD – Continuous Venovenous Hemodialysis
CVVHD – Continuous Venovenous Hemodialysis
Removes _____, ____, & _____
Protein loss is an issue: ~_____ g of aa/d
Can have ______% absorption of dextrose from dialysate
water, electrolytes, & waste products
10-15
35-45
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 ____
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
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 ____
Replace output + 500 ml
anuric
not on CRRT
1-1.2
CRRT
K+
PO4
HD
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 __________
non-renal
renal failure formula
Additional Concerns in the ICU
shock
hyperglycemia
stress ulcers
shock in ICU
patients have ______________
Treated with _____, _____, _____, and _____
do not give ______
Hemodynamically instability
high dose epinephrine, norepinephrine, dopamine, dobutamine
EN
Hyperglycemia in ICU
Caused by _____, _____, _____
Should Promote ______: between ______ mg/dL
Avoid ________
metabolic response to stress
medications
overfeeding
RBG control: between 140-180 mg/dL
Avoid overfeeding
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
Acute
peptic ulcer
stomach & duodenum
bleeding
gastric ischemia
Curling ulcer come from ____ Cushing ulcers come from ______
burns
brain
Prevention & Treatment of Stress Ulcers
Meds?
MNT?
Medications used to reduce gastric acid production
MNT=>Early continuous EN may decrease risk
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 _______)
albumin
prealbumin
NFPE
acute illness/injury
Used to assess protein status and also to determine protein needs of patients in ICU
Nitrogen Balance
Nitrogen Balance equation ?
What is goal for healing ?
What is the goal for critical illness?
(protein intake/6.25) – (UUN + 4)
+2 to +4
0 (positive is not rlly possible)
Negative nitrogen balance can indicate ____________, __________, or __________
Cannot be accurately calculated in patients with ______ or ______
inadequate intake of protein
increased needs
excessive losses of protein
renal disease
excessive exudative losses
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
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
Goals for nutritional needs in ICU
Provide adequate nutrition to slow loss of ____, ____, ____
Avoid overfeeding to prevent
_____, ____, and ____
LBM
heal wounds
fight infection
Hyperglycemia
Excessive CO2 production
Lipogenesis=> fatty liver
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
Indirect calorimetry (IC)
O2 consumption & CO2 production
Weir formula
Candidates for IC
Patients with:
obesity
cachexia
TBI; SCI
burns
failure to wean from ventilator
delayed wound healing
amputations
Required Conditions for IC
Measurement taken:
______ or _______
After a __________ period
Relaxed & not moving
_______ environment
Fasting (at least 7 hours)
receiving continuous feeding
30-minute resting
Thermoneutral
Clinical Situations Which Decrease Validity of IC Results
Air leak*****
Physical agitation
Unstable body temperature
Unstable pH
ECMO
Equation Used for critically ill, mechanically-ventilated, patients
Penn State 2010 Equation
Penn State Equation uses…
____ calculated using the ________ equation
_____________________
& ____________
RMR
Mifflin-St. Jeor
maximum temperature (Tmax) in degrees Celsius
minute ventilation (VE) in liters per min
For patients with _____ who are >____yo
Use the Modified Penn State 2010 equation
RMR = Mifflin(0.71) + Tmax(85) + VE (64) - 3085
obesity
>60 yo
kcal/kg for ICU patients
20-30 kcal/kg estimated dry weight
_____, ____ Feeding should be used for Patients with Obesity in ICU.
Why? (3)
Hypocaloric, High Protein
Promote steady weight loss
preventing loss of LBM
may possibly reduce complications
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____
65-70
11-14
actual
30-50
22-25
IBW
>50
Protein for obese patients in ICU
BMI _______: __________
BMI ____ (Class III Obesity): up to _______
30-39.9
2.0 g/kg IBW
> 40
2.5 g/kg IBW
Protein for Non-obese patients in ICU
______ g/kg
1.2-2.0
Fluid: individualized
Use age & weight-based guidelines
Goal: maintain adequate ______
Consider losses
Consider additional sources of fluid
urine output
Oral nutrition may be delayed by=> _______ (7)
For nutrition support: ___ preferred
____ - confirm indication when ordered
inability to chew or swallow
altered mental status
mechanical ventilation
weakness
anorexia
GI distress
sedation
EN
PN
Nutrition cannot abolish the hypermetabolism & catabolism but may ____________
Without exogenous protein:
Decreased: ______ and _____
Increased: ______, ______, and _____
slow the loss of protein
wound healing
immune function
risk of infections
pressure injury
respiratory insufficiency
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)
24-48
48-72
30-45° HOB elevation
delayed gastric emptying
supine position
NG suction
high aspiration risk
Enteral Nutrition Formulas Often use _______, _____
May consider use of _________ for patients with TBI, major surgery, & severe trauma
- Not recommended for patients with _____
high protein, polymeric
immune-modulating formulas
severe sepsis
Consider use of a ________ formula if persistent diarrhea
Avoid both soluble & insoluble fiber for patients at high risk for:
_______ and _____
soluble fiber-containing
Bowel ischemia
Severe dysmotility
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
3.4
sedation
1.1
from fat
lowering BP
2
fat (safflower emulsion)
3.4 kcal/g bc dextrose
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
Monitor patients
