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864 > Nutrition > Flashcards

Nutrition Flashcards

1
Q

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

A
  • NBW = IBW + 0.25(wt – IBW)
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2
Q

Alleviate the Stress Response

  • Provide macro- and micronutrient delivery
  • Careful ___ control
  • Begin enteral nutrition ___
A
  • glycemic
  • early
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3
Q

Benefits of Early Initiation

decreased:
- disease ___ /complications
- ICU ___ of stay

better patient outcomes

A

severity
length

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4
Q

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*

A
  • 20%
  • 10%, 6
  • 10
  • 7
  • gut
  • ventilation
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5
Q

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*

A
  • burn
  • steroids
  • proteins
  • empty
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6
Q

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)
A
  • NUTRIC
  • Nutritional Risk Score (NRS-2002)
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7
Q

Screening Tools - NUTRIC

high risk: ___ - ___

A

6-10

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8
Q

Visceral Protein Status

MAY NOT ACCURATELY REPRESENT NUTRITION STATUS IN THE ICU
SETTING!
- look at both ___ and ___

A

transthyretin (prealbumin) and C-reactive protein (CRP)

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9
Q

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

A
  • 2-3
  • 15-40
  • decreases, normal
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10
Q

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 ___
A
  • inflammation
  • 1
  • prealbumin
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11
Q

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

A
  • Marasmus
  • Kwashiorkor
  • trauma, burn
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12
Q

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

A

protein
↑, ↑
3-5

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13
Q

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

A
  • protein intake
  • UUN

goal 3-5

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14
Q

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 ___

A

TEE = REE x stress/activity factor(s)

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15
Q

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)

A

20-25
25-30
11-14
22-25

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16
Q

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

A

REE
0.85-0.95

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17
Q

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)
A
  • 0.8-1
  • 1-1.5
  • 1.5-2
  • 2
  • 2.5, ideal
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18
Q

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)

A
  • NPC
  • renal, hepatic
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19
Q

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

A

70/30
100/0

20
Q

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 ( ___ )

A
  • 7
  • ileus
  • resection
  • mucositis
21
Q

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

A
  • hypertonic
  • 900
  • enhance
22
Q

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

A
  • large
  • calories
  • 7-10
23
Q

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

A
  • hypertonic
  • infection
24
Q

Central Venous Access

Central venous catheter (CVC) insertion sites
- ___ (SC)
- ___ (IJ)
- Femoral

Short term: ___ inserted

Long term:
- ___ (peripherally inserted central catheter)
- Tunneled
- Implanted ___

A
  • subclavian
  • internal jugular
  • percutaneously
  • PICC
  • port
25
Q

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%

A

4 kcal

26
Q

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)

A
  • 70
  • peripheral
  • 4-5
27
Q

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

A

concentrated
10

28
Q

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

A
  • Soybean
  • glycerin
  • egg yolk
29
Q

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)

A
  • soybean
  • medium
  • olive
  • fish
30
Q

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

A
  • Intralipid
  • liver
  • TG
  • inflammatory
  • liver
  • infection
  • length
31
Q

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

A
  • 60%
  • 1-1.5
  • 2.5
  • 1.1
32
Q

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)

A
  • 10%, 20%
  • peripheral
  • incorporated
33
Q

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

A
  • pathogen
  • 12
  • 24
34
Q

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 ___

A
  • Dextrose, AA, and lipids
  • separate
  • lipids
35
Q

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)

A

microorganisms
1.2

36
Q

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

A

electrolytes
lipid
50

37
Q

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)

A

25%
24

38
Q

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

A
  • 4-6
  • 200
  • insulin
  • 2
  • 50
39
Q
  • 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)

A
  • 12-18
  • 200
40
Q

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)
A
  • 10-20 mEq, 10
  • 8-24 mEq, 8
  • 15-45, 0.3, 1.4
  • 1-2
  • 0.5-1, 2
  • 2/3
  • 1/3
41
Q

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

A
  • K, Phos, Mg
  • Ca, Phos
42
Q

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

A

10
2

43
Q

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

A
  • Discontinue
  • zinc
  • selenium
  • selenium, chromium
44
Q

Iron

T or F: The addition of iron to PN is recommended

A

FALSE
- Can destabilize IV fat emulsion in 3-in-1 formulations
- May contribute to infectious complications

45
Q

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

A
  • famotidine
  • PPIs
  • regular
  • 5-10
  • 0.1
  • 200
46
Q

MIVF = __ - __ mL/kg/day

A

30-40 mL/kg/day

47
Q

Balancing Ions

positives ( ___ , ___ ) - negatives ( ___ , ___ , and ___ )
remainder = what is left to balance
- must equal 0

A
  • Na, K
  • Cl, acetate, Phos

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