Disease Specific Considerations

Question 1

FFMI

Answer 1

Fat free mass index

FFMI > BMI in assessing nutrition of PMV pts

Low FFMI is positively correlated w/ airway obstruction, lung hyperinflation, and inspiratory load

Independent predictor of long term survival of PMV pts (long term O2)

Question 2

Caloric debt

Answer 2

Associated w/ immunosuppression
⬆️ infection rates
⬆ ️LOS
⬆️ days on vent
⬆️ mortality

> 10,000 kcal debt = longer ICU stay and prolonged ventilator weaning.

Question 3

Most important initial goal for intubated pts?

Answer 3

establish early enteral feeding of any amount

Question 4

Permissive hypercapia

Answer 4

Limiting tidal volumes to prevent further inflammation

Key therapeutic strategy for vented pts

Allow Arterial Co2 to rise above normal, but maintain pH >7.2

Need to tightly regulate amount of Co2 produced (calories)

Question 5

Which pt population is most affected by Overfeeding?

Answer 5

Critical care; hypermetabolic, nutritionally depleted, stressed, unable to eliminate CO2, PMV

Question 6

Clinical signs of Overfeeding

Answer 6

⬆️ plasma CO2 (without hx of copd)

triggers ⬆️ resp rate (tachypnea) so that normal pH is maintained

Question 7

Pulmonary Failure Considerations

Answer 7

Most pts are on steroids - hyperglycemia

Paralytics decrease ability to assess for abd pain, although they do not limit peristalsis

Fat Free Mass index (FFMI) > BMI for assessing nutritional status

Question 8

EN target

Answer 8

Initiate within 24-48 hrs after resuscitation

65% of goal EN within first week

Question 9

Nutrition needs and formula selection for intubated pts

Answer 9

Avoid giving excessive calories (avoid high fat)

1.5-2 g protein/kg

Question 10

PN for Pulmonary Failure

Answer 10

Withhold soy-based lipids during 1st week

Supplement with IV glutamine

Mild permissive under feeding (80% kcal goal) initially

Consider supplemental PN if EN goal can’t be reached in 7-10 days

Question 11

Pulmonary failure adjuvants

Answer 11

• EN glutamine for burn, trauma, mixed ICU pts
• Immune-modulating diets on vent
• Avoid arginine with severe sepsis
• Fish Oil/antioxidant supp for ARDS pt

Question 12

How to achieve efficacy of immune modulating formula?

Answer 12

Provide at least 50% of goal

Question 13

What changes in serum chemistries are expected as a result of Tumor Lysis Syndrome (TLS)?

Answer 13

Hyperkalemia and hyperphosphatemia

Question 14

Cirrhosis

Answer 14

REE x 1.2-1.4

1.0-1.5 g/kg

Fat req: 30-40% of nonprotein kcal

Replace zinc & vit D prn (avoid excess iron and copper intake)

Question 15

Calorie range for pts at refeeding risk

Answer 15

Start at 15-20 kcal/kg

Question 16

Pancreatic enzymes and EN

Answer 16

Panc enzyme preparations are
NOT COMPATIBLE with jejunal tubes due to clogging potential.

Need to use semielemental formula instead

If pt can’t tolerate, then use elemental

Question 17

Typical pancreatic enzyme dosing

Answer 17

500-2500 units lipase/kg/meal