Exam 1 Flashcards
1
Q
Vitamin C deficiency
A
Scurvy – connective tissue dysfunction
2
Q
Vitamin A deficiency
A
Night blindness
3
Q
Vitamin D deficiency
A
Ricketts or osteomalacia
4
Q
Thiamin deficiency
A
Beriberi – muscle weakness/atrophy
5
Q
Riboflavin deficiency
A
Skin breakouts
6
Q
Niacin deficiency
A
Pellagra (dermatitis, diarrhea, dementia). alcoholics
7
Q
Pyridoxine (Vit B6) deficiency
A
Mild–mood disorders. Severe – neuropathy/convulsions
8
Q
Folic acid deficiency
A
Anemia, birth defects, esp pregnant women and alcoholics
9
Q
Zn deficiency
A
Poor growth, healing, immune response, sexual development
10
Q
Glucose transporter influenced by insulin
A
GLUT4
11
Q
Glucose transporter in liver
A
GLUT2
12
Q
Glucose transporter in brain
A
GLUT3
13
Q
Caloric intake for preterm infant
A
100-120+ kcal/kg/day
14
Q
Caloric intake for infant 0-6 mos
A
100-110 kcal/kg/day
15
Q
Caloric intake for infant 6-12 most
A
90-100 kcal/kg/day
16
Q
Caloric intake for child 1-7 yrs
A
60-80 kcal/kg/day
17
Q
Protein intake for preterm infant
A
3.5-4 g/kg/day
18
Q
Protein intake for infant 0-6 mos
A
2-3 g/kg/day
19
Q
Protein intake for infant 6-12 mos
A
1.5-2 g/kg/day
20
Q
Protein intake for child 1-7 yrs
A
1-2 g/kg/day
21
Q
Fluid requirements for infant 0-3 kg
A
120 mL/kg/day
22
Q
Fluid requirements for infant 3-10 kg
A
100 mL/kg/day
23
Q
Fluid requirements for infant 11-20 kg
A
1000 mL/day + 50 mL/kg/day
24
Q
Fluid requirements for infant >20 kg
A
1500 mL/day + 20 mL/kg/day
25
Caloric density of breastmilk
20 kcal/ounce
26
Wt loss goal for pt BMI >30 or >25 w comorbidity
5-10% over 6 most without regain
27
Who is bariatric surgery recommended for?
Pt BMI >40 or >35 w comorbidity
28
Noradrenergic agent important points
For short-term management, potential for abuse, watch out if cardiovascular issues--tends to aggravate
29
Orlistat Xenical and Alli important points
Causes oily stools through mechanism of action, bad if absorptive issues already, good for T2DM or HLD patients
30
Lorcaserin (Belviq) important points
Suppresses appetite thru serotonin pathways, good tolerability and dosing schedule, lower weight loss
31
Topiramate/phentermine (Qsymia) important points
Titration schedule, greatest weight loss, REMS program because teratogen, avoid if HTN, CVD
32
Naltrexone/bupropion (Contrave) important points
CYP enzyme interactions, titration schedule, avoid if HTN, seizure, opioid addiction, high % nausea
33
Liraglutide (Saxenda) important points
Increase satiety by increasing insulin release, slow gastric emptying, titration, BEST for T2DM, REMS program, high # GI side effects
34
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
35
Introducing 1 new food every 4-5 days, increasing serving size gradually, and emphasizing all food groups -- bad idea or good idea?
Good idea
36
mEq Na in NS
154
37
NS -- maintenance, rehydration, or resuscitation?
Resuscitation
38
LR -- maintenance, rehydration, or resuscitation?
Resuscitation
39
1/2 NS -- maintenance, rehydration, or resuscitation?
Maintenance
40
D5W -- maintenance, rehydration, or resuscitation?
Rehydration
41
Most common MIVF
1/2NS + D5W + 20mEq KCl
42
Which is for fluid restricted patients -- Albumin 5% or Albumin 25%?
Albumin 25%
43
Which are used for fluid expansion -- crystalloids or colloids?
Colloids
44
List specific monitoring parameters to assess fluid balance
UOP, HR, BP, CVP, MAP, wt, I/O, BUN/SCr ratio
45
What is the most common cause of hypertonic hyponatremia?
Elevated blood glucose
46
What is the most common cause of pseudohyponatremia?
High proteins/lipids causing increased plasma volume, falsely diluting Na
47
What are the characteristic symptoms of hypervolemic hypotonic hyponatremia?
Edema and weight gain
48
What do you always use to treat hypervolemic hypotonic hyponatremia?
Furosemide (3% saline only if symptomatic)
49
What is a common cause of isovolemic hypotonic hyponatremia?
SIADH
50
What treatment is usually enough for isovolemic hypotonic hyponatremia?
Water restriction with NS. If symptomatic, treat like hypervolemic hypotonic hyponatremia.
51
What needs to be done for patients with hypovolemic hypotonic hyponatremia?
Restore volume deficit. If symptomatic, 3% NaCl first.
52
What general category of causes can lead to hypovolemic hypotonic hyponatremia?
Fluid losses -- blood, GI fluid, loss from skin (burn)
53
What do you treat first in hypovolemic hypernatremia?
Volume status if needed -- use NS. Then restore free water deficit.
54
What synthetic hormone is the treatment for isovolemic hypernatremia?
Vasopressin (synthetic ADH)
55
What treatment is usually enough to correct hypervolemic hypernatremia?
Stop hypertonic fluids or other cause. Diuretic only if needed.
56
What major symptom do we worry about in potassium disorders?
Cardiac arrhythmias or changes in function
57
If a patient has asymptomatic hypokalemia, what should they be given to treat it?
PO potassium -- liquid, powder, tablets, etc.
58
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)
59
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.
60
What is a signature symptom of hyperkalemia?
Peaked T wave
61
What do you use to treat hyperkalemia? (Correct order necessary)
1. CaCl2, IVP2. Insulin with D50W or NaHCO3 or albuterol3. (If needed) Furosemide or hemodialysis or Kayexalate (only if GI intact)
62
What other electrolyte disturbances are magnesium disturbances related to?
Potassium and calcium
63
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
64
What is ratio of mEq of Mg to grams of Mg?
8 mEq = 1 gm
65
What is the normal range for ionized calcium?
4.6 - 5.1 mg/dL
66
What equivalents do we use when replacing calcium?
1 gram CaCl2 = 3 grams Ca gluconate = 270 mg elemental calcium
67
When should calcium gluconate be used?
If only line in is peripheral and in non-acute/non-emergent situations
68
When should calcium chloride be used?
When administering into central line or during a code
69
At what rate should calcium be replaced?
1 gram of calcium product per hour
70
What other disorder is it important to watch out for in calcium disorders?
Magnesium disorders
71
Which types of patients are more prone to hypercalcemia?
Cancer patients -- treatments also more chronic
72
What electrolyte besides calcium is regulated by vitamin D and parathyroid hormone?
Phosphate
73
In asymptomatic hypophosphatemic patients, are there PO products available?
Yes -- administer in divided doses
74
Under which situations should you choose KPhos for IV replacement over NaPhos?
If K <4 mEq/L
75
What is the mMol to mEq equivalent for NaPhos?
1 mMol NaPhos = 1.33 mEq each Na and PO4
76
What is the mMol to mEq equivalent for KPhos?
1 mMol KPhos = 1.47 mEq each K and PO4
77
What rate should you not exceed when replacing phosphate?
NMT 7 mMol/hr
78
What amount of phosphate should you give if a patient's phosphate is <1.6?
1 mMol/kg
79
What amount of phosphate should you give if a patient's phosphate is 1.6 - 2.2?
0.64 mMol/kg
80
What is used to treat hyperphosphatemia?
IV calcium
81
How fast should a patient's sodium deficit be replaced?
1/2 over 1st 8 hours, then next half over next 16 hours
82
How fast should a patient's free water deficit be replaced?
1/2 over 1st day, then next half over next day or two
83
What are the short term routes of enteral nutrition?
Nasogastric, nasoenteric, and jejunal tubes
84
What are the long term routes of enteral nutrition?
Jejunostomy, gastrostomy, PEG
85
What are the two routes of parenteral nutrition?
Peripheral parenteral nutrition and central parenteral nutrition
86
True or false: Most hospitalized patients suffer from acute malnutrition
False -- most hospitalized patients are somewhere between acute and chronic malnutrition
87
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
88
Which type of malnutrition usually develops over months to years?
Marasmus -- protein/calorie malnutrition
89
True or false: Albumin responds quickly to changes in nutrition
False -- Prealbumin is a better indicator of protein and calorie intake
90
Is urine the only way we lose nitrogen?
No. Also sweat, feces, respirations, GI fistula, wound drainage, burns, etc.
91
What is the goal nitrogen balance for a hospitalized patient?
+4 grams (but 0 for maintenance)
92
How many calories does propofol provide?
1.1 kcal/mL
93
What ions should monitor to look for refeeding syndrome?
Mg, Phos, and K
94
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.)
95
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
96
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
97
Under what circumstances should you use a nutrition body weight?
If actual bw is between 130% and 150% of IBW.
98
If a patient's body weight is >150% IBW, what weight should you use?
IBW (permissive underfeeding)
99
What is your goal daily calorie range for a non-stressed, non-depleted patient?
20 - 25 kcal/kg/day
100
What is your goal daily calorie range for a trauma/surgery/stressed patient?
25 - 30 kcal/kg/day
101
What is your goal daily calorie range for a major burn patient?
35 - 40 kcal/kg/day
102
What is your goal daily calorie range for a for an obese patient?
22 - 25 kcal/kg/day times IBW (kg) *permissive underfeeding*
103
What is your goal daily protein range for a non-hospitalized patient?
0.8 - 1 g/kg/day
104
What is your goal daily protein range for a mild to moderately stressed patient (medical floor/repletion)?
1 - 1.5 g/kg/day
105
What is your goal daily protein range for a moderate to severely stressed patient (trauma/surgery/ICU)?
1.5 - 2 g/kg/day
106
What is your goal daily protein range for a burn patient?
2 - 2.5 g/kg/day
107
What is your goal daily protein range for an obese patient?
2 g/kg/day times IBW
108
What component of a TPN should be eliminated if a patient has an infection or sepsis?
Fat
109
What is a goal respiratory quotient (RQ)?
0.85 - 0.95 (>1 indicates overfeeding)
110
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.
111
Dysphagia, dementia, head and neck surgery, esophageal obstruction, and trauma/burn are all indications for what type of nutrition?
Enteral nutrition
112
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?
Parenteral nutrition
113
What administration frequency of enteral nutrition is best tolerated?
Continuous administration
114
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
115
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
116
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.
117
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)
118
What do 3-in-1 TPNs have that 2-in-1 TPNs do not?
Fat
119
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)
120
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
121
What is a typical maximum carbohydrate utilization rate?
4 - 5 mg/kg/minute (up to 7 if trauma/burn)
122
If a patient has an egg allergy, what part of a TPN might they react to?
Egg yolk phospholipid -- fat part
123
What value should daily lipid intake not exceed?
2.5 g/kg/day -- no more than 60% daily caloric intake
124
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)
125
What protein should never be added to TPN?
Albumin (high microbial growth potential)
126
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)
127
BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, P, AST, ALT
1 - 2 times a week
128
BUN, creatinine, glucose, Na, K, Cl, CO2, Mg, Ca, and P should all be measured ____ in an unstable patient.
Daily
129
What can an elevated INR indicate?
Long-term malnutrition
130
What patients are high risk for refeeding syndrome?
Malnourished patients
131
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.
132
Which should come first -- electrolyte correction or nutrition support?
Electrolyte correction
133
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.
134
Trissel's manual is an especially good reference for determining what kind of interaction?
Medication-TPN interactions
135
What is always the first step in writing TPN for a patient?
Determining the correct weight to use
136
For making TPN, what is the standard stock concentration for dextrose? Fat? Protein?
Dextrose -- 70%Fat -- 20% Protein -- 10%
137
How much "TPN space" do electrolytes usually take up?
~150 mL
138
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.
139
What changes to TPN should be considered in patients with short bowel syndrome?
High-carb, low-fat diet with vitamin B12 supplementation prn
140
What changes to TPN should be considered in patients with diabetes?
30% of total kcal given as fat, be sure to monitor blood glucose
141
What changes to TPN should be considered in patients with cardiac disease?
Fluid restriction (check minimal volume), avoid overfeeding
142
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.
143
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)
144
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
145
What is a normal pH range?
7.35 - 7.45
146
What blood gas do metabolic disorders involve?
Bicarbonate (HCO3-)
147
What blood gas do respiratory disorders involve?
CO2
148
What is the henderson-hasselbach equation specified for our physiological bicarbonate buffer?
pH = 6.1 + log (HCO3-/0.03xpCO2)
149
What is a normal pCO2?
40
150
What is a normal HCO3-?
24
151
Are decreased cardiac output and contractility, hyperkalemia, insulin resistance, inhibited anaerobic glycolysis, and coma signs of acidemia or alkalemia?
Acidemia
152
Are decreased coronary and cerebral blood flow, increased angina, stimulation of anaerobic glycolysis, and seizures signs of academia or alkalemia?
Alkalemia
153
What are our three buffers and which is the most prevalent?
Bicarbonate/carbonic acid, phosphate, and protein. Principal buffer = bicarbonate.
154
What are the four systems that regulate acid/base balance?
Buffers, kidneys, lungs, and some liver.
155
What are the two main ways that the kidney regulates acid base balance?
Reabsorbing bicarb and secreting H+
156
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.
157
In bicarbonate reabsorption, what is the net change in bicarbonate and H+?
One filtered HCO3 reabsorbed, no change in H+
158
What ion is hydrogen exchanged for when it is secreted?
Na+
159
What is the end result of carbonic anhydrase inhibitor therapy?
Prevents bicarb reabsorption -- urinate it out. Can cause metabolic acidosis or correct metabolic alkalosis.
160
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
161
What ion does the secreted H+ bind with in titratable acidity?
Phosphate. Lower capacity because phosphate harder to access.
162
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
163
What gas do chemoreceptors detect for ventilatory regulation?
PaCO2
164
Where are the chemoreceptors for ventilatory regulation located?
Carotid artery, aorta, medulla
165
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.
166
What disorder is characterized by low pH, low pCO2, and low HCO3?
Metabolic acidosis
167
In what disorder is it always necessary to calculate an anion gap?
Metabolic acidosis
168
What is a normal anion gap?
3 - 11 mEq/L
169
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.
170
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
171
What does MULEPAKS stand for?
Methanol intoxication, uremia, lactic acidosis, ethylene glycol, paraldehyde ingestion, aspirin (salicylates), ketoacidosis, sepsis
172
Which acid/base disorder is MULEPAKS associated with?
Anion gap metabolic acidosis -- HCO3 losses replaced by something other than Cl
173
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
174
Which acid/base disorders can be caused by salicylate toxicity?
Respiratory alkalosis from stimulation of breathing or metabolic acidosis from accumulation of organic acids.
175
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
176
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
177
What are the risks associated with bicarb therapy?
Overalkanization impairing O2 release, hypernatremia, hyperosmolality, CSF acidosis, electrolyte shifts (hypokalemia, hypocalcemia)
178
Citrate and acetate are metabolized to...
bicarb.
