Critical Care Part 3 Flashcards by Sydney Perry

Causes of AKI in Critically Ill Patients

Acute tubular necrosis (ATN)

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Risk factors for ATN

Decreased renal perfusion
Nephrotoxic medications
Sepsis or SIRS

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Treatment Options for AKI in the ICU

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

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Continuous Renal Replacement Therapy (CRRT) involves
________________

CVVHD – Continuous Venovenous Hemodialysis

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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

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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

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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

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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

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Additional Concerns in the ICU

shock
hyperglycemia
stress ulcers

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shock in ICU

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

Hemodynamically instability

high dose epinephrine, norepinephrine, dopamine, dobutamine

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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

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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

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Curling ulcer come from ____ Cushing ulcers come from ______

burns
brain

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Prevention & Treatment of Stress Ulcers
Meds?
MNT?

Medications used to reduce gastric acid production

MNT=>Early continuous EN may decrease risk

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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

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

Nitrogen Balance

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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