Disease Specific Nutrition Overview Flashcards
what is the inpatient glycemic target for critically ill patients
140-180 mg/dL
Under conditions of sepsis and stress, glucose production will ____ and glucose uptake will ____
increased blood glucose production & decreased glucose uptake
during sepsis and stress hormones induce ____ resistance and ____
insulin resistance
hyperglycemia
what immunomodulating nutrients may be harmful in patients with sepsis/septic shock
arginine
Arginine is considered beneficial for immune function because
it increases tissue oxygenation
what is a benefit of enteral glutamine supplementation in the critically ill patient with multi organ failure
decreases nosocomial infections
what are the counter regulatory hormones responsible for hypercatabolism in critically ill trauma patients?
Glucagon
Epinephrine
Cortisol
Glucagon, epinephrine and cortisol are hormones released during _____ and lead to these four metabolic processes
traumatic injury glycogenolysis gluconeogenesis proteolysis free fatty acid release
What is the goal of releasing hormones such as epinephrine, cortisol, and glucagon during trauma
maintain survival and homeostasis and promote recovery
In a trauma patient, after timely resuscitation, restoration of perfusion, oxygenation and hemodynamic stability, what is the next important component of supportive therapy
early initiation of nutrition
In patients with burns, providing caloric support above energy expenditure has been found to have ____ effect on preservation of lean body mass
have no effect
although patients with burns have increased caloric needs, feeding in excess is still not recommended because it may cause
hyperglycemia, hepatic steatosis, or prolonged ventilatory dependence
In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in
respiratory acidosis
respiratory acidosis results from disorders producing alterations in ventilatory control due to the increased production of
CO2 and respiratory muscle weakness
Essential fatty acid deficiency in patients with cystic fibrosis is rare after _____ because EFA profiles have been shown to improve after it
lung transplantation
In cystic fibrosis, disruption of the exocrine function of the pancreas contributes to malabsorption of
fat, protein and fat soluble vitamins
EFAD status is usually evaluated by measuring
triene: tetraene ratio
clinical trials have ____ results in using omega 3 fatty acids in routine supplementation in the management of CF
mixed
what is the best choice for feeding a pancreatic insufficient infant with CF and why
Human Milk with enzymes because it has good immunologic properties, growth factors, pre and probiotics
Protein hydrolysate or free amino acid formulas with MCT are not indicated in infants with CF unless
there is another medical reason such as bowel resection leading to malabsorption or liver abnormalities
What is the glomerular filtration rate (GFR) for a patient with ESRD?
<15mL/min/1.73m2
a GFR indicating stage 1 kidney damage equates to
> 90mL/min/1.73m2
what is a GFR of Stage 2 Kidney damange
60-89mL/min/1.73m2
what is a GFR of Stage 3 Kidney Damage
30-59 mL/min/1.73m2
what is a GFR of Stage 4 kidney disease
15-29mL/min/1.73m2
Increased mortality in maintenance of HD patients has been associated with
low baseline body fat percentage and low muscle mass
low muscle mass reflects poor ____ status and ______
nutrition status
inflammation
low fat mass reflects low body stores of _____
energy
Elevated CRP levels in HD can cause
weight loss
decreased albumin
decreased appetite
which BMI is considered protective in HD patients
30-34.9
A BMI less than ____ and hypoalbuminemia are strong indicators of mortality in HD patients
< 23
What has been shown to delay weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease who are receiving enteral nutrition
refeeding syndrome
underfeeding
overfeeding
Hypophosphatemia can delay weaning from mechanical ventilation because
hypophosphatemia exacerbates respiratory dysfunction, diaphragmatic weakness and decreased cellular energy production
_____ feeds are defined as feeding in an amount of substrate enough to provide gut stimulation and are typically at a rate of 10-20mL/hr of EN
trophic feeds
What is the maximum dietary protein intake in critically ill adult patients getting continuous renal replacement therapy (CRRT)
2.5 g/kg/day
high protein needs of 2.5g/kg/day in the critically ill adult on CRRT is due to
hyper-catabolism, obligatory use of protein as preferred fuel source during the stress response and the likelihood of significant protein losses in CRRT effluent
Typical protein losses in CRRT equate to
10-17%
what are some disadvantages of going over 2.5g/kg/day of protein in CRRT
uremia
increased hepatic and renal demand
increased costs
what are the protein requirements for a stable patient getting peritoneal dialysis
1.2-1.3 g/kg/day (when clinically stable)
what are some causes of protein energy malnutrition in liver disease
malabsorption decreased kcal intake abnormal fuel metabolism early satiety fat malabsorption from altered bile acid circulation increased protein and fat oxidation
Energy expenditure is ___ in patients with infections and ascites with liver disease
increased
Protein energy malnutrition is most common in which of the following types of liver disease
Cirrhosis
patients with viral disease such as hepatitis B and C are not susually
severely malnourished
Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for
azotemia
Loop diuretics cause electrolyte imbalances as a result of decreased urine output, so azotemia is caused by
volume depletion
hypoglycemia requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease
Fulminant Hepatic Failure from impaired glycogenolysis, gluconeogenesis, and hyperinsulinemia requiring aggressive glucose administration
which metabolic derangements are common in fulminant hepatic failure
impaired glycogenolysis
hypoglycemia
impaired gluconeogenesis
hyperinsulinemia
patients with fulminant hepatic failure are in a ____ state with increased energy ____ and can rapidly become ____
hypercatabolic
expenditure
malnourished
In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting association starvation during the night
late evening snack
Cirrhotic patients have ____ glycogen stores and utilize more ____ as fuel during periods of prolonged starvation (usually seen in an overnight fast of 12-18 hours)
depleted glycogen stores
fat as fuel
what is an important indicator of protein energy malnutrition in chronic liver disease
muscle wasting & subcutaneous fat
in patients with chronic liver disease, using triceps skin fold and mid arm circumference can possibly be skewed by
fluid retention
Treatment for patients with overt hepatic encephalopathy who have impairments in cognitive and neuromuscular function include
supplementing zinc, thiamine, b6 and b12, use lactulose, provide a meal pattern of 3 meals and 3 snacks
______ is no longer restricted in patients with advanced liver disease
protein restriction
what micronutrients are common deficiencies in chronic liver disease due to poor intake and decreased absorption
thiamine vitamin B6 B12 Folate zinc
which types of cancer have the highest prevalence & severity of weight loss
pancreatic and gastric cancer
what types of cancer have the lowest prevalence of weight loss
sarcomas, breast cancer, hematological cancers
that is the benefit of megesterol acetate in patients with cancer associated cachexia?
improves appetite and ameliorates weight loss
______ is a synthetic progestational agent that promotes weight gain and helps to stimulate the appetite
megace
In the first 1-3 months after a bone marrow transplant the nutritional needs of a patient are best met with
30-35 kcal/kg body weight
>/= 1.5 g protein/kg body wt
Which nutrient should NOT be supplemented routinely in the early stages following hematopoietic stem cell transplantation (HSCT)
Iron
in Hematopoietic Stem Cell Transplantation, blood products and transfusions are required before, after, and during HSCT and can cause an overabundance of which nutrient
iron
Iron overload in HSCT patients can increase the chance of
acute graft vs host disease
blood/fungal infection
sinusoidal obstruction of liver
What acute changes in serum chemistry profile would be expected in a patient who is experiencing tumor lysis syndrome?
hyperkalemia
hyperphosphatemia
_____ is caused by massive tumor cell lysis with the release of large amounts of potassium, phosphate and nucleic acids into systemic circulation
Tumor Lysis Syndrome
Tumor Lysis Syndrome is common after
initiation of cytotoxic therapy
What is the best treatment of diarrhea in inflammatory bowel disease
Start anti-diarrheal agents once infectious etiology is ruled out
Anti-diarrheal medication should not be given to patients with IBD until what has been ruled out. Why?
infectious diarrhea such as CDiff. If to they can develop toxic megacolon
In patients with extensive bowel resection ______ can be given in conjunction with anti diarrhea medications
Cholestyramine to help with bile salt malabsorption
how much stool output is concerning for possible electrolyte deficiencies and volume depletion
> 500mL for 2 consecutive days
there are currently no evidenced based recommendations for using ___ or ____ as standard therapy with diarrhea
prebiotics & probiotics
A patient with Chron’s Disease that involves the distal ileum should be closely monitored for malabsorption of which micronutrient
vitamin B12
what is a major contributing factor in the development of metabolic bone disease in patients with IBD?
corticosteroid use
complications of metabolic bone disease is associated with IBD are
osteopenia and osteoporosis
when patients are on long term steroids, what should be supplemented to reduce osteopenia
calcium & vitamin D
what is commonly found in patients with IBD?
malnutrition vitamin D deficiency corticosteroid therapy magnesium deficiency chronic inflammation
____, ____ and _____ may be associated with PN associated MBD
aluminum toxicity, hypercalciuria, magnesium deficiency
In patients with severe acute pancreatitis, the use of enteral nutrition via naso-jejunal feeding tube rather than PN is associated with
a lower risk of developing infectious complications, maintained equal nitrogen balance and reduced incidence of hyperglycemia than those with PN
when is PN recommended in severe acute pancreatitis
when EN is not available, tolerated or patient is not meeting nutritional requirements via EN alone
A patient with chronic heart failure on high dose furosemide is started on EN for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms
Thiamine
which two medications are known for decreasing thiamine by uptake of cardiac cells in heart failure patients
furosemide and digoxin
Thiamine deficiency is a form of _____ which is characterized by an enlarged heart, electrolyte alterations, vasodilation and peripheral neuritis
Wet BeriBeri
gastric hypersecretions following significant small bowel resection can become problematic. Which of the following medications have shown to be the most successful in suppressing gastric hypersecretion
Proton Pump Inbitors
What metabolic complication may occur in patients with short bowel syndrome and small bowel intestinal bacterial overgrowth
metabolic acidosis
intestinal resection involving removal of the terminal ileum and or the ileocecal valve with the colon in continuity predisposes patients to
small intestinal bacterial overgrowth
in rare instances patients with short bowel syndrome can develop ____and encephalopathy. D lactate producing bacteria thrive in an acidic environment which is common in SBS as a result of metabolism of unabsorbed carbs leading to the production of lactate and decreases the pH
metabolic acidosis
patients with short bowel syndrome would benefit most from octreotide injections in the presence of
refractory diarrhea not controlled with diet and medication
what medication reduces the production of a variety of GI secretions and slows jejunal transit
octreotide
why should Octreotide by reserved only for patients with large volume stool loss whose fluid & electrolyte management is problematic
increases the risk for cholelithiasis
expensive
can inhibit bowel adaptation
has not been shown to improve absorption or eliminate the need for PN
what diet should be recommended to patients with short bowel syndrome (ileal resection) and colon in continuity
high complex carbohydrates 50-60% of total calories, low fat (20-30%) to increase energy absorption, optimize SCFA production & reduce instance of steatorrhea
a high complex carb diet low in fat helps reduce
magnesium & calcium losses, decreases oxalate absorption
oxalates bind to ____ and are excreted in the stool
calcium
patients with SBS who have a colon in continuity should restrict dietary oxalate intake & consume high calcium food or calcium citrate supplements to avoid
oxalate nephrolithiasis
A patient with SBS (regardless of bowel anatomy) complex carbs are important in the diet becuase
they reduce the osmotic load & may help with intestinal adaptation
Why are complex carbs recommended in SBS verses simple sugars
they take longer to break down than simple sugars which improves tolerance
why should concentrated sugars be avoided in short bowel syndrome
they can generate a high osmotic load and increase or promote stool output
calcium oxalate nephrolithiasis can occur in patients with short bowel syndrome with an intact colon who
don’t maintain adequate hydration
patients with short bowel syndrome are at a high risk for oxalate stones because
there is increased availability of oxalate absorption in the colon as patients with SBS usually have steatorrhea
normally, oxalates bind to ____ and are excreted through the stool
calcium & magnesium
in patients with SBS and steatorrhea, why are oxalates absorbed at an increased rate?
calcium binds to fatty acids, allowing excess and unbound oxalate to be absorbed from the colon & be filtered through the kidneys leading to stone formation also exacerbated by dehydration
to avoid calcium oxalate nephrolithiasis, maintaining hydration with a goal urine output of _____ is important, with oral calcium supplements between ___ and ___ mg/day not exceeding ___ mg a a time is recommended
> 1200mL a day
800-1200mg/calcium a day at does of no more than 500mg at one time
low dietary fat intake of 20-30% of total kcals is important in SBS in order to
minimize steatorrhea
minimize oxalate absorption
minimize loss of calcium & magnesium
SBS patients with less than ____ cm of terminal ileum resected are at lower risk of bile salt malabsorption & steatorrhea
100
what types of fistulas will result in the greatest degree of nutritional loss
proximal high output
the higher a fistula occurs in the GI tract, the ____ the output and risk of metabolic derangements
higher (more proximal)
patients with proximal high output fistulas in their GI tract will reuqire
increased protein/calorie needs
close monitoring of fluids & electrolytes
patients with low output fistulas less than ____mL/day of stool loss will decrease the possibility of enteral nutrition
500mL/day
to minimize fistula output in distal ileal or colonic fistulas, what type of enteral nutrition formula should be used as high up as possible to increase surface area for absorption
fiber free or low fiber
A 24 year old, 10 week pregnant woman presents with persistent nausea & vomiting for the past 6 weeks associated with a 10% wt loss. Her symptoms were refractory to a 48 hour trials of anti-emetics & IVF. Given mother’s nutritional status, decision was made to initiate nutrition support. What vitamin should be supplemented in this patient before providing nutrition support
thiamine
A 24 year old, 10 week pregnant woman presents with persistent nausea & vomiting for the past 6 weeks associated with a 10% wt loss. Her symptoms were refractory to a 48 hour trials of anti-emetics & IVF. Given mother’s nutritional status, decision was made to initiate nutrition support to minimize further deterioration of the mother’s nutritional status & possible negative side effects on the fetus. What is the most appropriate initial nutrition therapy to implement
EN with polymeric formula via NG tube
severe, intractable nausea and vomiting complicated by dehydration, electrolyte imbalance, nutrition deficiencies and weight loss in pregnant women is called
hyperemesis gravidarum
because constipation is often a problem in pregnancy, what type of formula should be considered in EN
fiber
A 14 year old with a 4 month history of intentional weight loss of 15% of her usual weight & a BMI < the 5th percentile is diagnosed with anorexia nervosa. She is admitted to the hospital for medical stabilization and is unwilling to consume enough food to meet her nutritional needs. A 24 hour calorie count reveals that the patient is consuming a very restricted diet averaging 850 calories a day. Which is the most appropriate nutrition intervention at this time
structured meal plan with supplemental enteral feedings
what is the preferred modality for nutrition rehabilitation
oral refeeding
a critically ill hyperglycemic patient receiving continuous enteral nutrition with a history of insulin dependent diabetes should ideally be placed on
continuous IV infusion
in the critical care setting, _______ has been shown to be the best method for achieving glycemic targets and allows for off cycles during the 24 hr period when EN is held or discontinued
continuous IV insulin infusion
Human Immunodeficiency Virus (HIV) associated lipodystrophy syndrome is most commonly associated with which class agent to treat HIV infection
nucleoside reverse transcriptase inhibitors (NRTI’s)
_____ is manifested by subcutaneous adipose tissue loss with visceral adipose tissue sparing or accumulation
HIV associated lipodystrophy syndrome
where is subcutaneous tissue loss often seen in HIV
face, buttocks, lower extremities
Patients with lipodystrophy are at increased risk of being
insulin resistant
what is the most appropriate feeding strategy for a morbidly obese trauma patient
hypocaloric high protein
zinc supplementation should be considered for patients with
unexplained skin rashes & alopecia
Zinc is an essential trace element for ____ and ___
cell replication & growth
Zinc is a cofactor for ____ & ____ synthesis and proliferation of inflammatory cells/epithelial cells
collagen & protein synthesis
zinc deficiencies usually occur from
GI surgery
diseases that impair intestinal absorption
diseases that increase zinc loss es
Celiac, CF, IBD, Chron’s
Chronic diarrhea &exudate from large wounds cause ___ deficiency
zinc
why are zinc levels not always reflective of zinc status?
the presence of inflammation and are dependent on albumin for transport, so interpret cautiously in presence of hypoalbuminemia & inflammation
what are the symptoms of zinc deficiency
rash, alopecia, impaired night vision, alterations in taste & smell, impaired immune function, anorexia, and diarrhea
Nutrition support for solid-organ transplant patients receiving cyclosporine may need to be modified due to the presence of
hyperkalemia
Cyclosporines, medications used after solid organ transplantation for immune suppression can cause electrolyte imbalances including
hyperkalemia, hypomagnesemia
hyperglycemia
hypercholesterolemia as it effects the renin angiotensin aldosterone system altering potassium homeostasis as well as decreased renal excretion of potassium
A patient with AKI who requires PN would most likely benefit from a solution containing
essential and non essential amino acids
A 51 year old F who is 10 years post gastric bypass surgery presents w/ numbness & tingling in her distal lower extremities that had progressively worsened. She had been on an oral MVI supplement. She was significantly anemic & neutropenic. Her vit B12 level was normal as were her serum iron, ferritin and transferrin levels. What nutritional deficiency is the most likely cause of all of these symptoms
Copper deficiency
Vitamin B12 deficiency in gastric bypass can cause
anemia & peripheral neuropathy (numbness & tingling in lower extremities)
Iron & Folate deficiencies cause ____ in gastric bypass patients
anemia
Thiamin deficiency can cause peripheral neuropathy but not _____ in gastric bypass patients
not anemia
what are the symptoms of copper deficiency
anemia
leukopenia
neutropenia
peripheral neuropathy
ERAS (Enhanced Recovery After Surgery) is a care program that has been shown to improve outcome after major surgery. The key mechanisms behind the ERAS effectiveness is
decrease the stress of surgery and support recovery
what are the objectives of ERAS
avoid starvation before surgery
limit post op IVF
optimize GI function & mobilization
What is done as part of ERAS protocol
avoid preop fasting by providing CHO nutrition/fluid and withholding routine bowel prep
ERAS was originally designed for which types of surgeries
colon resection
