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PHRM 864: Therapeutics IV > Nutrition > Flashcards

Nutrition Flashcards

1
Q

What is the way that we calculate IBW?

A
  • Male: 50kg + (2.3 x in over 60’’)
  • Female: 45.5kg + (2.3 x in over 60’’)
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2
Q

What is Nutrition Body Weight?

A
  • NBW = IBW + 0.25(wt - IBW)
  • USE when body weight is 130% more than IBW [<110% use actual body weight]
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3
Q

What are some of the ways that we are able to alleviate stress response?

A
  • Give MACRO and MIRCO nutrients [Protein, Carbs, Fat]
  • Gylcemic Control
  • START EARLY
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4
Q

What are some of the benefit of starting early?

A
  • DECREASE disease severity
  • DECREASE complication
  • DECREASE ICU stay
  • INCREASE patient outcomes
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5
Q

What are the 5 things we look at for Nutritional Assessments?

A
  • Risk factors for Malnutrition
  • History
  • Anthropometrics
  • Classifications of Malnutrition
  • Nitrogen Balence
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6
Q

What are some of the risk factors for Malnutrition?

A
  • 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
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7
Q

When should we start using Nutrition within the ICU?

A
  • 48 HOURS
  • Can screen to see
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8
Q

What are the two important screening tools that are used for Nutrition?

A
  • NUTRIC & Nutritional Risk Score [NRS-2002]
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9
Q

What is important to remember about the NUTRIC scores?

A
  • HIGH RISK: 6-10 [5-9 w/o IL-6]
  • LOW RISK: 0-5 [0-4 w/o IL-6]
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10
Q

How is History used in Nutritional Assessments?

A
  • Dietary [intake, swallowing, ulcers, vomiting, diarrhea…]
  • Medical [GI trat connected?]
  • Medications [can decrease absorption]
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11
Q

What is Anthropometrics in Nutritional Assessment?

A
  • Looks at both Protein and Muscle [IBW]
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12
Q

What Viceral Protein is the most important within Nutrition?

A
  • Prealbumin; 2-3 half life; 15-40mg/dL conc.
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13
Q

What is C-Recactive Protein?

A
  • Positive reactant [increase by 25% during inflammation]
  • ALWAYS checked with Prealbumin
  • Prealbumin DECREASES; CRP INCREASES = inflammation
  • Prealbumin DECREASES; CRP NORMAL = Malnutrition
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14
Q

What are the Classifications of Malnutrition in the Nutrition Assessment?

A
  • Marasmus: PROTEIN/CALORIE - wasting of muscle
  • Kwashiorkor: PROTEIN - not about to get enough protein to keep up
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15
Q

What are some of the symptoms for Maramus and Kwashiorkor?

A
  • Marasmus: Hair loss, edema, skin folds
  • Kwashiorkor: Large Belly, decreased muscle mass, fatigue
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16
Q

What are some of the treatments for Maramus and Kwashiorkor?

A
  • Maramus: Macros + Vit B
  • Kwashiorkor: Carbs the High Protein
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17
Q

What is the Nitrogen Balence?

A
  • A measurement of urinary excertion of nitrogen as urea nitrogen [urinary urea nitrogen = UUN]
  • GOAL: +3 to +5g
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18
Q

What is the equation to find Nitrogen Balence?

A
  • Nitrogen Balence = Nin - Nout
  • Nin = 24h protein intake / 6.25
  • Nout = 24h UUN + Factor [4g]
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19
Q

What is the Harris-Benedict Equation?

A
  • Just shows how well we are doing at rest
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20
Q

What are some of the general guidelines about Caloric needs?

A
  • Non-stressed = 20-25 kcal/kg/day
  • STRESSED = 25-30 kcal/kg/day [IMPORTANT]
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21
Q

What is Indirect Calorimetry?

A
  • 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?]
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22
Q

For Respiratory Quotient Values, what is the most important one?

A
  • MIXED SUBSTRATE = 0.85 - 0.95 once weekly
  • Over 1 = OVERFEEDING - too much calories
  • Under 1 = UNDERFEEDING - using protein for calories
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23
Q

What are some of the general guidelines about Proteins?

A
  • 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**
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24
Q

What are some additional considerations about Proteins?

A
  • “Tolerance” may be decreased in some disease states; like renal and Hepatic failure
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25
Q

What is the Non-Protein Caloire [NPC] Distribution?

A
  • 70/30
  • 70-90% = DEXTROSE
  • 15-30% = FATS
  • Gets adjusted based on tolerances; increase Blood sugar = decrease DEX & increase fats = decrease FAT
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26
Q

When might 100/0 NPC be used in a patient?

A
  • During sepsis or bloodstream infections [FUNGAL]
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27
Q

What is the definition for Parenteral Nutrition?

A
  • The process of supplying nutrients via IV
  • EXAMPLES: TPN, PN, TNA, 3-in-1
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28
Q

What are some of the indications for PN?

A
  • NPO > 7days
  • Cannot absorb nutritents [ILEUS, SMALL BOWEL RESECTION]
  • Fistulas [nutrition goes somewhere else]
  • IBD
  • Hyperemesis Gravidum [Pregnant People]
  • Mucositis
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29
Q

What are the two route for administration for PN?

A
  • Peripheral & Central
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30
Q

What are some advantages and disadvantages for Central PN?

A
  • Advantages: Can use hypertonic, MORE calories
  • Disadvantages: Risk of infection, complications [Pneumothorax, Air Embolus, thormbus]
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31
Q

What is the main Central route in PN?

A
  • Venous Access [Subclavian, Internal Jugular, Femoral]
  • Long Term: PICC
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32
Q

What type of catheter is best to use in a PN and why?

A
  • Triple Lumen because it allows for other meds to be add; ONE lumen is ONLY for TPN
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33
Q

What is requirements for Proteins [how many kcal]?

A
  • 4 kcal = 1g
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34
Q

What is the requirements for Carbohydrates [how many kcal]?

A
  • 3.4kcal = 1g
  • Want D10W [10% dextrose]; Max D70W [70% dextrose]
  • For 100/0 [fungal] use 4-5 mg/kg/min
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35
Q

What is the requirements for Lipids [how many kcals]?

A
  • ~10kcal = 1g
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36
Q

What are the two Lipid Emulsions that are used in PN?

A
  • Intralipids
  • SMOFlipid
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37
Q

What is in Intralipid?

A
  • Soybean oil 10% [omega-6]
  • Glycerin 2.25% [allergies?]
  • Egg Yolk 1.2% [allergies?]
  • Water
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38
Q

What is in SMOFlipid?

A
  • Soybean Oil 30%
  • Medium-chain triglyceride 30%
  • Olive Oil 25% [omega-9]
  • Fish Oil 15% [omega-3]
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39
Q

What is the maximum intake of lipids within PN?

A
  • MAX: 2.5g/kg/day if TOLERATING
  • 1-1.5g/kg/day in general
  • PROPOFOL has 1.1kcal/ml of fat
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40
Q

What is the recommended hangtime for fat emulsions?

A
  • 12 hours for FAT
  • 24 hours for TPN
  • Helps reduce infectious complications
41
Q

What are some of the filter sizes that are used and why are they used?

A
  • 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]
42
Q

What is a Premix PN Solution?

A
  • “Standard” TPN
  • Contains amino acids + dextrose [+/- Na, K, Mag, Ca, Acetate, Cl, Phos]
43
Q

When should a patient be started on a Premix PN solution?

A
  • CrCl > 50: PN with electrolytes
  • CrCl < 50: PN without electrolytes
44
Q

What is the way that we Initiate or Discontinue a PN?

A
  • 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?]
45
Q

What is cycling PN?

A
  • Infusion over 12-18 hours OR going to EN or PO
  • The FIRST and LAST hour has to be lower to prevent dysglycemia
46
Q

What are some of the additives that are used in PN?

A
  • Electrolytes, Vitamins, Trace Elements, Medications?
47
Q

What are the electrolytes and their daily ranges?

A
  • 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]
48
Q

What are some of the considerations for Eletrolytes?

A
  • Renal disease: caution with Potassium, Phosphate, Magnesium
  • AVOID Calcium + Phosphate = Precipitation
49
Q

What are some of the vitamins that are used in PN?

A
  • Thiamin, Riboflavin, Niacin, Folic Acid, Panthotenic Acid, Pyridoxine, xyancobalamin, Biotin, Ascorbic Acid, A, D, E, K
  • ADULTS: 10 ml/day
  • PEDS: 2 ml/day
50
Q

What are some of the trace elements that are used in PN?

A
  • Zinc, Copper, Chromium, Selenium, Manganese, Iron
51
Q

What is important to know about Iron within PN?

A
  • NOT RECOMMENDED to add to PN [piggyback separately]
52
Q

What are some of the complications for PN?

A
  • Mechanical [clotting line, moved]
  • Infectious [Sepsis, Bacterial Translocation]
  • Metabolic [Electrolyte/Fluid imbalence, HYPER- or HYPOglycemia]
53
Q

What is Bacterial Translocation?

A
  • When the bacterial is traveling somewhere that it shouldn’t be
54
Q

What are some of the baseline monitoring parameters for PN?

A
  • CMP, Mg, Phos, Ca [ionized]
  • Hepatic Function Panel
  • Prealbumin/CRP [ALWAYS together]
  • PT/INR [Clotting?]
55
Q

What are some of the ongoing monitoring for PN?

A
  • Daily: vitals, stools, CMP [eletrolytes, glucose, BUN]
  • Twice Weekly: CBC, PREALBUMIN/CRP [ICU –> daily]
  • Weekly: Triglucerides, RQ, Indirect Calorimetry [finds REE & RQ]
56
Q

What is Refeeding Syndrome?

A
  • Rapid feeding within a starved patient that can be life threatening [fluid, micronutrient, electrolyte, vitamin imbalence]
57
Q

What are some of the important clinical findings for Refeeding Syndrome?

A
  • HYPOPHOSPHATEMIA [VERY IMPORTANT]
  • HYPOMAGNESEMIA, HYPOKALEMIA
58
Q

What are some of the risk factors that are associated for Refeeding Syndrome?

A
  • Rapid Feeding [feed slowly]
  • Low BMI [16-18.5]
  • Already low K, Phos, Mag before feeding
  • Others: Alcoholism, Anorexia Nervosa, Maramus
59
Q

What are some of the ways that we are able to prevent Refeeding Syndrome?

A
  • Limit Carbs: 100-150g
  • Limit Fluids: 800ml/day
  • GIVE electrolytes
  • 50% of total calories
  • GIVE thiamine 100mg daily x5-7d
60
Q

What is Essential Fatty Acid Deficiency?

A
  • 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
61
Q

What is the way that we are able to prevent EFAD?

A
  • 500ml of 10% twice weekly OR
  • 250ml of 20% twice weekly
62
Q

What are the indications for Enteral Nutrition?

A
  • “if the guts works, use it”
  • Contrainidications: anything where they cant swallow
63
Q

What are some of the advantages of EN?

A
  • GI stimulation: decrease bacterial translocation [DECREASED morbidity & mortality]
  • AVOIDS IV risks: decreased infections
  • can do bolus feeds
64
Q

What are some of the contraindications [or indications to PN] for EN?

A
  • Mechanical obstruction [blockage]
  • Non-Mechanical [ILEUS = leads to sepsis]
  • FISTULAS
65
Q

What are some of the general routes of administration for EN?

A
  • 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)
66
Q

What route of administration is better for feeds and/or Medications?

A
  • NG/OG are better for medications
  • NJ/OJ are better for feeds
67
Q

What are some of that way that we determine the route of access in EN?

A
  • Aspiration: Low risk = gastric; High risk = jejunal
  • Tolerance: Vomiting = jejunal; Gastric Residuals = jejunal
  • Long Term: PEG or PEJ
68
Q

What are some of the methods of administration in EN?

A
  • Bolus, Intermittent, Continuous Infusion, Trickle or Trophic
69
Q

What is important to know about Bolus administration in EN?

A
  • mimic meals
  • > 200ml over 5-10mins
70
Q

What are the advantages and disadvantages for Bolus administration in EN?

A
  • Advantages: convenient, JUST syringe, less interactions
  • Disadvantages: can’t feed small bowel, aspirations
71
Q

What is important to know about Intermittent administration in EN?

A
  • > 200ml over 20-30mins [gravity drip]
  • help with tolerance BUT needs a lot of equipment
72
Q

What is important to know about Continuous Infusion administration for EN?

A
  • over 12-24 hours
  • INFUSION PUMP
  • Preferred method for jejunum
73
Q

What are some of the advantages and disadvantages for Continuous Infusion administration in EN?

A
  • Advantages: low risk of aspiration
  • Disadvantages: INFUSION PUMP & 24 hour
74
Q

What is important to know about Trickle or Trophic administration in EN?

A
  • SLOW infusion at 10-30ml/hr
  • Can prevent mucosal atrophy & bacterial translocation BUT hard to get proper calories
75
Q

What are some of the EN formulas that are used?

A
  • 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
76
Q

What are some of the immune-modulating contents of Impact 1.5 in EN?

A
  • Arginine, Glutamine, Omega-3, Antioxidants
77
Q

What are some of the adjunctive therapies?

A
  • Modular Supplements
  • Glutamine
  • Probiotics
  • Vitamins and trace elements
78
Q

What is the most important modular supplements in EN?

A
  • Pro-Stat: Protein; 30mL; 15 g protein
79
Q

What in important to know about Glutamine [Glutasolve] in Modular Supplements?

A
  • Reduce ICU stay
  • Reduce mortality in burn patients
  • DO NOT supplement if getting glutamine [Impact 1.5?]
80
Q

What is important to know about Probiotics in EN?

A
  • NOT COMMONLY USED
  • Inhibits bacterial growth
  • Blocks pathogen
  • Eliminates Toxins
  • Enhances inflammatory response
81
Q

What is important to know about the Vitamins and Trace Elements in EN?

A
  • Vitamin E & C
  • Trace: Slenium, Zinc, Copper, Chromium, Manganese
  • GOOD in burn patients
82
Q

What are some of the complications for EN?

A
  • Gastrointenstinal
  • Metabolic
  • Mechanical
  • Medication-Related
83
Q

What are the Gastrointestinal Complications for EN?

A
  • High Gastric Residual [Jejunal]
  • Aspirations [Jejunal]
  • N/V [Use Metoclopramide or Erythromycin]
  • Diarrhea or Constipation
84
Q

What is important to know about High Gastric Residuals in EN?

Cutoffs?

A
  • NOT GOOD CUTOFFS
  • < 500mL: DO NOT HOLD unless tolerance
  • 200-500mL: reduction to AVOID aspiration
85
Q

What is important to know about Aspirations in EN?

A
  • Elevate HOB [Head of Bed] to 30-45* [lets gravity work]
  • Continuous Infusion [Lower volume]
  • Post-pyloric delivery [Jejunal]
86
Q

What are some of the medications that can be used to decrease motility [N/V]?

A
  • Metoclopramide 10mg QID
  • Erythromycin 250-500mg TID or q8h
  • Naloxone 8mg QID [high dose]
  • Methylnaltrexone [NEVER 1st line]
87
Q

What is important to know about diarrhea in EN?

A
  • NEED TO LOOK AT MEDS
  • Hyperosmolar meds, meds with SORBITOL, bowel regimen, Antibiotics
88
Q

What are some of the Hyperosmolar Medications that can cause Diarrhea in EN?

A
  • Acetaminophen [exlixir or liquid]
  • Docusate
  • Lactulose
  • Metoclopramide
89
Q

What should you do when you have 2 Hyperosmolar Medications in EN?

A
  • DC, Decrease Dose, Make PRN
90
Q

What are some of the medications that have Sorbitol?

A
  • Acetaminophen
  • Guaifenesin/Dextromethorphan
  • Lithium Syrup
  • Metoclopramide
  • Kecellate???
91
Q

What are some of the Metabolic Complications in EN?

A
  • HYPER- or HYPOglycemia [check meds/insulin]
  • Electrolyte Imbalence [HYPOnatremia is common]
92
Q

What are some of the mechanical Complications for EN?

A
  • Clogging of Tube
  • Malposition [move, came out…]
  • Rhinitis
  • Sinusitis [move to mouth]
93
Q

What is some of the general guidelines for medication delivery via EN?

A
  • LIQUID!!
  • If using oral –> CRUSH IT
  • DO NOT CRUSH SUSTAINED RELEASE OR ENTERIC COATED
94
Q

What is important to know about Liquid medications in EN?

A
  • AVOID viscous –> Clogging [NO syrups, Mineral Oils, Granules]
95
Q

What is on the “DO NOT CRUSH” list?

A
  • Delayed or Extrended Release
  • Enteric Coated
  • Buccal or Sublingual
  • Carcinogenic, Teratogenic, Cytotoxic
  • +/- Capsules
96
Q

What is the way that we can Unclog an EN tube?

A
  • 1 sodium bicarb tab
  • 1 pancreatic enzyme cap
  • 10 ml of warm sterile warm
97
Q

What are some of the Drug/Tube Feed Interactions?

A
  • Antibiotics
  • Anti-Retrovirals
  • Others [Levothyroxine, Phenytoin, Theophylline, Warfarin]
98
Q

What is important to know when giving a drug that interacts with tube feed, like step to take?

A
  • Hold Feed
  • WAIT 1 hour
  • Give meds
  • WAIT 2 hours [Total 3 except keflex is 6]
  • Resume Feed

PHRM 864: Therapeutics IV (28 decks)

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