Nutrition Flashcards
What is the way that we calculate IBW?
- Male: 50kg + (2.3 x in over 60’’)
- Female: 45.5kg + (2.3 x in over 60’’)
What is Nutrition Body Weight?
- NBW = IBW + 0.25(wt - IBW)
- USE when body weight is 130% more than IBW [<110% use actual body weight]
What are some of the ways that we are able to alleviate stress response?
- Give MACRO and MIRCO nutrients [Protein, Carbs, Fat]
- Gylcemic Control
- START EARLY
What are some of the benefit of starting early?
- DECREASE disease severity
- DECREASE complication
- DECREASE ICU stay
- INCREASE patient outcomes
What are the 5 things we look at for Nutritional Assessments?
- Risk factors for Malnutrition
- History
- Anthropometrics
- Classifications of Malnutrition
- Nitrogen Balence
What are some of the risk factors for Malnutrition?
- Under Body Weight = 20% below IBW
- Weight Loss [>10% within 6m]
- NPO >10 days [clinical use 7days]
- Gut problems
- Mechanical Issues
- Metabolic needs
- Substance Abuse
When should we start using Nutrition within the ICU?
- 48 HOURS
- Can screen to see
What are the two important screening tools that are used for Nutrition?
- NUTRIC & Nutritional Risk Score [NRS-2002]
What is important to remember about the NUTRIC scores?
- HIGH RISK: 6-10 [5-9 w/o IL-6]
- LOW RISK: 0-5 [0-4 w/o IL-6]
How is History used in Nutritional Assessments?
- Dietary [intake, swallowing, ulcers, vomiting, diarrhea…]
- Medical [GI trat connected?]
- Medications [can decrease absorption]
What is Anthropometrics in Nutritional Assessment?
- Looks at both Protein and Muscle [IBW]
What Viceral Protein is the most important within Nutrition?
- Prealbumin; 2-3 half life; 15-40mg/dL conc.
What is C-Recactive Protein?
- Positive reactant [increase by 25% during inflammation]
- ALWAYS checked with Prealbumin
- Prealbumin DECREASES; CRP INCREASES = inflammation
- Prealbumin DECREASES; CRP NORMAL = Malnutrition
What are the Classifications of Malnutrition in the Nutrition Assessment?
- Marasmus: PROTEIN/CALORIE - wasting of muscle
- Kwashiorkor: PROTEIN - not about to get enough protein to keep up
What are some of the symptoms for Maramus and Kwashiorkor?
- Marasmus: Hair loss, edema, skin folds
- Kwashiorkor: Large Belly, decreased muscle mass, fatigue
What are some of the treatments for Maramus and Kwashiorkor?
- Maramus: Macros + Vit B
- Kwashiorkor: Carbs the High Protein
What is the Nitrogen Balence?
- A measurement of urinary excertion of nitrogen as urea nitrogen [urinary urea nitrogen = UUN]
- GOAL: +3 to +5g
What is the equation to find Nitrogen Balence?
- Nitrogen Balence = Nin - Nout
- Nin = 24h protein intake / 6.25
- Nout = 24h UUN + Factor [4g]
What is the Harris-Benedict Equation?
- Just shows how well we are doing at rest
What are some of the general guidelines about Caloric needs?
- Non-stressed = 20-25 kcal/kg/day
- STRESSED = 25-30 kcal/kg/day [IMPORTANT]
What is Indirect Calorimetry?
- Shows energy expenditure [REE, RQ] at ONE point in time; within 24 hours
- TEE = REE x 1.2 [REE is given]
- RQ = Vco2 / Vo2 [RQ is given?]
For Respiratory Quotient Values, what is the most important one?
- MIXED SUBSTRATE = 0.85 - 0.95 once weekly
- Over 1 = OVERFEEDING - too much calories
- Under 1 = UNDERFEEDING - using protein for calories
What are some of the general guidelines about Proteins?
- Maintenance = 0.8 - 1 g/kg/day
- Mild to Mod = 1 - 1.5 g/kg/day
- ** Mod to Severe = 1.5 -2 g/kg/day**
What are some additional considerations about Proteins?
- “Tolerance” may be decreased in some disease states; like renal and Hepatic failure
What is the Non-Protein Caloire [NPC] Distribution?
- 70/30
- 70-90% = DEXTROSE
- 15-30% = FATS
- Gets adjusted based on tolerances; increase Blood sugar = decrease DEX & increase fats = decrease FAT
When might 100/0 NPC be used in a patient?
- During sepsis or bloodstream infections [FUNGAL]
What is the definition for Parenteral Nutrition?
- The process of supplying nutrients via IV
- EXAMPLES: TPN, PN, TNA, 3-in-1
What are some of the indications for PN?
- NPO > 7days
- Cannot absorb nutritents [ILEUS, SMALL BOWEL RESECTION]
- Fistulas [nutrition goes somewhere else]
- IBD
- Hyperemesis Gravidum [Pregnant People]
- Mucositis
What are the two route for administration for PN?
- Peripheral & Central
What are some advantages and disadvantages for Central PN?
- Advantages: Can use hypertonic, MORE calories
- Disadvantages: Risk of infection, complications [Pneumothorax, Air Embolus, thormbus]
What is the main Central route in PN?
- Venous Access [Subclavian, Internal Jugular, Femoral]
- Long Term: PICC
What type of catheter is best to use in a PN and why?
- Triple Lumen because it allows for other meds to be add; ONE lumen is ONLY for TPN
What is requirements for Proteins [how many kcal]?
- 4 kcal = 1g
What is the requirements for Carbohydrates [how many kcal]?
- 3.4kcal = 1g
- Want D10W [10% dextrose]; Max D70W [70% dextrose]
- For 100/0 [fungal] use 4-5 mg/kg/min
What is the requirements for Lipids [how many kcals]?
- ~10kcal = 1g
What are the two Lipid Emulsions that are used in PN?
- Intralipids
- SMOFlipid
What is in Intralipid?
- Soybean oil 10% [omega-6]
- Glycerin 2.25% [allergies?]
- Egg Yolk 1.2% [allergies?]
- Water
What is in SMOFlipid?
- Soybean Oil 30%
- Medium-chain triglyceride 30%
- Olive Oil 25% [omega-9]
- Fish Oil 15% [omega-3]
What is the maximum intake of lipids within PN?
- MAX: 2.5g/kg/day if TOLERATING
- 1-1.5g/kg/day in general
- PROPOFOL has 1.1kcal/ml of fat
What is the recommended hangtime for fat emulsions?
- 12 hours for FAT
- 24 hours for TPN
- Helps reduce infectious complications
What are some of the filter sizes that are used and why are they used?
- Helps reduce infusion of particulates, precipitates, microorganisms…
- SIZES: 1.2 micron for TNAs or 3-in-1 & 0.22 micron for 2-in-1 [NO lipids]
What is a Premix PN Solution?
- “Standard” TPN
- Contains amino acids + dextrose [+/- Na, K, Mag, Ca, Acetate, Cl, Phos]
When should a patient be started on a Premix PN solution?
- CrCl > 50: PN with electrolytes
- CrCl < 50: PN without electrolytes
What is the way that we Initiate or Discontinue a PN?
- Initiate: start ~25% –> final within 24hours [titrate up] & check Blood Glucose q 4-6 [Hyper?]
- Discontinue: decrease by 1/2 q2hr until rate <50 [Hypo?]
What is cycling PN?
- Infusion over 12-18 hours OR going to EN or PO
- The FIRST and LAST hour has to be lower to prevent dysglycemia
What are some of the additives that are used in PN?
- Electrolytes, Vitamins, Trace Elements, Medications?
What are the electrolytes and their daily ranges?
- Calcium: 10-20 mEq
- Magnesium: 8-24 mEq
- Phosphorus: 15-45 mMol
- Sodium: 1-2 mEq/kg
- Potassium: 0.5-1 mEq/kg up to 2 mEq/kg
- Chloride: PRN [~2/3]
- Acetate: PRN [~1/3]
What are some of the considerations for Eletrolytes?
- Renal disease: caution with Potassium, Phosphate, Magnesium
- AVOID Calcium + Phosphate = Precipitation
What are some of the vitamins that are used in PN?
- Thiamin, Riboflavin, Niacin, Folic Acid, Panthotenic Acid, Pyridoxine, xyancobalamin, Biotin, Ascorbic Acid, A, D, E, K
- ADULTS: 10 ml/day
- PEDS: 2 ml/day
What are some of the trace elements that are used in PN?
- Zinc, Copper, Chromium, Selenium, Manganese, Iron
What is important to know about Iron within PN?
- NOT RECOMMENDED to add to PN [piggyback separately]
What are some of the complications for PN?
- Mechanical [clotting line, moved]
- Infectious [Sepsis, Bacterial Translocation]
- Metabolic [Electrolyte/Fluid imbalence, HYPER- or HYPOglycemia]
What is Bacterial Translocation?
- When the bacterial is traveling somewhere that it shouldn’t be
What are some of the baseline monitoring parameters for PN?
- CMP, Mg, Phos, Ca [ionized]
- Hepatic Function Panel
- Prealbumin/CRP [ALWAYS together]
- PT/INR [Clotting?]
What are some of the ongoing monitoring for PN?
- Daily: vitals, stools, CMP [eletrolytes, glucose, BUN]
- Twice Weekly: CBC, PREALBUMIN/CRP [ICU –> daily]
- Weekly: Triglucerides, RQ, Indirect Calorimetry [finds REE & RQ]
What is Refeeding Syndrome?
- Rapid feeding within a starved patient that can be life threatening [fluid, micronutrient, electrolyte, vitamin imbalence]
What are some of the important clinical findings for Refeeding Syndrome?
- HYPOPHOSPHATEMIA [VERY IMPORTANT]
- HYPOMAGNESEMIA, HYPOKALEMIA
What are some of the risk factors that are associated for Refeeding Syndrome?
- Rapid Feeding [feed slowly]
- Low BMI [16-18.5]
- Already low K, Phos, Mag before feeding
- Others: Alcoholism, Anorexia Nervosa, Maramus
What are some of the ways that we are able to prevent Refeeding Syndrome?
- Limit Carbs: 100-150g
- Limit Fluids: 800ml/day
- GIVE electrolytes
- 50% of total calories
- GIVE thiamine 100mg daily x5-7d
What is Essential Fatty Acid Deficiency?
- When you have low levels of EFAs [linoleic & lenolenic] that has an onset of 10-14 days
- Shows as Dry Skin, Brittle Hair, Lack of luster
What is the way that we are able to prevent EFAD?
- 500ml of 10% twice weekly OR
- 250ml of 20% twice weekly
What are the indications for Enteral Nutrition?
- “if the guts works, use it”
- Contrainidications: anything where they cant swallow
What are some of the advantages of EN?
- GI stimulation: decrease bacterial translocation [DECREASED morbidity & mortality]
- AVOIDS IV risks: decreased infections
- can do bolus feeds
What are some of the contraindications [or indications to PN] for EN?
- Mechanical obstruction [blockage]
- Non-Mechanical [ILEUS = leads to sepsis]
- FISTULAS
What are some of the general routes of administration for EN?
- Nasogastric [NG = Nose –> Stomach]
- Orogastric [OG = Mouth –> Stomach]
- Nasojejunal [NJ = Nose –> Small Intestine]
- Orojejunal [OJ = Mouth –> Small Intestine]
- Surgery [Gastrostomy (PEG: cant do nose or mouth) or Jejunosotmy (PEG/PEJ: PEG that goes into small intestine)
What route of administration is better for feeds and/or Medications?
- NG/OG are better for medications
- NJ/OJ are better for feeds
What are some of that way that we determine the route of access in EN?
- Aspiration: Low risk = gastric; High risk = jejunal
- Tolerance: Vomiting = jejunal; Gastric Residuals = jejunal
- Long Term: PEG or PEJ
What are some of the methods of administration in EN?
- Bolus, Intermittent, Continuous Infusion, Trickle or Trophic
What is important to know about Bolus administration in EN?
- mimic meals
- > 200ml over 5-10mins
What are the advantages and disadvantages for Bolus administration in EN?
- Advantages: convenient, JUST syringe, less interactions
- Disadvantages: can’t feed small bowel, aspirations
What is important to know about Intermittent administration in EN?
- > 200ml over 20-30mins [gravity drip]
- help with tolerance BUT needs a lot of equipment
What is important to know about Continuous Infusion administration for EN?
- over 12-24 hours
- INFUSION PUMP
- Preferred method for jejunum
What are some of the advantages and disadvantages for Continuous Infusion administration in EN?
- Advantages: low risk of aspiration
- Disadvantages: INFUSION PUMP & 24 hour
What is important to know about Trickle or Trophic administration in EN?
- SLOW infusion at 10-30ml/hr
- Can prevent mucosal atrophy & bacterial translocation BUT hard to get proper calories
What are some of the EN formulas that are used?
- Jevity: 1.06kcal/mL & 44.3 protein
- Impact 1.5: 1.5kcal/mL & 94 protein [ICU!]
- Glucerna: 1.2kcal/ml & 60 protein
- Nepro: 1.8kcal/mL & 81 protein
What are some of the immune-modulating contents of Impact 1.5 in EN?
- Arginine, Glutamine, Omega-3, Antioxidants
What are some of the adjunctive therapies?
- Modular Supplements
- Glutamine
- Probiotics
- Vitamins and trace elements
What is the most important modular supplements in EN?
- Pro-Stat: Protein; 30mL; 15 g protein
What in important to know about Glutamine [Glutasolve] in Modular Supplements?
- Reduce ICU stay
- Reduce mortality in burn patients
- DO NOT supplement if getting glutamine [Impact 1.5?]
What is important to know about Probiotics in EN?
- NOT COMMONLY USED
- Inhibits bacterial growth
- Blocks pathogen
- Eliminates Toxins
- Enhances inflammatory response
What is important to know about the Vitamins and Trace Elements in EN?
- Vitamin E & C
- Trace: Slenium, Zinc, Copper, Chromium, Manganese
- GOOD in burn patients
What are some of the complications for EN?
- Gastrointenstinal
- Metabolic
- Mechanical
- Medication-Related
What are the Gastrointestinal Complications for EN?
- High Gastric Residual [Jejunal]
- Aspirations [Jejunal]
- N/V [Use Metoclopramide or Erythromycin]
- Diarrhea or Constipation
What is important to know about High Gastric Residuals in EN?
Cutoffs?
- NOT GOOD CUTOFFS
- < 500mL: DO NOT HOLD unless tolerance
- 200-500mL: reduction to AVOID aspiration
What is important to know about Aspirations in EN?
- Elevate HOB [Head of Bed] to 30-45* [lets gravity work]
- Continuous Infusion [Lower volume]
- Post-pyloric delivery [Jejunal]
What are some of the medications that can be used to decrease motility [N/V]?
- Metoclopramide 10mg QID
- Erythromycin 250-500mg TID or q8h
- Naloxone 8mg QID [high dose]
- Methylnaltrexone [NEVER 1st line]
What is important to know about diarrhea in EN?
- NEED TO LOOK AT MEDS
- Hyperosmolar meds, meds with SORBITOL, bowel regimen, Antibiotics
What are some of the Hyperosmolar Medications that can cause Diarrhea in EN?
- Acetaminophen [exlixir or liquid]
- Docusate
- Lactulose
- Metoclopramide
What should you do when you have 2 Hyperosmolar Medications in EN?
- DC, Decrease Dose, Make PRN
What are some of the medications that have Sorbitol?
- Acetaminophen
- Guaifenesin/Dextromethorphan
- Lithium Syrup
- Metoclopramide
- Kecellate???
What are some of the Metabolic Complications in EN?
- HYPER- or HYPOglycemia [check meds/insulin]
- Electrolyte Imbalence [HYPOnatremia is common]
What are some of the mechanical Complications for EN?
- Clogging of Tube
- Malposition [move, came out…]
- Rhinitis
- Sinusitis [move to mouth]
What is some of the general guidelines for medication delivery via EN?
- LIQUID!!
- If using oral –> CRUSH IT
- DO NOT CRUSH SUSTAINED RELEASE OR ENTERIC COATED
What is important to know about Liquid medications in EN?
- AVOID viscous –> Clogging [NO syrups, Mineral Oils, Granules]
What is on the “DO NOT CRUSH” list?
- Delayed or Extrended Release
- Enteric Coated
- Buccal or Sublingual
- Carcinogenic, Teratogenic, Cytotoxic
- +/- Capsules
What is the way that we can Unclog an EN tube?
- 1 sodium bicarb tab
- 1 pancreatic enzyme cap
- 10 ml of warm sterile warm
What are some of the Drug/Tube Feed Interactions?
- Antibiotics
- Anti-Retrovirals
- Others [Levothyroxine, Phenytoin, Theophylline, Warfarin]
What is important to know when giving a drug that interacts with tube feed, like step to take?
- Hold Feed
- WAIT 1 hour
- Give meds
- WAIT 2 hours [Total 3 except keflex is 6]
- Resume Feed
