E3 nutrition Flashcards by Cole O'Connor

IBW male

50 kg + (2.3 x inches over 60)

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IBW female

45.5 kg + (2.3 x inches over 60)

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DBW

IBW + 0.4 (weight-IBW)

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when to use DBW

if actual body weight is 130% or more of IBW

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NBW

IBW + 0.25 (weight-IBW)

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when to use NBW

if actual body weight is 130% or more of IBW

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what does NBW apply to?

fluids, electrolytes, and nutrition parameters

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benefits of early initiation (4)

dec disease severity
dec complications
dec ICU stay
inc patient outcomes

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in risk factors for malnutrition, what is considered UBW (under body weight)

20 % below IBW

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risk factors for malnutrition:
involuntary weight loss of >__% within _ months

10
6

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risk factors for malnutrition:
NPO > _ days

10, clinically we use inadequate intake > 7 days *

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3 other risk factors for malnutrition with asterisks in the slides

gut malfunction
mechanical ventilation
inc metabolic needs (burn or trauma)

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NUTRIC is what?

nutritional risk assessment

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nutric high risk range

6-10

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nutric low dose range

0-5

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wtf is anthropometrics?

somatic (muscle) protein status
- weight
- triceps skin fold
- arm muscle circumference
- physical appearancee

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what is transthyretin

prealbumin

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normal serum conc of transthyretin

15-40

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what is CRP

C-reactive protein.
Positive acute phase reactant used to assess accuracy of prealbumin

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normal CRP

<1 mg/dL

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T or F:
Prealbumin is falsely decreased in the presence of inflammation

True

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Prealbumin decreases as CRP increases ->

inflammation

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prealbumin decreases as CRP normal ->

malnutrition

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marasmus

protein-calorie malnutrition

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Marasmus: - dec total intake and/or utilization of food - wasting of skeletal muscle and _____ - ________ in severe cases - cachectic appearance

SQ fat immunosuppresion

Kwashiorkor

protein malnutrition

Kwashiorkor (protein malnutrition) - _______ caloric intake; relative protein malnutrition - catabolic ______ and _____ patients

adequate trauma and burn

Protein/Calorie A. Kwashiorkor B. Marasmus

protein A. Kwashiorkor B. Marasmus

wasting of muscle A. Kwashiorkor B. Marasmus

provide carbs followed by high protein A. Kwashiorkor B. Marasmus

large belly, diarrhea, decreased muscle mass A. Kwashiorkor B. Marasmus

consider addition of vitamin B A. Kwashiorkor B. Marasmus

nitrogen balance: measurement of _______ _______ of nitrogen as _____

urinary excretion urea (UNN = urinary urea nitrogen)

ideal goal of nitrogen balance study

+3 to +5 grams

Nitrogen balance equation thing

(N in) - (N out) no. way.

N in =

24-hour protein intake (g) / 6.25

N out =

24-hour UUN (g) + factor (3-5g) (generally use 4 as estimate *

what is harris-benedict equation used for/

estimating caloric needs

what is TEE?

total energy expenditure

% of REE (resting energy expenditure): % of REE and activity factor maintenance

120-130 % of REE 1.2-1.3

% of REE (resting energy expenditure): % of REE and activity factor mild;moderate

150 % of REE 1.5

% of REE (resting energy expenditure): % of REE and activity factor severe;thermal burn

200+ % of REE 2

TEE = REE x ____

stress activity factor(s)

general guidelines: 20-25 kcal/kg/day A. Non-stressed/Non-depleted B. Trauma/Surgery/Major burns C. BMI 30-50 D. BMI >50

general guidelines: 25-30 kcal/kg/day A. Non-stressed/Non-depleted B. Trauma/Surgery/Major burns C. BMI 30-50 D. BMI >50

general guidelines: 11-14 kcal/kg/day (ACTUAL body weight) A. Non-stressed/Non-depleted B. Trauma/Surgery/Major burns C. BMI 30-50 D. BMI >50

general guidelines: 22-25 kcal/kg/day IDEAL body weight A. Non-stressed/Non-depleted B. Trauma/Surgery/Major burns C. BMI 30-50 D. BMI >50

BMI =

weight in kg / ht in m2

when is indirect calorimetry the preferred method

for critically ill patients

TEE = REE x ?

1.2 (said this will be a question from slide 45)

for all energy production, oxygen is _______ and carbon dioxide is ______

consumed, produced

what is RQ?

respiratory quotient

goal RQ for overfeeding vs underfeeding

0.85-0.95 this is paired with mixed substrate

what does an RQ < 0.85 mean?

underfeeding

what does an RQ >0.95 mean?

overfeeding

Protein general guidelines: 0.8-1 gm/kg/day A. Maintenance B. Mild-Moderate stress C. Moderate-severe stress D. BMI >30 E. BMI >40

Protein general guidelines: 1-1.5 gm/kg/day A. Maintenance B. Mild-Moderate stress C. Moderate-severe stress D. BMI >30 E. BMI >40

Protein general guidelines: 1.5-2 gm/kg/day A. Maintenance B. Mild-Moderate stress C. Moderate-severe stress D. BMI >30 E. BMI >40

Protein general guidelines: 2 gm/kg/day (IDEAL BW) A. Maintenance B. Mild-Moderate stress C. Moderate-severe stress D. BMI >30 E. BMI >40

Protein general guidelines: 2.5 gm/kg/day (IDEAL BW) A. Maintenance B. Mild-Moderate stress C. Moderate-severe stress D. BMI >30 E. BMI >40

what does standard distribution of non-protein calorie distribution entail?

70/30. 70 % dextrose 30% fat

when could 100% dextrose and 0% fat be utilized for NPC distribution

during sepsis or bloodstream infections **

PN or EN? ileus or small bowel resection

PN or EN? fistulas

PN or EN hyperemesis gravidum

PN or EN bone marrow transplantation

Peripheral PN: dextrose and AA solutions are ____tonic. what does this mean?

hyper. not well tolerated via a peripheral vein

Peripheral PN: restrict final dextrose conc. to 5-10% or, total osmolarity to < ___ mOsm/L

900 *

Peripheral PN or central PN? requires large volumes of fluid

Peripheral

in NICU all TPNs are (peripheral/central)

peripheral

2 advantages of central TPN

allows admin. of hypertonic solutions more calories can be delivered

2 disadvantages of central TPN

risk of infection central line is not a benign procedure (just means putting it in sucks and you can push air where you dont want air)

are TPNS central or peripheral in the NICU?

all peripheral

what are the 3 insertion sites for central lines?

subclavian internal jugular femoral

Is PICC (peripherally inserted central catheter) central or peripheral

central, ignore the P

one gram protein = _ kcal

T or F: many hospitals order protein in gm/day

true

what are travasol freamine aminosyn

standard amino acid products

one gram dextrose = _ kcal

3.4

when should final dextrose concentration not be infused peripherally? adults: pediatrics:

>10% >12.5%

maximum carbohydrate utilization = _-_ mg/kg/min

4-5 (max a person can actually absorb)

1 gram lipids = _ kcal

what does IV fat emulsion - intralipid prevent?

fatty acid deficiency

two allergens you should check for in intralipid thing

glycerin and egg

what is SMOFlipid?

soybean oil medium-chain TGs olive oil fish oil

general lipids for adults: __-__ gm/kg/day MAX of __ gm/kg/day if tolerated

1-1.5 2.5

T or F: propofol is a lipid solution

true

propofol provides _kcal/mL for lipid shit

1.1

Must be incorporated into a total nutrient admixture for administration A. IV fat emulsion 10% and 20% B. IV fat emulsion 30%

hang-time of IV fat emulsion by itself should be limited to how many hours after opening of manufacturer packaging?

if IV fat emulsion being hung is added as TNA what is the new hang time limit from 12 hours to ?

24 hours

dextrose, AA, and lipids A. total nutrient admixture B. Conventional admin C. premix for injection

Dextrose and AA A. total nutrient admixture B. Conventional admin C. premix for injection

no lipids A. total nutrient admixture B. Conventional admin C. premix for injection

with or without electrolytes A. total nutrient admixture B. Conventional admin C. premix for injection

can be used for all TNAs or 3-in-1 A. 1.2 micron filter B. 0.22 micron filter

used only for 2-in-1 (no lipids) A. 1.2 micron filter B. 0.22 micron filter

T or F: you are able to customize clinimix

false

"standard' TPN name

clinimix

T or F: Clinimix contains AAs + dextrose + electrolytes

false kinda because it can be with or without electrolytes

what CrCL do you avoid adding electrolytes with clinimix?

CrCl <50 is bad

when discontinuing PN you should consider starting at __% of goal and achieve final rate within __ hours

25 24

when initiating PN how often should you check blood glucose

every 4-6 hours

if BG > 200 after initiation of PN what do you do?

continue at same rate and recheck. if it is >200 after that consider insulin

T or F: There is no specific guideline for cycling PN

True

max __ mL/hr for cycling PN

200

standard daily range for phos __-__ mMol (or __ mMol/kg to start)

15-45 0.3

what 3 electrolytes should be used in caution with renal disease?

potassium phos magnesium

which two electrolytes do you avoid mixing together due to risk of precipitation

calcium and phos

avoid going over ___ for calcium x phos

150

when do you avoid giving trace elements

liver dysfunction

what two trace elements do you supplement individually in liver dysfunction

zinc and selenium

which 2 trace elements should be used in caution with renal disease?

selenium and chromium

T or F: the addition of iron is recommended for most patients

false it can destabilize iv fat emulsion and contribute to infectious complications

what med may be utilized for gerd or stress ulcer prophylaxis with PN

famotidine

T or F: PPIs are compatible with PN

false

what insulin options do you have in PN?

regular only*

MIVF is __-__ mL/kg/day

30-40 good review

"average" = _ mMol phos = _ mEq phos

1=1.4

what balances against chloride?

acetate

what are the positive ions for ion balance (2)

sodium potassium

what are the negative ions for ion balance? (3)

chloride acetate phos

2 complications of mechanical PN

clotting of line displacement

highlighted infectious complication of PN

catheter-related sepsis

what is bacterial translocation?

Time-dependent passage of bacteria or endotoxins from GI tract to extra-intestinal sites

highlighted metabolic complication of PN

hyper and hypoglycemia

4 things under baseline monitoring for PN

CMP, Mg, Phos, Ca hepatic function panel prealbumin/crp PT/INR

1 highlighted thing to monitor twice weekly during PN and niche thing in ICU setting

prealbumin/CRP daily in ICU

2 things to monitor weekly on PN

TG RQ

T or F Refeeding syndrome can be life-threatening

true

what is the most likely clinical finding of refeeding syndrome

hypophosphatemia

3 highlighted clinical findings of refeeding syndrome

hypophos hypomag hypokalemia

some general risk factors for refeeding

low BMI rapid feeding excessive weight loss low levels of K, phos, mag prior to feeding

3 high risk comorbidities for refeeding

alcoholism anorexia marasmus

Prevention of refeeding syndrome: Initiation recommendations (Day #1): - Limit carbohydrates (dextrose) to ___-___ gm - Limit fluids to ___ mL/day - Provide adequate amounts of ________ - Provide approximately __% of total caloric needs

100-150 800 electrolyts 50%

essentia fatty acid (EFA) are estimated to be _-_% of daily calories

4-10

what is the mechanism for EFA deficiency?

cont. infusion of hypertonic dextrose increases insulin levels and inhibits lipolysis and fatty acid mobilization

clinical onset of EFA deficiency

10-14 days on fat-free PN regimen

3 sxs of EFAD

dry scaly skin brittle hair lack of luster

there are two ways to prevent EFAD with fat emulsion and shit but i think he just wanted us to know how often. so, how often?

twice weekly

Decreased chance for bacterial translocation. A. PN B. EN

Provides GI stimulation. A. PN B. EN

More physiologic. A. PN B. EN

contraindications to EN (few highlighted ones just know the first couple that i put in there)

- non-mech obstruction -> ileus - severe GI hemorrhage - certain types of fistulas (high output, proximal small bowel) - vomiting intractable - severe malabsorption

what are the routes of admin for EN? (4)

nasogastric nasojejunal gastrostomy jejunostomy (PEG/PEJ)

nasogastric

nose to stomach

orogastric

mouth to stomach

nasojejunal

nose to duodenum

orojejunal

mouth to duodenum

gastrostomy

percutaneous surgical placement

PEG/PEJ inserted how?

percutaneously

determining routes of EN access: risk of aspiration: low risk -> high risk ->

low -> gastric high -> jejunal is preferred

determining routes of EN access: tolerance: vomiting -> gastric residuals ->

use jejunal for both

determining routes of EN access: duration of therapy: long term ->

consider PEG or PEJ

Methods of Admin EN: Mimics meals A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

A. Bolus

Methods of Admin EN: admin > 200 mL formula over 5-10 min. max volume 300-400 mL A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

Methods of Admin EN: Primarily for pts with gastrostomy A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

3 advantages of bolus

convenient minimal equipment less med interactions

2 disadvantages of bolus

cannot feed into small bowel higher risk of aspiration and intestinal side effects

Methods of Admin EN: admin >200 mL formula over 20-30 min (gravity drip) A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

how many feedings a day for intermittent admin in EN?

4-8

1 advantage of intermittent admin in EN

helps tolerance

1 disadvantage of intermittent admin in EN

more equipment required (needs reservoir bottle or bag)

Methods of Admin EN: admin cont over 12-24 hours/day A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

Methods of Admin EN: requires use of infusion pump A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

Methods of Admin EN: Preferred method when feeding into the jejenum A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

2 advantages of continuous infusion

- lower risk of gastric distention and aspiration - better tolerated by patient

2 disadvantages of continuous infusion

- problematic for medication admin - requires infusion pump

Methods of Admin EN: slow cont infusion at 10-30 mL/hr A. Bolus B. Intermittent C. Continuous infusion D. trickle or trophic

2 advantages of trickle or trophic admin in EN

- prevent mucosal atrophy and bacterial translocation - may shorten time on ventilator and decrease mortality

1 disadvantage of trickle or trophic admin in EN

Difficult to achieve sufficient calorie delivery

Initiation & Advancement of Tube Feeding: - initiate full strength at __ mL/hr - advance __ mL/hr q4-6 hrs as tolerated up to goal rate

25 25

EN – ICU Initiation Points: - achieve __-__% goal calories within first week (if you dont, consider PN instead)

50-60 %

EN – ICU Initiation Points: do not initiate if hemodynamically unstable. why?

concern for intestinal ischemia

T or F: EN promotes gut motility

true, youre using it still so

2 reasons to minimize holding times in NPO

- inadequate nutrient delivery (duh) - may stimulate ileus development (bad)

EN Nutrient Composition: protein: - _______ protein -> requires complete digestion into smaller peptides - partially digested (peptide-based) -> ________; may be beneficial for pts with ________ or ________**

intact elemental malabsorption, diarrhea

EN Nutrient Composition: Fat: - long-chain fatty acids - ______-chain fatty acids -> more water soluble, rapid _______, little or no pancreatic lipase for absorption

medium hydrolysis

EN Nutrient Composition: Carbohydrates: - ________ polymers primarily used for tube feeding formulas - simple glucose used for _____ supplements (higher in osmolality)

glucose oral

what does modular mean in the context of this exam

added onto EN or PN

what are the key contents in the modular supplement pro-stat?

15 g protein 72 kcal 3g CHO

when would you give Juven as a modular supplement?

wound care/HIV/AIDs/Cancre

glutamine (modular supplementation): - may reduce ___ or ___ - reduces mortality in ____ pts - no systemic effect when give by _____ route - do NOT supplement if already receiving glutamine via immune-modulating formula

hospital/ICU length of stay burn enteral

Probiotics: - Inhibit _______ ________ growth - Block _______ attachment - Eliminate toxins - Enhance host inflammatory response

pathogenic bacterial pathogen

Vitamins and trace elements: - used for _______ effects and/or repletion - Vitamin _ and vitamin __ - beneficial in most ____ patients

antioxidant E and C ICU (burn/trauma/mech ventilated)

6 complications for gastrointestinal

- high gastric residuals - aspiration - N/V or decreased motility - Abdominal distention - diarrhea - constipation

T or F: lower cut offs protect patient from high gastric residuals

false

High gastric Residuals: < 500 mL: (do/ do not) hold unless intolerance signs 200 to 500 mL: implement risk reduction measures to avoid ________ Cutoffs may vary by site

do not aspiration

what are the 4 drug options for decreased motility from enteral feeding?

metoclopramide (most common)* erythromycin naloxone methylnaltrexone

when to consider hyperosmolar meds and meds with sorbitol

diarrhea, said we didnt need to know the meds that fall under those categories tho

3.5 metabolic complications

- hyper/hypo glycemia - overhydration/dehydration - electrolyte imbalance

what is the most common electrolyte imbalance from the metabolic complications slide

hyponatremia **

goal blood glucose in ICU

<180

2 mechanical complications (the others are common sense)

rhinitis sinusitis

some of the general guidelines for med delivery via enteral feeding tubes (just give it your best shot)

- liquid meds pref - crush oral dosage forms - DO NOT crush sustained-release or enteric coated shit - admin meds separately - ensure adequate flushing

what 2 things do you mix and put into water to unclog feeding tubes

1 sodium bicarb tab and 1 pancreatic enzyme cap

some monitoring things for gastrointestinal

gastric residuals emesis stools daily bloating/distension bronchial/tracheal aspirate

metabolic monitoring: how often should you check for each? - weight - electrolytes/BUN/Scr - Mg/Phos/Ca/TG/LFTs - Albumin/CRP/Nitrogen

- 2-3 times/week - daily until stable->twice weekly-> weekly - weekly - weekly

consideration for acute renal failure: use a ?

Use a normal EN formula unless electrolyte profile dictates otherwise**

Acute renal failure special considerations: CRRT (cont renal replacement therapy): increased protein requirement to prevent ______ deficit

nitrogen

Acute renal failure special considerations: Hemodialysis -> __-__ g/kg/day protein

0.8-1.2

Acute renal failure special considerations: loss of water soluble micronutrients (3)

selenium, zinc, thiamine

Acute renal failure special considerations: _______ accumulates due to it being cleared renally

prealbumin, this makes it falsely high

what kind of failure do you incorporate fluid-restriction, calorically dense formulations 1.5-2.0kcal/mL

pulmonary

what failure do you watch and monitor phosphate closely

pulmonary (important for breathing)

T or F: Parenteral nutrition does not affect pancreatic secretion and function

true

what acute disease state do you consider lipid infusions and adding glutamine

acute pancreatitis

Burn pts: metabolic changes - (inc/dec) basal metabolic rate and nitrogen loss - glycolysis, proteolysis, lipolysis

increase

burn pts: nutritional requirements: - high in protein (__-__g/kg/day) and calories - early feeding with __

2-2.5 EN

burn pts: supplements: - adult multivitamin - If TBSA >10% -> - If TBSA > 20% -> - Vitamin __ (if deficient), Vitamin __ (if on steroids)

- ascorbic acid, zinc, vitamin e, selenium - oxandrolone/ growth hormones - D, A