GI Case - Pediatric Trauma and TPN

Question 1

Why should we even evaluate nutritinoal status of trauma patients?

Answer 1

malnutrition delays wound healing - general malnutrition and specific deficiencies

Question 2

How can rapidly replenishing a malnourished patient cause life threatening complications?

Answer 2

refeeding syndrome - their body is used to the malnutrition, so when they get the rush of glucose, their body can’t handle it and htey get hyperglycemia, glucosuria, dehydration, hyperosmolar coma and hypokalemia resulting in heart arrhythmias and hypophosphatemia

Question 3

Why did Tyler have glucose in his urine?

Answer 3

his body’s under severe stress, so cortisol and epinephrine are blocking insulin’s effects and he has hyperglycemia

glucagon is also ramping up glycogenolysis

Question 4

How could nutrition be delivered? How was it given to Tyler?

Answer 4

enteral - through the GI either by mouth or tube
parenteral - via central line (TPN) or peripheral IV (PPN)
combo of the two

Question 5

What are the complications of parenteral nutrition?

Answer 5

1. mechanical damage to the veins
2. infections passing through the catheters or in the lipid solutions
3. metabolic disturbances - the regulatory mechanisms get thrown off somewhat

Question 6

What are the three components of human energy expenditure?

Answer 6

basal energy expenditure (BEE)
Thermic effect of food
Energy expenditure of physical activity

Question 7

For a sedentary individual, what perentage of the total energy expenditure is made of the BEE?

Answer 7

about 60%

Question 8

What is the thermic effect of food exactly?

Answer 8

the energy expended in digestion and absorption of food

varies depending on diet, but accounts for 5-10% of total energy expenditure

Question 9

How can you determine someone’s total energy expenditure?

Answer 9

Find the BEE with the harris-benedict equation and then use multipliers to find the TEE depending on patient’s state.

normal TEE = 1.2-2xBEE
fever: BEE x 1.1 per degree over
mild stress: Bee x 1.2
severe stress: BEE x 1.6

Question 10

How much protein is required during trauma recovery compared to normal?

Answer 10

twice as much

Question 11

What are some other nutritional substances that should be increased

Answer 11

omega3 and omega6 fatty acids - the eicosanoids

also any specific micronutrients that may be depleted, like copper depletion in severe burns

Question 12

To find the nitrogen balance, what do you substract from nitrogen intake (which is grams of protein x .16)?

Answer 12

24 hr urinary urea nitrogen

plus a value to take other factors into account (in kids, 3 g for parenteral feeding, 4 g for enteral feeding,)

Question 13

Why are you calculating nitrogen balance in a trauma patient?

Answer 13

you want it to be positive so they have nitrogen for biosynthesis needed for healing

note that a slightly negative nitrogen balance is tolerable in a patient recovering from major trauma, but only for the short term

Question 14

During the hypercatabolistic state after trauma, what fuel is mobilized in the “ebb phase” and what is mobilized in the “flow phase”

Answer 14

ebb with fatty acids from adipose mediated by catecholamines and glucagon

flow with amino acids from proteolysis mediated by cortisol and glucagon

Question 15

A 24 year old female is brought to the emergency room 20 minutes after sustaining multiple serious fractures in a car accident. The patient’s blood glucose concentration is 180 mg/dL (normal 70-100 mg/dL).What provides the carbon for the patient’s elevated blood glucose concentration?

Answer 15

hepatic glycogenolysis

Question 16

A 42 year old male is in the ICU following surgery to set a compound fracture in his leg. The patient is eating while he recovers. One day after surgery, four hours after his last meal, his blood glucose concentration is 165 mg/dL. What explains the patient’s elevated blood glucose concentration?

Answer 16

Muscle proteolysis