E3 nutrition Flashcards
IBW male
50 kg + (2.3 x inches over 60)
IBW female
45.5 kg + (2.3 x inches over 60)
DBW
IBW + 0.4 (weight-IBW)
when to use DBW
if actual body weight is 130% or more of IBW
NBW
IBW + 0.25 (weight-IBW)
when to use NBW
if actual body weight is 130% or more of IBW
what does NBW apply to?
fluids, electrolytes, and nutrition parameters
benefits of early initiation (4)
dec disease severity
dec complications
dec ICU stay
inc patient outcomes
in risk factors for malnutrition, what is considered UBW (under body weight)
20 % below IBW
risk factors for malnutrition:
involuntary weight loss of >__% within _ months
10
6
risk factors for malnutrition:
NPO > _ days
10, clinically we use inadequate intake > 7 days *
3 other risk factors for malnutrition with asterisks in the slides
gut malfunction
mechanical ventilation
inc metabolic needs (burn or trauma)
NUTRIC is what?
nutritional risk assessment
nutric high risk range
6-10
nutric low dose range
0-5
wtf is anthropometrics?
somatic (muscle) protein status
- weight
- triceps skin fold
- arm muscle circumference
- physical appearancee
what is transthyretin
prealbumin
normal serum conc of transthyretin
15-40
what is CRP
C-reactive protein.
Positive acute phase reactant used to assess accuracy of prealbumin
normal CRP
<1 mg/dL
T or F:
Prealbumin is falsely decreased in the presence of inflammation
True
Prealbumin decreases as CRP increases ->
inflammation
prealbumin decreases as CRP normal ->
malnutrition
marasmus
protein-calorie malnutrition
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
B
protein
A. Kwashiorkor
B. Marasmus
A
wasting of muscle
A. Kwashiorkor
B. Marasmus
B
provide carbs followed by high protein
A. Kwashiorkor
B. Marasmus
A
large belly, diarrhea, decreased muscle mass
A. Kwashiorkor
B. Marasmus
A
consider addition of vitamin B
A. Kwashiorkor
B. Marasmus
B
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
A
general guidelines:
25-30 kcal/kg/day
A. Non-stressed/Non-depleted
B. Trauma/Surgery/Major burns
C. BMI 30-50
D. BMI >50
B
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
C
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
D
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
A
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
B
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
C
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
D
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
E
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
PN or EN?
fistulas
PN
PN or EN
hyperemesis gravidum
PN
PN or EN
bone marrow transplantation
PN
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
4
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
10
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%
B
hang-time of IV fat emulsion by itself should be limited to how many hours after opening of manufacturer packaging?
12
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
A
Dextrose and AA
A. total nutrient admixture
B. Conventional admin
C. premix for injection
B
no lipids
A. total nutrient admixture
B. Conventional admin
C. premix for injection
C
with or without electrolytes
A. total nutrient admixture
B. Conventional admin
C. premix for injection
C
can be used for all TNAs or 3-in-1
A. 1.2 micron filter
B. 0.22 micron filter
A
used only for 2-in-1 (no lipids)
A. 1.2 micron filter
B. 0.22 micron filter
B
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
B
Provides GI stimulation.
A. PN
B. EN
B
More physiologic.
A. PN
B. EN
B
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
A
Methods of Admin EN:
Primarily for pts with gastrostomy
A. Bolus
B. Intermittent
C. Continuous infusion
D. trickle or trophic
A
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
B
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
C
Methods of Admin EN:
requires use of infusion pump
A. Bolus
B. Intermittent
C. Continuous infusion
D. trickle or trophic
C
Methods of Admin EN:
Preferred method when feeding into the jejenum
A. Bolus
B. Intermittent
C. Continuous infusion
D. trickle or trophic
C
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
D
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
