ICM - Nutrition Flashcards
What was the EPaNIC Trial and what did it show
Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients
RCT n-4640 with insufficient enteral
Either, additional parenteral in 48 hours or after 7 days
No difference in anything
BUT excluded malnourished patients and was low mortality risk patients
What was the TICACOS study and what did it show
High risk ICU patients - showed the additional parenteral nutrition supplemented to enteral reduced mortality in hospital and at 60 days
What was the CALORIES trial and what did it show
ICNARC RCT
Route of early nutritional support in critically ill patients
No difference in 30 day mortality or infections between enteral and parenteral
60% never met their calorie target
EN - higher risk of vomiting and hypo’s
PN is neither mroe beneficial nor more harmful
In general, is early feeding supported?
Yes
Factors that may make enteral feeding fail
MOF
Vasoactive drugs
Sedation and opioids
Ways of measuring calorie needs
Indirect calorimetry (gold standard)
Harris-Benedict
Schofield eqns
Specific calorie adjustments
Fever: 10% more for every 1C above 37 (limit 40)
Sepsis: 9% more
Surgery/trauam: 6%
Burns: Increase by 100% for any burn over 30%
How would you start enteral nutrition
Commence at 50% of estimated target energy/protein needs
Increase over 24-48 hours
Continue full electrolye, fluid and vitamin needs from the start
Suggested calorie intake
25-35 KCal/kg
Some books say under 65 - 20kcal
over 65 25
Macronutrient requirements
Protein 0.8-1.5g/Kg
Lipid: 40% of total calories
Carbs 3-4g/kg
Carbs should be 60% of the non protein calories
Examples of micronutrients
Zinc
Copper
Selenium
Thiamine B1
Riboflavin B2
Vit D
Fluid/Electrolyte needs
Water 30ml/kg Sodium 1mmol/kg K 0.7 to 1mmol/Kg Calcium 0.1 Mg 0.1 Choride 1-2 Phosphate 0.4
Feeding points:
Haemodynamically stable patients unlikely to eat for 3 days and functioning GI tract
Enteral within 24 hours
If not at target enteral feed
Add parenteral
Should we “rest” patients for feeding overnight
No
Why should patients on enteral feed be sat up at 30 degrees
Reduced aspiration risk
Reduced VAP risk
Can peripheral access be used for feeding
Yes as a PICC
Short peripherals/midlines can be used for a short time and if the osmolarity is <850
Order of infection by CVC line site
Subclavian (lowest)
IJ
Fem
With the jugular vein, does a high or low approach increase risk of contamination and infection
High
Features of refeeding syndrome
Low PO3 –> muscle weakness
Low Mg - Myocardial dusfunction, neuro issues
Low K - Arrhythmias, arrest
High glucose - osmotic diuresis dehydration, metabolic ketoacidosis
Low thiamine -> Wernickes’s, Korsakoffs
Risk for Refeeding
One of:
BMI less than 16
Weight loss more than 15% in 3-6 months
Little no intake for 10 days
Low K, PO, Mg prior to feeding
Two of: BMI less than 18.5 Weight loss more than 15% in 3-6 months No/little intake for 5 days History of alcohol/drugs (insulin/chemo/antacids/diuretics)
Feeding strategy for refeeding
Dietitican
Slow feed (max 10kcal/kg/day)
Slowly increase over 4-7 days
Monitor fluid and electrolytes
Supplement Thiamine and Vit B
K, Mg and PO
Is there an increased risk of PE in upper limb DVT
No
ICU risk factors for VTE
Sepsis Vasopressors Resp/Cardiac failure Sedation MV CVC ESRF
CXR positioning for CVC
2cm from carina on CXR
Tip not pointing at wall of SVC
Formula methods for CVC
Pere’s formula
Right IJ - Height/10 Left IJ (Height/10)+4
Features of short bowel syndrome
Abdo pain Diarroheoa, steatoorrhoea Fluid/micronutrient depletion Weight loss Fatigue
What is a high output stoma
More than 1500ml/day
How to manage a high output stoma
Exclude organic causes (infection/steroid withdrawel/obstruction/sepsis)
Restrict oral intake to 500ml/day
Loperamide 4mg qds and increase to 8mg
Codeine 15-60 qds
Omeprazole
Trial Abx for bacterial overgrowth
Add St Marks solution - glucose electrolyte.
NBM 24-48 hours
Octreotide 200mcg tds for 3-4 days
