exam 1 (electrolytes, TPN, obesity, pediatric nutrition) Flashcards
Vitamin C deficiency
Scurvy – connective tissue dysfunction
Vitamin A deficiency
Night blindness
Vitamin D deficiency
Ricketts or osteomalacia
Thiamin deficiency
Beriberi – muscle weakness/atrophy
Riboflavin deficiency
Skin breakouts
Niacin deficiency
Pellagra (dermatitis, diarrhea, dementia). alcoholics
Pyridoxine (Vit B6) deficiency
Mild–mood disorders. Severe – neuropathy/convulsions
Folic acid deficiency
Anemia, birth defects, esp pregnant women and alcoholics
Zn deficiency
Poor growth, healing, immune response, sexual development
Glucose transporter influenced by insulin
GLUT4
Glucose transporter in liver
GLUT2
Glucose transporter in brain
GLUT3
Caloric intake for preterm infant
100-120+ kcal/kg/day
Caloric intake for infant 0-6 mos
100-110 kcal/kg/day
Caloric intake for infant 6-12 most
90-100 kcal/kg/day
Caloric intake for child 1-7 yrs
60-80 kcal/kg/day
Protein intake for preterm infant
3.5-4 g/kg/day
Protein intake for infant 0-6 mos
2-3 g/kg/day
Protein intake for infant 6-12 mos
1.5-2 g/kg/day
Protein intake for child 1-7 yrs
1-2 g/kg/day
Fluid requirements for infant 0-3 kg
120 mL/kg/day
Fluid requirements for infant 3-10 kg
100 mL/kg/day
Fluid requirements for infant 11-20 kg
1000 mL/day + 50 mL/kg/day
Fluid requirements for infant >20 kg
1500 mL/day + 20 mL/kg/day
Caloric density of breastmilk
20 kcal/ounce
Wt loss goal for pt BMI >30 or >25 w comorbidity
5-10% over 6 most without regain
Who is bariatric surgery recommended for?
Pt BMI >40 or >35 w comorbidity
Noradrenergic agent important points
For short-term management, potential for abuse, watch out if cardiovascular issues–tends to aggravate
Orlistat Xenical and Alli important points
Causes oily stools through mechanism of action, bad if absorptive issues already, good for T2DM or HLD patients
Lorcaserin (Belviq) important points
Suppresses appetite thru serotonin pathways, good tolerability and dosing schedule, lower weight loss
Topiramate/phentermine (Qsymia) important points
Titration schedule, greatest weight loss, REMS program because teratogen, avoid if HTN, CVD
Naltrexone/bupropion (Contrave) important points
CYP enzyme interactions, titration schedule, avoid if HTN, seizure, opioid addiction, high % nausea
Liraglutide (Saxenda) important points
Increase satiety by increasing insulin release, slow gastric emptying, titration, BEST for T2DM, REMS program, high # GI side effects
Putting anything but breastmilk/formula into bottle, giving child under 1 year honey, cow’s milk, choking hazards, or potential allergens – bad idea or good idea?
Bad idea
Introducing 1 new food every 4-5 days, increasing serving size gradually, and emphasizing all food groups – bad idea or good idea?
Good idea
mEq Na in NS
154
NS – maintenance, rehydration, or resuscitation?
Resuscitation
LR – maintenance, rehydration, or resuscitation?
Resuscitation
1/2 NS – maintenance, rehydration, or resuscitation?
Maintenance
D5W – maintenance, rehydration, or resuscitation?
Rehydration
Most common MIVF
1/2NS + D5W + 20mEq KCl
Which is for fluid restricted patients – Albumin 5% or Albumin 25%?
Albumin 25%
Which are used for fluid expansion – crystalloids or colloids?
Colloids
List specific monitoring parameters to assess fluid balance
UOP, HR, BP, CVP, MAP, wt, I/O, BUN/SCr ratio
What is the most common cause of hypertonic hyponatremia?
Elevated blood glucose
What is the most common cause of pseudohyponatremia?
High proteins/lipids causing increased plasma volume, falsely diluting Na
What are the characteristic symptoms of hypervolemic hypotonic hyponatremia?
Edema and weight gain
What do you always use to treat hypervolemic hypotonic hyponatremia?
Furosemide (3% saline only if symptomatic)
What is a common cause of isovolemic hypotonic hyponatremia?
SIADH
What treatment is usually enough for isovolemic hypotonic hyponatremia?
Water restriction with NS. If symptomatic, treat like hypervolemic hypotonic hyponatremia.
What needs to be done for patients with hypovolemic hypotonic hyponatremia?
Restore volume deficit. If symptomatic, 3% NaCl first.
What general category of causes can lead to hypovolemic hypotonic hyponatremia?
Fluid losses – blood, GI fluid, loss from skin (burn)
What do you treat first in hypovolemic hypernatremia?
Volume status if needed – use NS. Then restore free water deficit.
What synthetic hormone is the treatment for isovolemic hypernatremia?
Vasopressin (synthetic ADH)
What treatment is usually enough to correct hypervolemic hypernatremia?
Stop hypertonic fluids or other cause. Diuretic only if needed.
What major symptom do we worry about in potassium disorders?
Cardiac arrhythmias or changes in function
If a patient has asymptomatic hypokalemia, what should they be given to treat it?
PO potassium – liquid, powder, tablets, etc.
Under what situations should a hypokalemic patient receive IV potassium?
If K <2.5 or 3, cannot tolerate PO, or if S/Sx present (change in ECG/spasms)
At what rate can you administer IV potassium?
Without cardiac monitoring, 10 mEq/hr. With continuous cardiac monitoring, 20 mEq/hr. If emergent with severe hypokalemia, 40-60 mEq/hr.
What is a signature symptom of hyperkalemia?
Peaked T wave
What do you use to treat hyperkalemia? (Correct order necessary)
- CaCl2, IVP2. Insulin with D50W or NaHCO3 or albuterol3. (If needed) Furosemide or hemodialysis or Kayexalate (only if GI intact)
What other electrolyte disturbances are magnesium disturbances related to?
Potassium and calcium
If PO magnesium cannot be given to a hypomagnesemic patient, how much Mg be administered IV?
0.5 mEq/kg if Mg is 1-2 mg/dL or 1 mEq/kg if Mg is <1 mEq/dL at a rate of 1 gm/hr
What is ratio of mEq of Mg to grams of Mg?
8 mEq = 1 gm
What is the normal range for ionized calcium?
4.6 - 5.1 mg/dL
What equivalents do we use when replacing calcium?
1 gram CaCl2 = 3 grams Ca gluconate = 270 mg elemental calcium
When should calcium gluconate be used?
If only line in is peripheral and in non-acute/non-emergent situations
When should calcium chloride be used?
When administering into central line or during a code
At what rate should calcium be replaced?
1 gram of calcium product per hour
What other disorder is it important to watch out for in calcium disorders?
Magnesium disorders
Which types of patients are more prone to hypercalcemia?
Cancer patients – treatments also more chronic
What electrolyte besides calcium is regulated by vitamin D and parathyroid hormone?
Phosphate
In asymptomatic hypophosphatemic patients, are there PO products available?
Yes – administer in divided doses
Under which situations should you choose KPhos for IV replacement over NaPhos?
If K <4 mEq/L
What is the mMol to mEq equivalent for NaPhos?
1 mMol NaPhos = 1.33 mEq each Na and PO4
What is the mMol to mEq equivalent for KPhos?
1 mMol KPhos = 1.47 mEq each K and PO4
What rate should you not exceed when replacing phosphate?
NMT 7 mMol/hr
What amount of phosphate should you give if a patient’s phosphate is <1.6?
1 mMol/kg
What amount of phosphate should you give if a patient’s phosphate is 1.6 - 2.2?
0.64 mMol/kg
What is used to treat hyperphosphatemia?
IV calcium
How fast should a patient’s sodium deficit be replaced?
1/2 over 1st 8 hours, then next half over next 16 hours
How fast should a patient’s free water deficit be replaced?
1/2 over 1st day, then next half over next day or two
What are the short term routes of enteral nutrition?
Nasogastric, nasoenteric, and jejunal tubes
What are the long term routes of enteral nutrition?
Jejunostomy, gastrostomy, PEG
What are the two routes of parenteral nutrition?
Peripheral parenteral nutrition and central parenteral nutrition
True or false: Most hospitalized patients suffer from acute malnutrition
False – most hospitalized patients are somewhere between acute and chronic malnutrition
What are patients at risk for if they suffered weight loss of 5-10% body weight in 6 months, had abnormal dietary intake for 1 month, or had anorexia, nausea, vomiting, or diarrhea for a few days?
Moderate malnutrition
Which type of malnutrition usually develops over months to years?
Marasmus – protein/calorie malnutrition
True or false: Albumin responds quickly to changes in nutrition
False – Prealbumin is a better indicator of protein and calorie intake
Is urine the only way we lose nitrogen?
No. Also sweat, feces, respirations, GI fistula, wound drainage, burns, etc.
What is the goal nitrogen balance for a hospitalized patient?
+4 grams (but 0 for maintenance)
How many calories does propofol provide?
1.1 kcal/mL
What ions should monitor to look for refeeding syndrome?
Mg, Phos, and K
Accelerated proteolysis, glycogenolysis, lipolysis, gluconeogenesis, insulin resistance, (-) nitrogen balance, and hypertriglyceridemia are metabolic responses to what?
Stress (could include sepsis, major surgery, major burns, etc.)
True or false: If you have correctly calculated a patient’s nutrition requirements, there is no need to watch them for overfeeding or underfeeding.
False – patient’s response to nutrition support should be monitored closely – treat the patient, not the number
Which value is higher – BEE, REE, or TEE?
TEE (total energy expenditure) because TEE = BEE*activity factor. BEE just metabolic activity required to maintain life if no activity
Under what circumstances should you use a nutrition body weight?
If actual bw is between 130% and 150% of IBW.
If a patient’s body weight is >150% IBW, what weight should you use?
IBW (permissive underfeeding)
What is your goal daily calorie range for a non-stressed, non-depleted patient?
20 - 25 kcal/kg/day
What is your goal daily calorie range for a trauma/surgery/stressed patient?
25 - 30 kcal/kg/day
What is your goal daily calorie range for a major burn patient?
35 - 40 kcal/kg/day
What is your goal daily calorie range for a for an obese patient?
22 - 25 kcal/kg/day times IBW (kg) permissive underfeeding
What is your goal daily protein range for a non-hospitalized patient?
0.8 - 1 g/kg/day
What is your goal daily protein range for a mild to moderately stressed patient (medical floor/repletion)?
1 - 1.5 g/kg/day
What is your goal daily protein range for a moderate to severely stressed patient (trauma/surgery/ICU)?
1.5 - 2 g/kg/day
What is your goal daily protein range for a burn patient?
2 - 2.5 g/kg/day
What is your goal daily protein range for an obese patient?
2 g/kg/day times IBW
What component of a TPN should be eliminated if a patient has an infection or sepsis?
Fat
What is a goal respiratory quotient (RQ)?
0.85 - 0.95 (>1 indicates overfeeding)
True or false: Parenteral nutrition is safer, less costly, better for the GI tract, and less wasteful than enteral nutrition.
False – all of these benefits are true for enteral nutrition.
Dysphagia, dementia, head and neck surgery, esophageal obstruction, and trauma/burn are all indications for what type of nutrition?
Enteral nutrition
Acute pancreatitis, high output proximal fistulas, intractable vomiting and diarrhea, GI ischemia, ileum, and nutrition need less than 7 days are all contraindications for what type of nutrition?
Enteral nutrition
What administration frequency of enteral nutrition is best tolerated?
Continuous administration
What is the caloric density of enteral formulations for normal patients? For fluid restricted patients?
1 kcal/mL normally; 2 kcal/mL for fluid restriction
Which of the following complications applies to enteral nutrition? Aspiration, GERD, pneumothorax, CVC infection, diarrhea, constipation, infusion pump failure, tube clogging
Aspiration, GERD, diarrhea, constipation, and tube clogging are all risks of enteral nutrition
Does administration of drugs with enteral nutrition tend to increase or decrease bioavailability and pharmacologic effect?
Tends to decrease efficacy – must interrupt continuous feed for a few hours to give meds.
In what form are the three macronutrients given in parenteral nutrition?
Protein – crystalline amino acids (4 kcal/g)Carbs – dextrose (3.4 kcal/g)Fat – emulsion with glycerol (10 kcal/g)
What do 3-in-1 TPNs have that 2-in-1 TPNs do not?
Fat
If a patient is in severe stress, malnutrition, has large caloric requirements, or will need PN >5 days, what kind of parenteral nutrition should he receive?
Central PN – via central line or PICC (peripherally inserted central catheter – good for 2-6 weeks)
If a patient has bowel ischemia, intractable vomiting/diarrhea, morning sickness, GI obstruction, ileus, inflammatory bowel disease, severe pancreatitis, NPO course >7 days, or short bowel syndrome, what type of nutrition is indicated?
Parenteral nutrition
What is a typical maximum carbohydrate utilization rate?
4 - 5 mg/kg/minute (up to 7 if trauma/burn)
If a patient has an egg allergy, what part of a TPN might they react to?
Egg yolk phospholipid – fat part
What value should daily lipid intake not exceed?
2.5 g/kg/day – no more than 60% daily caloric intake
In choosing whether to use chloride or acetate salts to administer cationic electrolytes, what ratio should you initially formulate them at?
2/3 salts chloride, 1/3 acetate. (May depend on pt acid/base balance)
What protein should never be added to TPN?
Albumin (high microbial growth potential)
What size filter should be used for 3-in-1 TPN? 2-in-1 TPN?
1.2 micron for 3-in-1 or 0.22 for 2-in-1 (2 in 1 lacks fat so filter won’t disrupt emulsion)
BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, P, AST, ALT
1 - 2 times a week
BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, and P should all be measured ____ in an unstable patient.
Daily
What can an elevated INR indicate?
Long-term malnutrition
What patients are high risk for refeeding syndrome?
Malnourished patients
To avoid refeeding syndrome, at what rate should you initiate TPN?
At half of the rate you calculated. In malnourished patients, consider initial rate of a quarter of calculation.
Which should come first – electrolyte correction or nutrition support?
Electrolyte correction
What is the biggest disadvantage of using 3-in-1 TPN over 2-in-1 TPN?
In 3-in-1 TPN, you cannot visibly detect problems with the mix (such as CaPO4 crystallization) because of the cloudiness caused by the fat emulsion.
Trissel’s manual is an especially good reference for determining what kind of interaction?
Medication-TPN interactions
What is always the first step in writing TPN for a patient?
Determining the correct weight to use
For making TPN, what is the standard stock concentration for dextrose? Fat? Protein?
Dextrose – 70%Fat – 20% Protein – 10%
How much “TPN space” do electrolytes usually take up?
~150 mL
True or false: Once a patient is ready to be discharged, TPN can be discontinued immediately. The patient’s GI tract is functional so he can just switch to food.
False – TPN must be tapered down by 1/2 every 2 hours.
What changes to TPN should be considered in patients with short bowel syndrome?
High-carb, low-fat diet with vitamin B12 supplementation prn
What changes to TPN should be considered in patients with diabetes?
30% of total kcal given as fat, be sure to monitor blood glucose
What changes to TPN should be considered in patients with cardiac disease?
Fluid restriction (check minimal volume), avoid overfeeding
What changes to TPN should be considered in patients with renal disease?
Fluid restriction. If pre-dialysis, give low protein. If receiving dialysis, give standard protein.
What changes to TPN should be considered in patients with pulmonary failure?
Give 30% - 50% of total kcal as fat, protein 1 - 2 g/kg, limit carbohydrates (think about RQ)
What changes to TPN should be considered in patients with hepatic disease?
High calorie intake (35 kcal/kg/day), protein restriction if encephalopathy, sodium restriction if ascites or edema
What is a normal pH range?
7.35 - 7.45
What blood gas do metabolic disorders involve?
Bicarbonate (HCO3-)
What blood gas do respiratory disorders involve?
CO2
What is the henderson-hasselbach equation specified for our physiological bicarbonate buffer?
pH = 6.1 + log (HCO3-/0.03xpCO2)
What is a normal pCO2?
40
What is a normal HCO3-?
24
Are decreased cardiac output and contractility, hyperkalemia, insulin resistance, inhibited anaerobic glycolysis, and coma signs of acidemia or alkalemia?
Acidemia
Are decreased coronary and cerebral blood flow, increased angina, stimulation of anaerobic glycolysis, and seizures signs of academia or alkalemia?
Alkalemia
What are our three buffers and which is the most prevalent?
Bicarbonate/carbonic acid, phosphate, and protein. Principal buffer = bicarbonate.
What are the four systems that regulate acid/base balance?
Buffers, kidneys, lungs, and some liver.
What are the two main ways that the kidney regulates acid base balance?
Reabsorbing bicarb and secreting H+
Is the distal tubule responsible for reabsorbing bicarb or creating bicarb?
Creating bicarb – this is where H+ excretion mainly takes place and this is essential for bicarb synthesis.
In bicarbonate reabsorption, what is the net change in bicarbonate and H+?
One filtered HCO3 reabsorbed, no change in H+
What ion is hydrogen exchanged for when it is secreted?
Na+
What is the end result of carbonic anhydrase inhibitor therapy?
Prevents bicarb reabsorption – urinate it out. Can cause metabolic acidosis or correct metabolic alkalosis.
What type of bicarb generation has the highest capacity?
Ammonium excretion/ammoniagenesis – instead of the excreted H+ binding with HCO3 to reabsorb it, it binds with ammonia, so the bicarbonate that was made in the cell is essentially new bicarb that is absorbed into the capillary
What ion does the secreted H+ bind with in titratable acidity?
Phosphate. Lower capacity because phosphate harder to access.
What type of bicarb generation relies on ATP?
Distal tubular hydrogen ion secretion – H+ is transported into lumen by ATPase and HCO3 freely enters peritubular capillary
What gas do chemoreceptors detect for ventilatory regulation?
PaCO2
Where are the chemoreceptors for ventilatory regulation located?
Carotid artery, aorta, medulla
What is hepatic regulation of acid/base balance based on?
Urea synthesis because 2 bicarb and 2 ammonium are needed to create urea. An increase in urea synthesis decreases the amount of bicarb.
What disorder is characterized by low pH, low pCO2, and low HCO3?
Metabolic acidosis
In what disorder is it always necessary to calculate an anion gap?
Metabolic acidosis
What is a normal anion gap?
3 - 11 mEq/L
When loss of plasma HCO3 is replaced by chloride, what kind of metabolic acidosis is this?
Non-anion gap acidosis. If HCO3 loss is replaced by something else, this is anion gap acidosis.
GI bicarbonate loss, pancreatic fistulas/biliary drainage, renal bicarbonate loss (RTAs), TPN administration and chronic renal failure can all cause what acid/base disorder?
Non-anion gap metabolic acidosis
What does MULEPAKS stand for?
Methanol intoxication, uremia, lactic acidosis, ethylene glycol, paraldehyde ingestion, aspirin (salicylates), ketoacidosis, sepsis
Which acid/base disorder is MULEPAKS associated with?
Anion gap metabolic acidosis – HCO3 losses replaced by something other than Cl
Shock, seizures, leukemia, hepatic/renal failure, DM, malnutrition, rhabdomyolysis, alcohol, metformin, NRTIs, propofol, and propylene glycol can all cause which of the causes in MULEPAKS?
Lactic acidosis
Which acid/base disorders can be caused by salicylate toxicity?
Respiratory alkalosis from stimulation of breathing or metabolic acidosis from accumulation of organic acids.
When should you treat metabolic acidosis with bicarb?
If pH < 7.10 - 7.15, hyperkalemia, overdoses, and in cardiac arrest if defibrillation, ventilation, and meds have already been used
What is the calculation for dosing bicarb?
Dose (mEq) = (0.5 L/kg)(IBW)(12 mEq/L - actual HCO3) Give 1/3 to 1/2 calculated dose and monitor ABG~1 mEq/kg may be given in cardiac arrest
What are the risks associated with bicarb therapy?
Overalkanization impairing O2 release, hypernatremia, hyperosmolality, CSF acidosis, electrolyte shifts (hypokalemia, hypocalcemia)
Citrate and acetate are metabolized to…
bicarb.
