Nutrition Flashcards
nutrition body weight (NBW)
- NBW = ___
- Use if actual body weight is 130% or more of IBW
- Applies for calculating fluid, electrolyte, and nutrition (FEN) parameters
- NBW = IBW + 0.25(wt – IBW)
Alleviate the Stress Response
- Provide macro- and micronutrient delivery
- Careful ___ control
- Begin enteral nutrition ___
- glycemic
- early
Benefits of Early Initiation
decreased:
- disease ___ /complications
- ICU ___ of stay
better patient outcomes
severity
length
Risk Factors for Malnutrition
- UBW (under body weight) = ___ % below IBW
- Involuntary weight loss > ___ % within __ months
- NPO >___ days*
- Clinically we use inadequate intake > __ days
- ___ malfunction*
- Mechanical ___ *
ICU patients*
- 20%
- 10%, 6
- 10
- 7
- gut
- ventilation
Risk Factors for Malnutrition (cont.)
Increased metabolic needs*
- Trauma or ___ patients
- High dose ___
Alcohol/substance abuse
– Decreased functional ___
– “ ___ “ calories
Protracted nutrient losses
- Chronic disease states
ICU patients*
- burn
- steroids
- proteins
- empty
Screening Tools
- Mini Nutritional Assessment (MNA)
- Malnutrition Screening Tool (MST)
- Malnutrition Universal Screening Tool (MUST)
- NUTRIC
- Nutritional Risk Score (NRS-2002)
- Short Nutritional Assessment Questionnaire (SNAQ)
- Subjective Global Assessment (SGA)
- NUTRIC
- Nutritional Risk Score (NRS-2002)
Screening Tools - NUTRIC
high risk: ___ - ___
6-10
Visceral Protein Status
MAY NOT ACCURATELY REPRESENT NUTRITION STATUS IN THE ICU
SETTING!
- look at both ___ and ___
transthyretin (prealbumin) and C-reactive protein (CRP)
Transthyretin (prealbumin)
t1/2: __ - __ days
normal serum [ ]: __ - __ mg/dL
falsely decreased in the presence of
inflammation:
- Prealbumin decreases as CRP increases ->inflammation
- Prealbumin ___ as CRP is ___ -> malnutrition
- 2-3
- 15-40
- decreases, normal
C-Reactive Protein (CRP)
- Positive acute phase reactant (increased by at least 25% during ___ )
- Normal < ___ mg/dL (in clinical practice)
- Use to assess accuracy of ___
- inflammation
- 1
- prealbumin
Classifications of Malnutrition
Protein-calorie malnutrition ( ___ )
– ↓ total intake and/or utilization of food
– Wasting of skeletal muscle and SQ fat
– Immunosuppression in severe cases
– Cachectic appearance
Protein malnutrition ( ___ )
– Adequate caloric intake; relative protein malnutrition
– Catabolic ___ patients, ___ patients
Mixed
- Chronically ill, starved patients who are metabolically stressed
- ↓ visceral proteins, poor wound healing, immunocompromised
- Marasmus
- Kwashiorkor
- trauma, burn
Nitrogen Balance
Measurement of urinary excretion of
nitrogen as urea nitrogen (UUN)
___ catabolism
- Stress ↑, protein catabolism ___ and UUN ___
Nitrogen balance study used to assess the adequacy of protein repletion
- Ideal Goal: ___ - ___ grams
protein
↑, ↑
3-5
Formula
Nitrogen balance = (N in) - (N out)
- N in = 24-h ___ (g) / 6.25
- N out = 24-h ___ (g) + factor (3-5 g)
Generally, use 4 g as your estimate or adjust per specific indications
- protein intake
- UUN
goal 3-5
Estimating Caloric Needs
Harris-Benedict Equation:
* Basal Energy Expenditure (BEE)
* Resting Energy Expenditure (REE)
“Stress” or Activity Factor to Use
with Harris-Benedict Equation
- TEE = ___ x ___
TEE = REE x stress/activity factor(s)
General Guidelines
non-stressed, non-depleted : ___ - ___ kcal/kg/day
trauma/stress/surgery, criticall ill, major burns: ___ - ___ kcal/kg/day
obesity: BMI 30-50: __ - __ kcal/kg/day
(actual body weight)
obesity: BMI > 50: __ - __ kcal/kg/day (ideal body weight)
BMI = wt (kg)/ht (m2)
20-25
25-30
11-14
22-25
Indirect Calorimetry
Preferred method for critically ill patients
- provides energy expenditure (REE, RQ) at that ONE point in time; then extrapolated to 24 hrs
- TEE = ___ x 1.2
For all energy production, oxygen is consumed and carbon dioxide is produced
- RQ = Vco2 / Vo2
- goal: ___ - ___
- over = overfeeding
- under = underfeeding
REE
0.85-0.95
Protein General Guidelines
- Maintenance: __ - __ gm/kg/day
- Mild to moderate stress (floor patients): __ - __ gm/kg/day
- Moderate to severe stress
(ICU, trauma, surgery, burn) __ - __ gm/kg/day - Obesity (BMI > 30): __ gm/kg/day
(ideal body weight) - Severe obesity (BMI > 40): __ gm/kg/day ( ___ body weight)
- 0.8-1
- 1-1.5
- 1.5-2
- 2
- 2.5, ideal
Adequate calories must be present for
appropriate protein utilization
- Ensure adequate ___
- Usually include protein in calculation of total calories
Protein “tolerance” may be decreased in some disease states (e.g., ___ & ___ failure)
- NPC
- renal, hepatic
Non-Protein Calorie (NPC) Distribution
standard distribution ( __ / __ )
- 70-85% dextrose
- 15-30% fat
Adjust based on tolerance:
– Blood sugars
– Triglycerides
– RQ from Indirect Calorimetry
___ / __ may be utilized during sepsis or
bloodstream infections
70/30
100/0
PN Indication
Anticipated prolonged NPO course (> __ days)
Inability to absorb nutrients via the gut, such as secondary to:
- Small bowel or colonic ___
- Extensive small bowel ___
- Malabsorptive states
- Intractable vomiting/diarrhea
- Enterocutaneous fistulas
- Inflammatory bowel disease
- Hyperemesis gravidum
- Bone marrow transplantation ( ___ )
- 7
- ileus
- resection
- mucositis
Peripheral PN
Dextrose and amino acid solutions are ___
- Not well tolerated via a peripheral vein
Restrict final dextrose concentration to 5-10%, or total osmolarity to < ___ mOsm/L
- Total mOsm/bag = (g AA x10) + (g dextrose x5) + (mL fat x 0.3)
- Total mOsm/L = total mOsm/bag divided by # of liters in bag
Addition of other substances to solution may ___ vein tolerance
- hypertonic
- 900
- enhance
Peripheral PN (cont.)
Requires ___ volumes of fluid
- May not be the best choice for HF or AKI/CKD patients
Limited in ___
- Secondary to the osmolality AND fluid
Short term access (< __ - __ days)
- Does this patient need PN at all?
- always double check to make sure route was intentional
- large
- calories
- 7-10
Central PN
Advantages
- Allows administration of ___ solutions
- More calories can be delivered
Disadvantages
- Risk of ___
- Central line is not a benign procedure
* Pneumothorax
* Air embolus
* Thrombus
- hypertonic
- infection
Central Venous Access
Central venous catheter (CVC) insertion sites
- ___ (SC)
- ___ (IJ)
- Femoral
Short term: ___ inserted
Long term:
- ___ (peripherally inserted central catheter)
- Tunneled
- Implanted ___
- subclavian
- internal jugular
- percutaneously
- PICC
- port
Meeting Protein Requirements
One gram protein = __ kcal
- Many hospitals actually order protein in gm/day
Standard amino acid products:
– Travasol 3.5%, 5.5%, 8.5%, 10%
– FreAmine III 3%, 8.5%, 10%
– Aminosyn II 3.5%, 5%, 7%, 8.5%, 10%
4 kcal
Carbohydrates (Dextrose)
Max concentration available: D ___ W
One gram dextrose = ___ kcal
- Limitations: A final dextrose concentration >10% (adults) and >12.5% (pediatrics) should not be infused into a ___ vein due to irritation
- Maximum carbohydrate utilization: __ - __ mg/kg/min (double check)
- 70
- peripheral
- 4-5
IV Fat (Lipid) Emulsion – Intralipid
Provides a ___ source of calories:
- 10% lipid supplies 1.1 kcal/mL
- 20% lipid supplies 2.0 kcal/mL
- 30% lipid supplies 3.0 kcal/mL
- 1 gram lipids = ~ __ kcal
Prevents essential fatty acid deficiency
concentrated
10
IV Fat (Lipid) Emulsion – Intralipid (cont.)
Intralipid 10% consists of:
- ___ oil 10% (high in linoleic acid, an omega-6 fatty acid)
- Glycerin 2.25% (check for allergies)
- ___ Phospholipid 1.2% (check for allergies)
- Water for Injection
- Soybean
- glycerin
- egg yolk
IV Fat (Lipid) Emulsion – SMOFlipid
___ oil 30%
- omega-6 essential fatty acid
___ chain triglycerides 30%
- rapidly available energy source
___ oil 25%
- omega-9 monounsaturated fatty acid
___ oil 15% (check for allergies)
- omega-3 (source of EPA and DHA)
- soybean
- medium
- olive
- fish
IV Fat (Lipid) Emulsion – SMOFlipid (cont.)
Compared to pure soybean oil products (e.g., ___ ):
- Improved ___ function (lower ALT/AST concentrations)
- Lower increase in ___ levels from baseline
Compared to non-omega-3 PN:
- Less pro- ___
- Less negative impact on ___ function
- Reduced risk of ___
- Decreased ___ of hospital stay
- Intralipid
- liver
- TG
- inflammatory
- liver
- infection
- length
Additional Lipid Considerations
Maximum intake – do not exceed:
- ___% of caloric intake as lipid
- Generally ___ - ___ gm/kg/day of lipids in adults
- Max of ___ gm/kg/day of lipids in adults if tolerating
- 4 gm/kg/day of lipids in infants/pediatrics
Remember:
- Propofol is a 10% lipid solution; provides ___ kcal/mL
- 60%
- 1-1.5
- 2.5
- 1.1
IV Fat Emulsion – Administration
IV fat emulsion __ % and __ % are iso-
osmolar (isotonic) with serum
- May infuse via ___ vein
- Piggyback into PN
- Admix into dextrose/amino acid solution to decrease osmolarity
IV fat emulsion 30%
- Must be ___ into a total nutrient admixture (3-in-1)
- 10%, 20%
- peripheral
- incorporated
IV Fat Emulsion – Infectious Complications
IV lipids provide an environment suitable for ___ growth
- hang-time of IV fat emulsion by itself should be limited to ___ hours after opening of manufacturer packaging
- If added as TNA (3-in-1), safety is increased to __ hours
- pathogen
- 12
- 24
Administration of PN
Total nutrient admixture (“custom” TPN)
- ___ , ___ , and ___ in one bag
- “3-in-1” = TPN (total parenteral nutrition)
Conventional administration (“custom” TPN)
- Dextrose and AA in one bag
- Lipid 2-3 times a week as a ___ IVPB
Premix solution for injection (“standard” TPN)
- Available with or without electrolytes
- No ___
- Dextrose, AA, and lipids
- separate
- lipids
In-line Filters
Reduces infusion of particulates,
microprecipitates, ___ ,
pyrogens, and air
Filter sizes:
- ___ micron filter can be used for all total nutrient admixtures (TNAs) or 3-in-1 (w/ lipids)
- 0.22 micron filter only used for 2-in-1 formulations (no lipids)
microorganisms
1.2
Premix PN Solutions (Clinimix/Clinimix E)
“Standard” TPN
– Not able to customize these products
* Amino acid in dextrose
– With or w/o ___
* ___ compatible
* Peripheral and central line preparations
Clinimix (+/- E)
- CrCl < ___ , do not give electrolytes
electrolytes
lipid
50
PN Initiation & Discontinuation Guidelines
Start at ~ ___% of goal and achieve the final rate within ___ hrs
Example titration method:
- Start at 50 mL/hr x 4 hrs
- Then 75 mL/hr x 4 hrs
- Then 100 mL/hr x 4 hrs
- Then increase to final rate (if more than 100 mL/hr)
25%
24
PN Initiation & Discontinuation Guidelines (cont.)
Initiation:
– Check blood glucose q __ - __ hrs
– Before each increase in rate
– If BG > ___, continue at same rate x 4 hrs and recheck
– If repeat BG > 200, consider ___ therapy
Cessation:
– Decrease rate by half q __ hrs until rate < __ mL/hr; then discontinue
- 4-6
- 200
- insulin
- 2
- 50
- Infusion over ~ __ - __ hours per day
- Transitioning to EN or PO intake
- Patients who desire time free from the infusion pump (e.g., home PN patients)
- Rate of infusion generally cut back
(tapered) during the first/last hour of
infusion to prevent dysglycemias
No specific guidelines for cycling PN (max ~___ mL/hr)
- 12-18
- 200
Electrolytes
- Calcium: __ - __ mEq, start __ if normal
- Magnesium __ - __ mEq, start __ if normal
- Phosphorus __ - __ mMol* (or ___ mMol/kg to start, remember mMol to mEq conversions, x ___)
- Sodium __ - __ mEq/kg (or ~1/2NS)
- Potassium __ - __ mEq/kg to start (up to __ mEq/kg)
- Chloride As needed to maintain acid-base balance (~ __ /3)
- Acetate As needed to maintain acid-base balance (~ __ /3)
- 10-20 mEq, 10
- 8-24 mEq, 8
- 15-45, 0.3, 1.4
- 1-2
- 0.5-1, 2
- 2/3
- 1/3
Electrolyte Considerations
Sodium, potassium, calcium, magnesium, phosphorous, chloride, acetate
In patients with renal disease:
- Caution should be used with __ , ___ , and __
Acid-base balance obtained through balance of acetate and chloride
Avoid ___+ ___ precipitation
- Avoid Ca (mg/L) x Phos (mMol/L) > 150
- K, Phos, Mg
- Ca, Phos
Vitamins
Thiamin, riboflavin, niacin, folic acid, panthotenic acid, pyridoxine, cyanocobalamin, biotin, ascorbic
acid, A, D, E, K
Adult & Pediatric (> 40 kg)
- __ mL/day of injectable adult multivitamin-12
- Contains small amount of vitamin K (150 mcg)
Pediatric (3 kg - 40 kg)
- __ mL/day of injectable pediatric multivitamin
- Contains vitamin K
10
2
Trace Element Adjustments
Zinc, copper, chromium, selenium, manganese, Fe
Liver dysfunction (chronic liver disease or LFTs >2x ULN):
- ___ trace elements
Supplement individually:
- ___ 5 mg (1 mL)
- ___ 60 mcg (1 mL)
Renal disease (CKD/ESRD on hemodialysis):
- Consider checking serum levels if use expected beyond 14 days
- Use ___ and ___ with caution
- Different rules apply for CRRT
- Discontinue
- zinc
- selenium
- selenium, chromium
Iron
T or F: The addition of iron to PN is recommended
FALSE
- Can destabilize IV fat emulsion in 3-in-1 formulations
- May contribute to infectious complications
Medications in PN
For the most part, the addition of medications to PN formulations is not advised
- ___ may be utilized for GERD or stress ulcer prophylaxis
- ___ are not compatible with PN
Insulin:
- ___ insulin only
- __ - __ units “stick” to the bag
Common regimen: ___ units/gram of dextrose
- If BG > 150 mg/dL: 0.15 units/gram dextrose
- If BG > 300 mg/dL: do not initiate PN until < ___mg/dL
- Max amount: 0.3 units/gram dextrose
- famotidine
- PPIs
- regular
- 5-10
- 0.1
- 200
MIVF = __ - __ mL/kg/day
30-40 mL/kg/day
Balancing Ions
positives ( ___ , ___ ) - negatives ( ___ , ___ , and ___ )
remainder = what is left to balance
- must equal 0
- Na, K
- Cl, acetate, Phos
