Final Details Part I Flashcards
Standard EN administration rate
Initiate at 50ml/hr and increase by 15ml/hr q4h until goal rate i reached, Meet needs within 24-48hrs with goal of providing 80% of needs in 48-72 hours
Risk of re-feeding administration rate (General)
Initiate between 25-50% of needs or 15 kcal/kg/day and ensure that less than 100 g of CHO
–> Then meet needs within 4-7 days
EN risk of refeeding administration rate
10-25 ml/hr and increase q12hr over 4-7 days to reach target
Max fat infusion rate?
- 5 g/kg/day or 0.11g/kg/hour
- -> 1 g/kg/day if in ICU, HyperTG or pancreatitis
ICU En administration rate and initiation?
10-40 ml/kg/day and increased 10-20ml/hr q8-12hrs and reach goal in 24-48 hours.
–> Always no more than 3 mg/kg/CHO and 1 g/kg/day of fat
Best practice PN protocol on day 1?
Less than 50% of needs, and between 150-200 g of CHO or 100 g of CHO if poor glycemic control or low BMI
Energy when BMI >30?
IBW
Energy when IBW <90%?
Use IBW or ABW depending on range
Energy when ABW >125%?
Use IBW
Fluids when IBW >125%?
Use Adj. BW
Fluids when IBW <90%?
Use IBW
Protein when IBW >125%?
Use IBW
In high conjugated bilirubin, albumin is high/low/normal
Likely normal. issue with perfusion or liver function
Nitrogen balance equation?
=Input-(Output+4)
Input = total protein/6.24
Output = 24hr urea/35.7
Pale skin? pale tongue? Papillary atrophy?
- BICF
- RIBN
- FIRNB12
Severe manifestation of vitamin A ?
Bigots spots or Xerophthalmia
NS indications (I-AI-PISS)
- Inadequate oral intake unexpected to resolve in 7-14 days
- Altered GI Functions
- Impaired nutrient utilization
- PEM
- Increased nutrient needs unable to meet orally
- Significant involuntary weight-loss
- Swallowing or chewing difficulty
EN indications (FGT+UUHD)
Function GI tract AND:
- Unable or Unexpected to meet oral needs in 7-14 days
- Hemodynamically unstable
EN Contraindications (MISS-A-SHIP)
- Mechanical Obstruction
- Intractable N/V
- Severe GI bleed
- SBS
- Aggressive care not warranted
- Short-supply period
- High output GI fistula
- Inability to gain access to GI tract (PMSG)
- Paralytic Ileus
When is there inability to gain access to the GI tract?(PM)
- Paralytic Ileus
- Mesenteric Ischemia
- Short bowel obstruction
- GI High output fistula
Contraindications to PEG? (VAG-CIN)?
- Varice
- Ascites
- Gastroparesis
- Coagulopathy
- Inflammation of GI/Abdo
- Neoplasia
Diarrhea algorithm? (DM-SC-SFA)
- Distended/Painful abdo
- Medical or Sx reason
- Stool impaction
- Cathartic agents (sorbitol)
- C.Diff
- Fibre
- Anti-diarrheal agent
Cathartic agents which may cause diarrhea?
-Docusate, oral electrolyte rehydration solutions, lactulose
GRV Monitoring algorithm? (ECEM)
- Evaluate all gastric fed patients
- Confirm feeding tube in place prior to starting fees
- Elevate HOB 30-45 degrees
- Monitor q4h
GRV <250 ml?
- Re-instill aspirate
- Progress feeds
- -> ICU monitor q4h, if non-ICU now monitor q8h
GRV 250-500 ml no intolerance?
- Re-instill 250 ml aspirate
- Keep feeds at same rate
GRV 250-500 ml with tolerance?
- Re-instill 250 ml aspirate
- Inform MD, consider post-pyloric or pro-kinetic agents
GV >500ml?
- Discard aspirate
- Inform MD and RD
- Consider continuous feeds, post-pyloric
Diarrhea definition?
750 ml per day or >3 stools per day for 3 days
Examples of pro-kinetic agents?
- Erythromycin
- Neomycin
- Metoclopramide
Hypercapnia?
Low phosphate formula
PN Indications??
- Malnourished at baseline
- EN Contraindication OR has failed EN which is not expected to resolve in 7-14 days
- HD Stable
PPN Contraindications? (SSL-FPR)
- Significant malnutrition
- Severe stress
- Large fluid/electrolyte needs
- Fluid restriction
- PN > 2 week
- Renal or Liver Dysfunction
TG limit with PN? Normal?
- PN: <4.52
- Normal: 0.4-2.29
Glucose limit with PN? Normal?
- PN: <10 mmol/L
- Normal: 3.3-6.4mmol/L
How can we avoid rebound hyperglycemia in d/c PN?
- Taper PN by increasing EN or infuse 10% dextrose
- D/c PN completely when we are confident that glucose can be maintained with EN or oral feeds
What is azotemia?
Increased levels of nitrogen in blood, complication in PN
- -> High BUN, high creat, high protein, dehydration
- -> Associated with decreased renal function
Target population in critical care?
- Adults >18
- LOS greater than 2-3 days
- At least one organ failing
CI Obese energy BMI 30-50
22-25 kcal/kg ABW
CI Obese energy BMI >50
11-14 kcal/kg IBW
CI Obese protein BMI 30-40
2.0 g/kg/day of Adj.BW or IBW
CI Obese protein BMI >40
2.5 g/kg/day
Trophic feeds?`
10-20kcal/kg or 500 kcal per day
What is early EN needed for?
Not so much for energy, but for modulation of the immune response
–> When NRS >/5
If diarrhea is suspected _____ fibre should be used
mixed
In refeeding, feeding stimulates ____ which promotes ____, and therefore feeds should be started from 25-50%
- insulin
- anabolism
What is another way of calculating obese energy needs in the ICU?
Take 65-70% of requirements as per IC
When does propofol get d/c?
We CANNOT d/c as it’s what is keeping them sedated
We have to consider kcals and fluids when we do our prescription, and potentially withold IVFE
Beneprotein administration?
- 6 g of protein each
- Mix with 60-120ml of H2O and flush with 30-60 ml of H20
When to initate PN in critical care?
In a previously WELL-NOURISHED patient, initiate when (1) failure of EN to meet 60% of needs in 7-10 days (2) When EN contraindicated and NRS >3 Initiate PN right away
