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Hospital Medicine > Lecture 5: Nutrition, Fluids, and Electrolyte Therapy > Flashcards

Lecture 5: Nutrition, Fluids, and Electrolyte Therapy Flashcards

1
Q

What should we not base our nutrition assessment solely on?

A

Weight

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2
Q

What goes into a nutrition assessment?

A
  • BMI
  • Unintentional weight change
  • Changes in PO intake
  • Severity of illness
  • IBW
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3
Q

What is the criteria to diagnose malnutrition?

ASPEN Criteria

A
  • Insufficient caloric intake (energy intake)
  • Wt loss
  • Loss of muscle mass
  • Loss of subcutaneous fat (Body Fat)
  • Localized or generalized fluid accumulation masking wt loss (Fluid accumulation)
  • Diminished functional status (Grip strength)

At least 2

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4
Q

What can long-term overfeeding result in?

A
  • Hepatic steatosis
  • Ureagenesis
  • Immunosuppression (esp w/ liquids)
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5
Q

What equations are used to determine nutrition requirements?

A
  • Harris Benedict
  • Mifflin-St Jeor
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6
Q

Quick rule of thumb for estimating caloric needs and protein needs based on IBW

A
  • Cal: 25-30/kg/d
  • Protein: 1.2g/kg/d

Burn pts may require more protein, up to 2g/kg

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7
Q

What is the preferred method of feeding?

A

PO

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8
Q

When do we start enteral or parenteral feeding?

A

7-10d of no oral intake and if its going to be in for at least 5 days.

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9
Q

How does enteral nutrition work?

A

Direct entry into GI system at stomach or small intestine

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10
Q

CIs to enteral nutrition

A
  • GI hemorrhage
  • Peritonitis
  • Severe ileus
  • Bowel obstruction distal to access site
  • Intestinal ischemia
  • Malabsorptive disorders with high volume diarrhea
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11
Q

How do we start enteral nutrition?

A
  • Low rate, tapering up after 24-48h
  • Monitoring for N/V/D/C/abd pain
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12
Q

How are macronutrients presented in parenteral nutrition?

A
  • Carbs: Dextrose (50%-60%)
  • Protein: Crystalline amino acids (15%-25%)
  • Lipids: Polyunsaturated long-chain triglycerides like soybean oil (20%-25%)

parenteral has the highest risk.

alphabetically in order of highest to lowest proportion CLP

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13
Q

What is refeeding syndrome?

A

Electrolyte abnormalities that occur during reinstitution of carbs to a starved patient

Phosphate, Mg, and K depletion may occur

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14
Q

What is the typical breakdown of macronutrients in parenteral nutrition?

A
  • Carbs: 50-60%
  • Proteins: 15-25%
  • Lipids: 20-25%
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15
Q

What kind of access does parenteral nutrition require?

A

Central venous access due to its hyperosmolar nature.

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16
Q

How often do we recheck labs in pts on TPN?

A
  • Glucose: every few hrs
  • BMP: Q8-12h
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17
Q

What is the general breakdown of fluid in the body?

A
  • ICF: 2/3
  • ECF: 1/3

Within ECF: 75% is interstitial, 25% is intravascular.

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18
Q

How do you approximate TBW (total body water)?

A

60% of body weight in males

50% for a female

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19
Q

Example distribution of TBW

A
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20
Q

Normal minimal obligatory water intake

A

1600 mL/d

21
Q

Where is most fluid loss through?

A

Urine

22
Q

What requires increased water intake? (7 conditions)

A
  • Fever
  • Sweating
  • Burns
  • Tachypnea
  • Surgical drains
  • Polyuria
  • Ongoing GI losses
  • 100-150 mL/d for every degree of body temp above 37C
23
Q

4 main ways we lose water from our body

A
  1. Urine: 500 mL
  2. Skin: 500 mL
  3. Respiratory tract: 400 mL
  4. Stool: 200 mL
24
Q

How do we estimate water requirements?

A
  • 35 mL/kg/d = 35x70 = 2450 mL/d
25
Q

Na requirements daily

A
  • 1-3 meqs/kg/d
  • 0.45% saline contains 77 meq NaCl/L
26
Q

K requirements daily

A
  • 1 meq/kg/d (50-100 daily)
  • Osmotically as active as sodium, so adding 40 mEq to 0.45% saline creates 3/4 isotonic saline.
  • Commonly added as 20meq/L

Oral is most preferred

27
Q

Why do we only infuse potassium at 10 meq/hr?

A

Rapid administration causes a burning sensation

28
Q

How do we estimate hypokalemia?

A

1 mmol/L below normal => total deficit of 200-400 mmol

29
Q

How do we calcuate the potassium deficit and correct it?

A
  • Deficit in mmol = (normal K lower limit - measured K) x BW in kg x 0.4
  • 10 mEq of KCl raises serum by abt 0.13 mEq for normal kidneys.

1 mmol = 1 mEq

30
Q

Average dosing to tx hypokalemia

A

40 to 100 mmol/d

31
Q

What are the 3 primary mechanisms we utilize to treat hyperkalemia?

A
  1. Membrane stabilizer: calcium gluconate
  2. Redestribution: insulin + B2 agonist (albuterol)
  3. Removal: Kayexalate or hemodialysis
32
Q

Why do we want to make sure glucose is normal and how?

A
  • If glucose is low, protein and body fat will get consumed. (Protein-sparing effect)
  • We need about 100-200g/d
33
Q

What are colloid solutions? (2)

A
  • Large molecules that DO NOT PASS through membranes
  • When infused, they remain in the intravascular compartment and expand intravascular volume by drawing fluid from extravascular spaces.

Albumin is the most common?

34
Q

What are crystalloids? (3)

A
  • Small molecules that flow between cell membranes
  • Increase fluid volume in both intra and extravascular spaces.
  • Subdivided into isotonic/hypotonic/hypertonic
35
Q

What is the danger with infusing sodium too fast?

A

Central pontine myelinolysis can occur

36
Q

What are the isotonic crystalloids? (4)

A
  • NS (0.9%)
  • LR’s
  • D5W (5% dextrose in water)
  • Ringer’s acetate solution
37
Q

What is in NS? (2)

A
  • 154 meq of Na
  • 154 meq of Cl
38
Q

What is in LR/hartmann solution? (5)

A
  • 130 meq of Na+
  • 4 meq of K+
  • 3 meq of Ca+
  • 109 meq of Cl-
  • 28 meq of HCO3-

Most physiologically adaptable due to similarity to body composition.

39
Q

When is LR typically used? (5)

A
  • Burn injuries
  • GI tract losses
  • Fistula drainage
  • Fluid losses due to burn/trauma
  • Acute blood loss or hypovolemia d/t 3rd spacing
40
Q

What is the concern with using LR? (3)

A
  • LR cannot be used in someone with liver dz, or it will make bicarb
  • Caution in severe renal impairment d/t K
  • Do not give in someone with pH > 7.5
41
Q

What happens when D5W is metabolized?

A

Hypotonia, causing fluid shift inward to cells.

42
Q

How many calories is D5W?

A

170 cal

43
Q

What are the primary options in treating hypovolemia via fluids? (2)

A

Volume expansion: NS or LR

We want intravascular volume expansion

44
Q

How do we treat dehydration/hyperosmolarity? (Not hypovolemia)

A

Free water replacement, aka D5W or 0.45% saline

45
Q

In post-op pts, how do we manage fluids?

A

NS is preferred because narcotics can stimulate SIADH.

46
Q

Why does NS cause volume expansion? (3)

A
  • Free water gets distributed
  • Na stays outside of cells
  • NS essentially has no free water.
47
Q

What is the 4 2 1 rule of peds for maintenance fluids?

A
  • First 10kg = 4 cc/kg/hr
  • Second 10kg = 2 cc/kg/hr
  • 1cc/kg/hr after

Maintenance fluids

48
Q

What is the IVF rate for an adult?

A

wt (kg) + 40 per hour.

Hospital Medicine (8 decks)

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