Nutrition

Question 1

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

Answer 1

• NBW = IBW + 0.25(wt – IBW)

Question 2

Alleviate the Stress Response

• Provide macro- and micronutrient delivery
• Careful ___ control
• Begin enteral nutrition ___

Answer 2

• glycemic
• early

Question 3

Benefits of Early Initiation

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

better patient outcomes

Answer 3

severity
length

Question 4

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*

Answer 4

• 20%
• 10%, 6
• 10
• 7
• gut
• ventilation

Question 5

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*

Answer 5

• burn
• steroids
• proteins
• empty

Question 6

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)

Answer 6

• NUTRIC
• Nutritional Risk Score (NRS-2002)

Question 7

Screening Tools - NUTRIC

high risk: ___ - ___

Answer 7

6-10

Question 8

Visceral Protein Status

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

Answer 8

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

Question 9

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

Answer 9

• 2-3
• 15-40
• decreases, normal

Question 10

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 ___

Answer 10

• inflammation
• 1
• prealbumin

Question 11

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

Answer 11

• Marasmus
• Kwashiorkor
• trauma, burn

Question 12

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

Answer 12

protein
↑, ↑
3-5

Question 13

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

Answer 13

• protein intake
• UUN

goal 3-5

Question 14

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 ___

Answer 14

TEE = REE x stress/activity factor(s)

Question 15

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)

Answer 15

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

Question 16

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

Answer 16

REE
0.85-0.95

Question 17

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)

Answer 17

• 0.8-1
• 1-1.5
• 1.5-2
• 2
• 2.5, ideal

Question 18

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)

Answer 18

• NPC
• renal, hepatic

Question 19

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

Answer 19

70/30
100/0

Question 20

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 ( ___ )

Answer 20

• 7
• ileus
• resection
• mucositis

Question 21

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

Answer 21

• hypertonic
• 900
• enhance

Question 22

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

Answer 22

• large
• calories
• 7-10

Question 23

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

Answer 23

• hypertonic
• infection

Question 24

Central Venous Access

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

Short term: ___ inserted

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

Answer 24

• subclavian
• internal jugular
• percutaneously
• PICC
• port

Question 25

# 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%

Answer 25

4 kcal

Question 26

# 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)

Answer 26

- 70 - peripheral - 4-5

Question 27

# 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

Answer 27

concentrated 10

Question 28

# 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

Answer 28

- Soybean - glycerin - egg yolk

Question 29

# 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)

Answer 29

- soybean - medium - olive - fish

Question 30

# 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

Answer 30

- Intralipid - liver - TG - inflammatory - liver - infection - length

Question 31

# 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

Answer 31

- 60% - 1-1.5 - 2.5 - 1.1

Question 32

# 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)

Answer 32

- 10%, 20% - peripheral - incorporated

Question 33

# 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

Answer 33

- pathogen - 12 - 24

Question 34

# 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 ___

Answer 34

- Dextrose, AA, and lipids - separate - lipids

Question 35

# 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)

Answer 35

microorganisms 1.2

Question 36

# 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

Answer 36

electrolytes lipid 50

Question 37

# 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)

Answer 37

25% 24

Question 38

# 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

Answer 38

- 4-6 - 200 - insulin - 2 - 50

Question 39

- 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)**

Answer 39

- 12-18 - 200

Question 40

# 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)

Answer 40

- 10-20 mEq, 10 - 8-24 mEq, 8 - 15-45, 0.3, 1.4 - 1-2 - 0.5-1, 2 - 2/3 - 1/3

Question 41

# 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

Answer 41

- K, Phos, Mg - Ca, Phos

Question 42

# 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

Answer 42

10 2

Question 43

# 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

Answer 43

- Discontinue - zinc - selenium - selenium, chromium

Question 44

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

Answer 44

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

Question 45

# 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

Answer 45

- famotidine - PPIs - regular - 5-10 - 0.1 - 200

Question 46

MIVF = __ - __ mL/kg/day

Answer 46

30-40 mL/kg/day

Question 47

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

Answer 47

- Na, K - Cl, acetate, Phos