Ex 2: Determining Estimating Energy and protein needs

Question 1

Why is there no formula/plan for determining calorie and protein needs that will accurately determine calorie and protein needs for every patient every time?

Answer 1

1) Formulas are based on groups and may not address an individual 2) Energy requirements differ among patients at the same height/weight

Question 2

TEE

Answer 2

Total Energy expenditure = BEE/BMR + PA + TEF (Basal Energy Expenditure, Basal metabolic rate, Physical activity, Thermic effect of food)

Question 3

TEE w/medical diagnosis

Answer 3

BEE + PA + TEF + Physiological stress

Question 4

BMR/BEE vs REE/RMR similarities

Answer 4

1) Estimate calories needed at rest for 24h 2) minimum calories to keep the body going

Question 5

BEE/BMR vs REE/RMR differences

Answer 5

1) BEE/BMR measured under more restrictive condition (need sleep) 2) REE/RMR - at rest but no sleep requirement

Question 6

Identify formulas for determining calorie needs most commonly used in the hospital setting.

Answer 6

1) Harris Benedict Equation 2) Mifflin-St. Jeor Equation 3) kcal/kg

Question 7

What do the Harris Benedict Equation and Mifflin-St. Jeor Equation provide an estimation for? What additional calculations are completed to estimate energy needs?

Answer 7

REE/RMR ; (illness, inactivity factor, increase of temperature,

Question 8

How does fever impact a patient’s BEE?

Answer 8

Raises BMR; 13% for each degree celsius or 7% for each degrees Fahrenheit

Question 9

Estimating needs using kcal/kg

Answer 9

Do not make adjustments; mild to moderate illness 25-30 kcal/kg; moderate to severe illness 30-35 kcal/kg; obesity 22 kcal/kg

Question 10

Stages of weight gain

Answer 10

Stage 1 - rapid/mostly water retention stage 2 - minimal despite adequate protein and calories (diuresis of fluid) Stage 3 - True weight gain where lean tissue and fat are restored.

Question 11

What is the gold standard for determining energy needs?

Answer 11

Indirect Calorimetry

Question 12

When is indirect calorimetry an appropriate and desirable mechanism for determining energy needs?

Answer 12

When measuring in the critically ill patient (Hypermetabolic, weaning off a ventilator, and inappropriate response to nutrition support.

Question 13

The results of indirect calorimetry must be adjusted based on what factor?

Answer 13

must adjust for activity

Question 14

Refeeding syndrome is a concern in what type of patient?

Answer 14

Patients who have undergone significant weight loss ; classic marasmus, absence of nutrition for 1-2 weeks, prolonged fasting, anorexia nervosa

Question 15

When does refeeding syndrome typically occur?

Answer 15

4 days

Question 16

Physiology of refeeding syndrome

Answer 16

Rapid uptake of glucose causes uptake of phosphorous. Results in dangerous hypophosphatemia, lowered amounts of electrolytes, glucose, potassium, magnesium in serum; can leads to cardiac dysfuntion

Question 17

What steps must be undertaken to prevent refeeding syndrome?

Answer 17

1) Feeding should aim to meet 1.0 x BEE (not total energy needs) and be advanced slowly over 1-3 days 2) monitor for evidence of hypophosphatemia, hypokalemia, hypo magnesemia, fluid overload, congestive heart failure, hyperglycemia 3) electrolytes prn

Question 18

RDA for protein

Answer 18

0.8 g/kg/day

Question 19

Protein requirements for adults

Answer 19

Min - 0.54 ; normal - 0.8 -1.0; catabolic states - 1.2 -2.0 ; critically ill/trauma - 1.5 - 2.0

Question 20

Children protein requirements

Answer 20

3.0 g/kg

Question 21

The hypermetabolic patient requires what % of calories as protein to achieve positive nitrogen balance?

Answer 21

15-20% of calories as protein to achieve nitrogen balance

Question 22

Nitrogen needs: normal vs ill

Answer 22

Normal: 1g N/300 kcal ; ill 1g N/ 120-180 kcal

Question 23

Protein to nitrogen conversion

Answer 23

g protein x 0.16 = g Nitrogen or g protein / 6.25

Question 24

What is an appropriate Calorie:N ratio?

Answer 24

150:1 17% of calories from protein