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NUTR 442 > Lecture 20-21: critical care > Flashcards

Lecture 20-21: critical care Flashcards

1
Q

what is critical care?

A

complex med management of seriously ill/injured person

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2
Q

lvl of illness/injury involves:

A

acute impairment of >/= one vital organ system, high probability of life threatening deterioration of pt condition, support of organ systems to prevent failure of body systems

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3
Q

prevent failure of which body systems?

A

CNS, circ, renal, hepatic, metabolic, resp, shock

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4
Q

types of ICUs in Canada

A

general med/surgical, specialized, pediatric/neonatl

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5
Q

____ model of care for ICU most common because:

A

closed; smaller and have one intensivist there that refers out

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6
Q

Canadian ICU have ___% mortality rate and ___% need invasive mechanical ventilation

A

9; 33

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7
Q

what is invansive mech ventilation?

A

endotracheal intubation

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8
Q

what is non-invasive mech ventilation?

A

BiPAP

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9
Q

a clinical (inflammatory) response to nonspecific insult of either infectious or noninfectious origin

A

SIRS

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10
Q

inflammatory cascade is complex process involving ___ and ___ responses, complement, and ___ cascades

A

humoural; cellular; cytokine

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11
Q

possible causes of SIRS?

A

ischemia, inflammation, trauma, infection, multiple insults

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12
Q

SIRS criteria defined as 2+ of following:

A

temp >38 or <36, elevated HR, resp rate high or PaCO3 low, WBC high or low

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13
Q

sepsis is response to ___

A

infection

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14
Q

severe sepsis is systemic response to infection + ________

A

organ dysfunction ,hypoperfusion, hypotension

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15
Q

septic shock is persistent hypotension and perfusion abnormalities despite ______

A

adequate fluid resuscitation

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16
Q

state of physio derangements in which organ fxn not capable maintainng homeostasis

A

multiple organ dysfunction syndrome (MODS)

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17
Q

metabolic response to stress is driven by:

A

macrophage activation, counter regulatory hormones, more pro inflammatory cytokines

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18
Q

metabolic response to stress involves liver doing _____

A

gluconeogenesis

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19
Q

shock phase characterized by:

A

conservation of energy and blood volume

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20
Q

shock phase needs this kind of resuscitation:

A

aggressive fluid resuscitation, vasopressor therapy, mechanical ventilation, early antibiotic therapy

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21
Q

catabolic phase is characterized by:

A

^ immune/inflamm response, catabolic response

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22
Q

goal in catabolic phase?

A

mobilization of energy stores

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23
Q

what happens in ICU in catabolic phase?

A

immobilization/bedridden, sedation, neuromusc blockade agents, corticosteroids, hyperglycemia and anabolic resistance

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24
Q

recovery phase often coincides with _____

A

liberation from mechanical ventilation and discharge from ICU

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25
Q

shock phase also called:

A

ebb phase

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26
Q

catabolic phase also called:

A

flow phase

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27
Q

flow phase consists of ___ phase and __ phase

A

acute; post-acute

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28
Q

acute phase composed of these two periods:

A

early period and late period

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29
Q

early period defined by:

A

metabolic instability and severe increase in catabolism

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30
Q

late period defined by:

A

significant muscle wasting and stabilization of metabolic disturbances

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31
Q

low muscularity is associated with:

A

^ mortality, v ventilator free days, ^ ICU and hospital LOS

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32
Q

head to toe assessment of critically ill pt involves:

A

neuro, resp, cardio, GI, genitourinary, infectious diseases, physical assessment

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33
Q

propofol is a ___ suspended in ___% lipid emulsion

A

sedative; 10

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34
Q

units to use for propofol:

A

kcal/mL

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35
Q

how to calculate mL/h for propofol?

A

dose (mcg/kg/min) x actual body wt (kg) x 60 min/g / 10 000 mcg/mL

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36
Q

what is APACHE II?

A

acute physiology and chronic health evaluation II score

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37
Q

APACHE 2 was developed to estimate ___ and is commonly reported in ____

A

ICU mortality; research

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38
Q

APACHE II is based on variables in first ___h of ICU admission, such as:

A

24; age, temp, MAP, pH, HR, RR, Na, K, Creat, Hct, WBC, etc

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39
Q

in APACHE II there are scores ranging from __ to ___

A

0; 77 (> = more severe)

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40
Q

what is SOFA?

A

sequential organ failure assessment score

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41
Q

what SOFA used for?

A

determine extent of organ fxn/rate of failure

42
Q

SOFA is based on these 6 organ dysfunction indicators:

A

resp, neuro, cardiac, liver, coagulation/liver, kidney

43
Q

score range of SOFA?

A

0-24 (>=worse)

44
Q

what is NUTRIC score?

A

nutrition risk in critically ill score

45
Q

NUTRIC score used to measure:

A

risk of critically ill pt whose neg outcomes could be modified thru aggressive nutr therapy

46
Q

6 variables of NUTRIC?

A

age, APACHE II, SOFA, # comorbidities, days from hospital to ICU admission, IL6

47
Q

what is diff about modified NUTRIC?

A

exclude measure of IL6 cuz not commonly measured in pt and difficult to obtain

48
Q

NUTRIC scored in range _____ and modified range ____

A

0-10; 0-9

49
Q

why wt not accurate in critically ill?

A

swelling, edema (fluid resusc)

50
Q

general guiding principles for feeding:

A

MNT should be considered for all pt with ICU LOS >48h, every critically ill pt in ICU >48h should be considered at risk for malnutrition

51
Q

instead of using rate, we are moving toward __ based feeding models

A

volume

52
Q

energy administration of around defined target, referred to as ___ diet

A

isocaloric

53
Q

energy administration below 70% of target considered to be:

A

hypocaloric (underfeeding)

54
Q

minimal administration of nutr having beneficial effects referred to as:

A

trophic feeding

55
Q

trophic feeding typically ____mL

A

5-10

56
Q

some of the beneficial effects of trophic feed?

A

preserve intestinal epithelium, stim secretion brush border enzymes, enhance immune fxn, preserve epithelial tight cell junctions, prevent bacterial translocation

57
Q

overfeeding is energy admin of ____% above target

A

110

58
Q

low protein diet is pro admin below ___g/kcal/d

A

0.5

59
Q

nrg recommendations (ASPEN) in non obese:

A

25-30kcal/kg or predictive equation (in absence of IC)

60
Q

nrg recommendations ESPEN in non obese:

A

use VO2 from pulmonary arterial catheter or VCO2 derived from ventilator, or 20-25kcal/kg

61
Q

nrg recommendations obese pt (ASPEN)

A

goal of EN/PN not exceed 65-70% target energy rqts as measured by IC

62
Q

why need to underfeed for obese?

A

achieve some degree of wt loss via hypocaloric feeding may ^ insulin sensitivity, facilitate nursing care, reduce risk of comorbidities

63
Q

in absence of IC, BMI 30-50 should have ____ kcal/d actual wt, and BMI >50 should have ____ kcal/kg ideal body wt

A

11-14; 22-25

64
Q

what is ideal body weight in Canada?

A

BMI 25

65
Q

ESPEN guidelines for nrg in obese pt:

A

use adjusted body wt (ideal wt + 1/3 actual BW)

66
Q

measurements in IC need to be taken in:

A

steady state conditions

67
Q

IC measures ___ in the body, specifically:

A

oxidation; O2 consumption, CO2 production, RQ (substrate utilization)

68
Q

lipogenesis is indicative of ____

A

overfeeding

69
Q

RQ < __ suggests underfeeding; RQ > ___ suggests overfeeding, lipogenesis, ^ resp demand

A

0.82; 1.0

70
Q

protein is most important nutrient for:

A

wound healing, immune fxn, maintain LBM

71
Q

protein recommended to be ___g/kg actual BW in non-obese

A

1.2-2

72
Q

pro recommendations for obese pt (ASPEN):

A

BMI 30-40: 2 g/kg ideal body wt, BMI >40: up to 2.5 g/kg

73
Q

protein recommendations (ASPEN) should be adjusted using ____ studies with goal of achieving _____ if possible

A

nitrogen balance; nitrogen equilibrium

74
Q

ESPEN guidelines for obese pt:

A

delivery guided by urinary N losses or LBM determination

75
Q

ESPEN obese pro requirements determined to be ___ g/kg adjusted BW if urinary N losses/Lbm determination not available

A

1.3

76
Q

UUN ____ in sickest of pt because of ____ due to inflammation/disease

A

increases; protein catabolism

77
Q

what is N balance equation?

A

N balance = (pro intake in g / 6.25) - (UUN excretion in g + 4 g)

78
Q

abnormal or unstable BP, esp. associated with hypotension:

A

hemodynamic instability

79
Q

broad definition of hemodynamic instability:

A

global/regional perfusion not adequate to support normal organ fxn

80
Q

____ are meds given for hemodynamic support

A

inotropes and vasopressors

81
Q

what do inotropes do?

A

alter (increase) force of energy of musc contractions (heart)

82
Q

what do vasopressors do?

A

cause constriction of blood vessels

83
Q

risk of __ if feeding hemodynamically unstable pt

A

bowel ischemia–>necrosis

84
Q

EN may be provided with caution to pt on chronic, low doses of ___

A

vasopressors

85
Q

EN should be withheld in pt who are:

A

hypotensive (MAP<50mmHg), catecholamine agents initiated, escalating doses of pressors required

86
Q

signs of intolerance that need to be monitored:

A

ab distention, ^ NG output/GRVs, v passage of stool/gas, hypoactive bowel sounds

87
Q

other circumstances warranting delay in initiate EN?

A

shock uncontrolled, uncontrolled hypoxemia/hypercapnia/acidosis, active upper GI bleeds, overt bowel ischemia, high output intestinal fistula, ab compartment syndrome

88
Q

what is early enteral nutrition defined as in ICU?

A

initiation of EN within 24-48 hrs of ICU admission

89
Q

ASPEN recommend early EN initiated in critically ill pt if unable maintain ____

A

volitional intake

90
Q

benefits of EN?

A

maintain gut integrity, modulate stress/systemic immune response, attenuate disease severity, + outcomes like v infection/LOS/rates of organ fail

91
Q

obese pt have lower ___ but higher ___ guidelines

A

kcal; protein

92
Q

exclusive PN should be withheld over first __ days after admission for pt with low nutr risk (ASPEN)

A

7

93
Q

what is low nutr risk?

A

NUTRIC <5

94
Q

(ASPEN) PN should be initiated ASAP if pt deemed at high nutrition risk of NUTRIC score > ___ or severely ___

A

5; malnourished

95
Q

ESPEN PN guidelines:

A

PN should be implemented within 3-7 days if can’t oral or EN

96
Q

supplemental PN should be considered when (ASPEN):

A

unable meet >60% nrg and pro rqts via EN after 7-10 days

97
Q

supplemental PN not started until all strategies to maximize EN tolerance have been attempted (ESPEN), should be weighed on _____ basis

A

case by case

98
Q

what is renal replacement therapy?

A

dialysis for managing renal failure

99
Q

what is continuous renal replacement therapy (CRRT)?

A

used in ICU treat critically ill pt with acute kidney injury or renal failure

100
Q

if acute kidney injury need energy ___kcal/kg, pro ___g/kg actual body wt, normal formulation

A

25-30; 1.2-2

101
Q

if on CRRT, need ____ kcal/kg nrg, pro up to max of ___g/kg

A

25-30; 2.5

102
Q

reasons for high protein when on CRRT?

A

CRRT associated with significant aa loss (10-15 g/d) and LBM losses in pt with AKI are 1.4-1.8 g/kg/d

NUTR 442 (34 decks)

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