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Critical Care > Nutrition > Flashcards

Nutrition Flashcards

1
Q

What is nutrition?

A

The intake and metabolism of nutrients to sustain life and maintain bodily functions. Often the term used in surgery encompasses the entire practice of assessing and maintain preoperative nutritional support in surgical patients

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2
Q

What is malnutrition?

A

The state of nutritional deficit due to reduced intake, malabsorption, catabolism or inability to metabolise specific nutrients that result inadverse effects on tissue function and clinical outcome

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3
Q

How to calculate total energy expenditure?

A

Method 1: Harris Benedict equation x stress factor x activity factor

Method 2: assuming metabolic stress from sepsis/trauma/surgery, 35kcal/kg/day

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4
Q

What are clinical signs of malnutrition?

A
  • Hair: loss, easily pluckable
  • Face: nasolabial seborrhoea, angular fissures of lips
  • Muscle bulk loss- temporalis, thenar eminence, lumbricals
  • Skin: increase fold, hyperkeratosis, non healing ulcers
  • Limbs: dependant edema
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5
Q

How do you assess nutritional status?

A
  • Clinically
  • Anthropometrically
  • Biochemically
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6
Q

What are the anthropometric assessments that can be made?

A
  • Tricep skin fold for fat content
  • Mid-arm circumference for muscle content
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7
Q

What are the biochemical assessments that can be made?

A
  • Albumin
  • Transferrin
  • Total lymphocyte count
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8
Q

What is the half life of albumin?

A

21 days

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9
Q

What is the half life of transferrin?

A

8 days

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10
Q

What would you like to ask on history taking for nutritional assessment?

A
  • Current clinical condition
  • Usual weight, weight loss
  • Type of diet tolerated
  • Symptoms related to possible cause
    • intake: dysphagia, vomiting, dentures, depression
    • output: diarrhea
  • Drug history
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11
Q

What would you like to ask on history taking for nutritional assessment?

A
  • Current clinical condition
  • Usual weight, weight loss
  • Type of diet tolerated
  • Symptoms related to possible cause
    • intake: dysphagia, vomiting, dentures, depression
    • output: diarrhea
  • Drug history
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12
Q

What would you assess on physical exam?

A
  • BMI
  • Hydration status
  • Evidence of etiology:
    • cervical LN, pallor, jaundice, organomegaly
    • wound/ fistula/ ileostomy
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13
Q

What are the advantages of enteral feeding?

A
  • Preserves gut mucosa preventing bacterial translocation
  • Encourages adequate immunological barrier across gut mucosa (IgA)
  • Fewer infection complications from PN
  • Attenuates physiological stress
  • lower cost
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14
Q

What are the advantages of parenteral feeding?

A
  • Easier to provide full energy requirements
  • Does not depend on gut integrity and function
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15
Q

What are disadvantages of enteral feeding?

A
  • Difficult to meet requirements if poor absorption/ileus
  • Increased risk of ventilator-associated pneumonia and sinusitis
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16
Q

Steps to nutritional management

A
  1. Determine route of nutritional supplement (intact swallowing mechanism? any GI non-function/perforation?)
  2. Determine fluid requirement
  3. Determine energy requirement (BEE + protein, fat, carbohydrate)
  4. Determine electrolytes + vitamins requirement
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17
Q

How to calculate fluid requirement?

A
  • Method 1:
    • 1st 10kg: 100ml/kg/day
    • 2nd 10kg: 50ml/kg/day
    • subsequent 10kg: 20ml/kg/day
  • Method 2:
    • 30-35 ml/kg/day
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18
Q

How to calculated basal energy expenditure?

A
  • Method 1: Harris Benedict equation (sex, age, weight, height)
  • Method 2: 30-35kcal/kg/day
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19
Q

What are the caloric equivalents of the individual energy substrates?

A
  • Carbohydrates: 4 kcal per gram
  • Fat: 9 kcal per gram
  • Protein: 4 kcal per gram
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20
Q

Steps to calculate total energy expenditure

A
  1. Basal energy expenditure
  2. Activity and stress factor
  3. Previous deficit to replace
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21
Q

How much protein/ nitrogen is needed?

A
  • Method 1: 1.2 g/kg/day in patient with acute illness
  • Method 2:
    • 250-300 Kcal : 1 gram N for normal body maintenance
    • 100-150 Kcal: 1 gram N in stress condition promotes anabolism
    • Estimated energy needed / 150kcal protein x 6.25 gram protein= grams of protein /day
    • If use 10% amino acid solution (100g/L)
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22
Q

How to calculate fat emulsion requirement?

A
  • Assume 40% of total energy from fat
  • Total body expenditure x 40% = kcal in fat
  • Common preparations:
    • 10% = 1.1kcal/ml= 1100kcal in 1L
    • 20% - 2.0 kcal/ml = 1000 kcal in 500ml
22
Q

How to calculate fat emulsion requirement?

A
  • Assume 40% of total energy from fat
  • Total body expenditure x 40% = kcal in fat
  • Common preparations:
    • 10% = 1.1kcal/ml= 1100kcal in 1L
    • 20% - 2.0 kcal/ml = 1000 kcal in 500ml
23
Q

How to calculate carbohydrate requirement?

A
  • 60%-70% of TEE – energy provided by fat
  • Max rate 7mg/kg/minute
  • Divide by 3.4 kcal/g = grams of dextrose
24
Q

What are electrolyte requirements?

A
  • Na: 1-2 mmol/kg/day
  • K: 1 mmol/kg/day
  • Ca: 0.1 - 0.3 mmol/kg/day
  • Mg: 0.1 - 0.3 mmol/kg/day
25
Q

How does malnutrition affect surgical patients?

A
  • poor wound healing
  • increase infective cx due to immune dysfunction
  • increase muscle wasting → respiratory dysfunction / limb dysfunction
  • overgrowth of bacterial in intestines
  • prolonged requirements for mechanical ventilatory support
26
Q

What are the absolute indications for parenteral nutrition?

A

Enterocutaneous fistula

27
Q

What are the relative indications for parenteral nutrition?

A
  • moderate to severe malnutrition
  • short gut syndrome
  • bowel obstruction
  • prolonged ileus
  • trauma & burns
  • acute pancreatitis if EN not possible
28
Q

What are the pros and cons of central TPN?

A
  • Pros:
    • concentrated solution
    • do not need to exchange line
  • Cons:
    • line sepsis
    • thrombosis
    • pneumothorax
    • line breakage
29
Q

What are the pros and cons of peripheral TPN?

A
  • Pros:
    • no central line insertion risks
    • lower osmolality
  • Cons:
    • high rate of thrombophlebitis
    • short period
30
Q

What is the cause of liver derangement after TPN?

A
  • Steatosis
    • increase calories → increase lipogenesis → fatty liver
  • Cholestasis
31
Q

How to manage liver dysfunction in TPN patients

A
  • Rule out other causes of impaired liver function
  • Check for sepsis
  • Switch to enteral feeding if possible
  • Avoid excessive caloric administration
  • use lipid emulsion with low polyunsaturated fatty acids
  • Avoid copper and manganese
32
Q

What are the TPN precaution in patients with known liver disease?

A
  • Avoid excessive glucose administration
  • Use lipid emulsion with unsaturated fatty acid
  • Use branch amino acid in case of hepatic encephalopathy
33
Q

What is refeeding syndrome?

A

Electrolyte and fluid imbalance when feeding after prolonged fasting.

Metabolic disturbance when nutrition recommenced after period of starvation.

34
Q

What are the biochemical disturbances expected with refeeding syndrome? What is the mechanism behind?

A
  • Hypokalemia
  • Hypophosphatemia
  • Hypomagnesemia

Insulin level rises in response to glycemic → cellular uptake of these ions

35
Q

Which specific group of people are at high risk for refeeding syndrome?

A
  • Alcoholics
  • Anorexia nervosa
  • Drug abusers
  • Chronically malnourished (elderly)
  • Patient NPO for prolonged period
35
Q

Which specific group of people are at high risk for refeeding syndrome?

A
  • Alcoholics
  • Anorexia nervosa
  • Drug abusers
  • Chronically malnourished (elderly)
  • Patient NPO for prolonged period
36
Q

How do you approach patient at risk with refeeding syndrome?

A
  • Correct electrolyte disturbance
  • Start thiamine and multivitamins
  • Initiate feeding at low rate (25-50% of target)
  • Achieve full feed by 72 hours
  • Check electrolytes every 6-12 hours

For high risk (starvation for 15 days, BMI <14) may need ICU monitor

37
Q

How may refeeding syndrome present?

A
  • Arrhythmia
  • Dyspnea
  • Muscle weakness
  • Tremor, paraesthesia, delirium
  • Deranged LFT
38
Q

What are the adverse effects of overfeeding?

A
  • Hypercapnia
  • Hyperglyemia
  • Fatty infiltration of liver
    • Dextrose → Steatosis (increase ALT, AST)
    • Fat → Cholestasis (increase GGT, bilirubin, ALP)
39
Q

What are the types of enteral nutrition? What

A
  • Polymeric: real and intact food
    • Standard
    • High nitrogen
    • Carbon dense
    • Fiber containing
  • Monomeric: partially or predigested food
    • Partially hydrolyzed
    • Elemental
    • Peptide based
40
Q
A
  • Hypercapnia
  • Hyperglyemia
  • Fatty infiltration of liver
    • Dextrose → Steatosis (increase ALT, AST)
    • Fat → Cholestasis (increase GGT, bilirubin, ALP)
41
Q

How many ATPs generated in glucose metabolism?

1) Glycolysis
2) Kreb cycle
3) ETC
4) Total

A

1) 2
2) 2
3) 36
4) 38

42
Q

How many ATPs generated in lipid metabolism?

1) 8 carbon fatty acid
2) 3 FA

A

1) 48
2) 144

43
Q

What are the principle components of triglyceride?

A

3 fatty acids + glycerol

44
Q

Explain the following processes

1) Lipolysis
2) Beta oxidation
3) Ketogenesis

A

1) breakdown of TG into principle components of FA + Glycerol
2) breakdown of fatty acids in the mitocondria via Kreb cycle
3) Excess acetyl CoA converted into Betahydroxybutyrate in mitochondria of liver cells

45
Q

What is the energy value for 1 gram of the following macronutrients?

1) Carbohydrate
2) Fatty acid
3) Amino acid

A

1) 4 kcal
2) 9 kcal
3) 4 kcal

46
Q

What is the daily caloric requirement?

A

30-35kcal/kg

47
Q

What is the half life of prealbumin?

A

2-3 days

48
Q

Harris Benedict equation

1) Use
2) Factors of the equation

A

1) to calculate basal energy expenditure
2) weight, height, age

49
Q

How to calculate total caloric requirements?

A

BMR x activity factor x injury factor

50
Q

Name of few predictive equations for basal metabolic rate

A

Harris Benedict
Schofield
Liu’s equation
Owen
Mifflin

51
Q

Holliday Segar Method

1) Use
2) Method

A

1)to measure fluid requirements
2) First 10kg: 100ml/kg
Second 10kg: 50ml/kg
>20kg: 20ml/kg

52
Q

Outline of calculating parenteral nutrition

A

1) Fluid requirements
2) Metabolic requirements
3) Macronutrient requirements
4) Micronutrient requirements
5) Rate of infusion

Critical Care (12 decks)

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