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PHRM 864 Exam 3 > Nutrition > Flashcards

Nutrition Flashcards

1
Q

Risk Factors for Malnutrition

A

UBW (under body weight) =20% below IBW

Involuntary weight loss >10% within 6 months

NPO > 10 days: clinically we use inadequate > 7 days

Gut malfunction

Mechanical ventilation

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2
Q

Risk Factors for Malnutrition (cont.)

A

Increased metabolic needs: trauma or burn patients, high dose steroids

Alcohol/substance abuse

Protracted nutrient losses

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3
Q

Determination of Nutrition Risk

A

All hospitalized patients within 48 hours

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4
Q

Screening Tools

A

NUTRIC

Nutritional Risk Score (NRS-2002)

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5
Q

NUTRIC

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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6
Q

History

A

Dietary: intake, swallowing, ulcers, weight loss, anorexia, vomiting, diarrhea

Medical: surgical history, PMH

Medications: decrease nutrient absorption, alter taste, increase/decrease appetite, N/V

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7
Q

Anthropometrics (look at protein stores)

A

Somatic protein status: weight, triceps skin fold, arm muscle circumference, physical appearance

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8
Q

Preablbumin

A

Half life: 2-3 days

Normal concentration: 15-40 mg/dL
In real-life: > 10 mg/dL

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9
Q

C-Reactive Protein (CRP)

A

Normal concentration: < 1 mg/dL
Assess accuracy of pre-albumin

Pre-albumin decreases as CRP increases–> inflammation

Pre-albumin decreases as CRP normal–> malnutrition

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10
Q

Marasumus

A

Protein and calorie malnutrition–> decrease in total intake or utilization

Characteristics: wasting of skeletal and subQ fat, immunosuppression, cachectic appearance

Treatment: well-balanced substrate + Vitamin B

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11
Q

Kwashiorkor

A

Protein malnutrition–> adequate calorie intake

Characteristics: large belly

Who? Catabolic trauma or burn patients

Treatment: carbohydrates followed by high protein

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12
Q

Mixed

A

Chronically ill starved patients who are metabolically stressed

Characteristics: decrease in visceral proteins, poor wound healing, immunocompromised

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13
Q

Nitrogen balance

A

Measurement of urinary excretion of nitrogen as urea nitrogen (UUN)

Nitrogen released from protein catabolism that is converted to urea and excreted in the urine

Goal: +3 to +5

N(in)-N(out)
N(in)=24-hr protein intake/6.25
N(out)=24-hr UUN +4

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14
Q

Kcal requirements

A

Trauma/stress/surgery/burn/illness: 25-30 kcal/kg/day

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15
Q

Indirect Calorimetry (preferred in critically ill patients)

A

Provides energy expenditure at that ONE point in time and then extrapolated to 24 hours

TEE=REE x 1.2
RQ=Vco2/Voz
Goal: 0.85-0.95

< 0.85–>underfeeding
> 0.95–> overfeeding

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16
Q

Protein requirements

A

Mild/moderate (FLOOR PTs): 1-1.5 g/kg/day
Moderate/severe (ICU/SURGERY/TRAUMA/BURN): 1.5-2 g/kg/day

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17
Q

Non-Protein Calorie Distribution

A

Standard: 70/30
70% dextrose
30% fat

Sepsis/bloodstream infections (fungal) : 100/0
100% dextrose
0% fat

Adjustments:
Blood sugar: reduce dextrose
Triglycerides: reduce fat

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18
Q

Parenteral nutrition indications

A

Anticipated prolonged NPO > 7 days

Small bowel or colonic ileus–>bowel stomachs moving

Extensive small bowel resection

Malabsorptive states

Intractable vomiting/diarrhea

Enterocutaneous fistules

Inflammatory bowel disease

Hyperemesis gravidum

Bone marrow transplantation

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19
Q

PN initiation and discontinuation

A

Start at 25% of goal and titrate up to goal within 24 hours
Check BG every 4-6 hours

BG > 200: continue x 4 hours and repeat
BG < 200 after repeat: insulin

Cessation: decrease rate by 50% every 2 hours until < 50 mL/hr THEN d/c

Cycling: infusion over 12-18 hours/day
Max rate: 200 mL/hr

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20
Q

Peripheral Route of Administration

A

Barriers:
-Solutions are hypertonic (dextrose,AA)
-Requires large volumes of fluid (not best for HF, AKI)
-Limited in calories
-Short term access ( < 7-10 days)

Solutions:
-Restrict dextrose concentration to 5-10%
-Total osmolarity < 900 mOsm/L

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21
Q

Central Route of Administration

A

Advantages:
-Administration of hypertonic solutions (dextrose, AA)
-Larger amounts of calories

Disadvantages:
-Risk of infection
-Not a benign procedure (pneumothorax, air embolus, thrombus, etc)

Access:
-Subclavian (SC)–> in the chest
-Internal jugular (IJ)–> in the neck
-Femoral–> in the groin

Short-term: percutaneously

Long-term:
-PICC, tunneled, implanted port

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22
Q

Protein

A

1 gram- 4 kcal

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23
Q

Carbohydrates

A

1 gram= 3.4 kcal

Maximum carb rate=4-5 mg/kg/min

Restrictions: dextrose concentration must be < 10% in adults for a peripheral vein

Dextrose concentration must be < 12.5% in pediatrics

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24
Q

Fat (lipid)

A

1 gram=10 kcal: prevents essential fatty acid deficiency

DO NOT EXCEED 60% of calorie intake
DO NOT EXCEED 2.5 g/kg/day
4 g/kg/day in pediatrics

PROPOFOL IS 10% LIPID–>1.1 kcal/mL

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25
Q

Intralipid 10%

A

Soybean oil 10%–> high in linoleic acid (omega-6)
Glycerin 2.25%–> CHECK ALLERGIES
Egg yolk phospholipid 1.2%–> CHECK ALLERGIES
Water for injection

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26
Q

SMOFlipid

A

Soybean oil 30%–>high in linoleic acid
Medium-chain triglycerides 30%
Olive oil 25%–>omega-9
Fish oil 15%–>omega-3-CHECK ALLERGIES

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27
Q

Advantages of SMOFlipid

A

Improved liver function
Lower increase in TG levels
Less pro-inflammatory
Reduced risk of infection and decrease length of hospital stay

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28
Q

Administration of lipids

A

IV Fat Emulsion 10 and 20%–>peripheral vein, piggyback in PN, admix into dextrose/AA solution

Max hang-time: 12 hours

IV Fat Emulsion 30%–>total nutrient admixture (3-in-1)

Max hang-time: 24 hours

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29
Q

Electrolytes

A

Considerations:
-Renal disease: caution K+, Phos, Mg+
-Avoid Ca x Phos > 150–>precipitation

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30
Q

Sodium

A

1-2 mEq/kg

31
Q

Potassium

A

0.5-1 mEq/kg up to 2 mEq/kg

32
Q

Calcium

A

10-20 mEq

33
Q

Magnesium

A

8-24 mEq

34
Q

Phosphorus

A

15-45 mMol

1mMol=1.4 mEq

35
Q

Chloride/Acetate

A

Cl: 2/3

Acetate: 1/3

36
Q

Vitamins

A

Adult (>40 kg): 10 mL of multivitamin
-Small amount of Vitamin K (150 mcg)

Pediatric (3-40 kg): 2 mL of multivitamin
-Small amount of Vitamin K (150 mcg)

37
Q

Trace Elements

A

Considerations:

38
Q

Mechanical complications of PN

A

Clotting of the line
Displacement of the line

39
Q

Infectious complications of PN

A

Catheter-related sepsis
Solution contamination

Bacterial translocation: if you stop feeding the gut, you stop making the acid to suppress bacteria allowing bacteria to go from below diaphragm to above diaphragm
-pneumonia, central line infection, abscess, multi-organ dysfunction syndrome

40
Q

Metabolic complications of PN

A

Hyper/hypoglycemia
Electrolytes imbalances
Fluid imbalance
Liver dysfunction
-Steatosis
-Intrahepatic cholestasis
-Cholelithiasis

41
Q

Clinical Signs of Refeeding Syndrome

A

Hypophosphatemia, hypomagnesemia, hypokalemia

Respiratory distress–>phos controls muscle contraction in diaphragm

Cardiac arrhythmia’s–> potassium controls

Anemia

Paraesthesia

Tetany

42
Q

Risk factors of refeeding syndrome

A

Rapid feeding and excessive dextrose infusion

Low BMI ( < 16-18.5)

Excessive weight loss

Insufficient caloric intake

Low levels of Phos, K, Mg prior to feeding

Loss of subQ fat or muscle

Alcoholism, anorexia, marasmus

43
Q

Prevention of Refeeding syndrome

A

REPLETE ELECTROLYTES BEFORE FEEDING

Day #1
Limit carbs to 100-150 gm
Limit fluids to 800 mL/day
Give only 50% of caloric needs
Thiamine 100 mg daily x 5-7 days

44
Q

Essential fatty acid deficiency

A

Goal: 4-10% of daily calories

Onset: 10-14 days on fat-free nutrition

Symptoms: dry scaly skin, brittle hair, lack of luster

Prevention:
At least 500 mL of 10% fat emulsion at least 3-5 hours twice weekly
OR
At least 250 mL of 20% fat emulsion over at least 5-9 hours twice weekly

45
Q

Baseline monitoring

A

CMP, Mg, Phos, Ca

Hepatic function

Pre-albumin/CRP

PT/INR

Blood glucose every 4-6 hours

Residuals, distention, vomiting, aspiration 4-6 hours

46
Q

Daily monitoring

A

Vital signs

Intake/outtake

CMP

Feeding tube placement and patency

47
Q

Twice weekly monitoring

A

Weight

CBC

Mg, phos, Ca

Prealbumin/CRP

48
Q

Weekly monitoring

A

Albumin, transferrin, nitrogen balance

Liver function

Triglycerides

RQ

PT/INR

49
Q

Clinimix/Clinimix E

A

Dextrose + AA +/- electrolytes

With or without electrolytes
CrCl < 50: clinimix
CrCl > 50: clinimix E

Peripheral or central

50
Q

Indications for EN

A

if the gut works, use it

Oral consumption inadequate
Oral consumption contraindicated

Esophageal obstruction
Head and neck surgery
Dysphagia
Trauma
Cerebrovascular accident
Dementia

51
Q

Contraindications to EN

A

Mechanical obstruction–>hernia, tumor, adhesions, scar tissue

Non-mechanical obstruction–>ileus

Intractable vomiting

Severe malabsorption

Severe GI hemorrhage

Fistulas

52
Q

Advantages of EN

A

Provides GI stimulation
-Decreased chance for bacterial translocation
-Stimulates biliary flow

Avoids line injections and pneumothorax

MORE PHYSIOLOGIC THAN PN

53
Q

Initiation of EN

A

Start at full strength at 25 mL/hr
Increase 25 mL/hr every 4-6 hours up to goal rate in 24 hours
Achieve 50-60% of goal calories within the first week

DO NOT START IF HEMODYNAMICALLY UNSTABLE–> intestinal ischemia
Monitor residuals every 4-6 hours
Hold for residuals > 500 mL

54
Q

Which type of administration for EN

A

Low risk of aspiration: gastric
High risk of aspiration: jejunal
Vomiting: jejunal
Gastric residuals: jejunal
Long-term: PEG or PEJ

55
Q

Bolus administration

A

Who? Patients with PEG/PEJ (nursing home, ambulatory)
What? > 200 mL formula over 5-10 minutes
Max volume 300-400 mL

Advantages: more convenient, requires minimal equipment, less interactions

Disadvantages: must be gastric tube, higher risk for aspiration

56
Q

Intermittent administration

A

Administer > 200 mL formula over 20-30 minutes: 4-8 feedings per day

Advantage: helps tolerance

Disadvantage: more equipment required–>reservoir bag/bottle

57
Q

Continuous infusion administration

A

most common

Who? Patients with jejunal tube

What? Administer continuously over 12-24 hours/day

Advantages: Low risk of gastric distention or aspiration, better tolerated

Disadvantages: More equipment required–>infusion pump, medication administration issues

58
Q

Trickle or Trophic

A

What? Administer slow continuous infusion at 10-20 mL/hr

Advantages: prevent mucosal atrophy and bacterial translocation, shorten time on ventilator

Disadvantages: difficult to achieve sufficient calorie delivery

59
Q

Types of formula

A

Jevity–>standard
Impact 1.5–>sepsis
Glucerna–>diabetes
Nepro–> renal disease

60
Q

Carbohydrates

A

Glucose polymers in tube feed

Simple glucose for oral supplements

61
Q

Protein

A

Intact and partially digested

Intact: requires complete digestion

Partially digested (elemental): beneficial for malabsorption or diarrhea

62
Q

Fat

A

Long chain fatty acid
Medium-chain fatty acid: more water soluble leading to rapid hydrolysis–> no lipase

63
Q

Fiber

A

Who? constipation
What? 1 packet/tbsp
How much? 3 g

64
Q

Protein (prostat)

A

Who? Burn, trauma, etc
What? 30 mL tube
How much? 15 g

65
Q

Juven

A

Who? Wound care, HIV/AIDS, Cancer

66
Q

Glutamine

A

Who? Burn patients
What? 0.3-0.5 g/kg/day over 2-3 doses
DO NOT GIVE IF ON IMPACT 1.5–>already receiving

67
Q

Probiotics

A

Who? Diarrhea

Inhibit pathogenic bacterial growth, block pathogen attachment, eliminate toxins, enhance host inflammatory response

68
Q

Vitamins

A

Vitamin E and Vitamin C

69
Q

Trace Elements

A

Who? burn, trauma, mechanically ventilated

70
Q

Mechanical complications of EN

A

Clogging of the feeding tube

Tube malabsorption

Rhinitis: reposition daily, use smaller bore tube, change from NG to OG

Sinusitis

71
Q

Metabolic complications of EN

A

Hyper/hypoglycemia
Goal: 140-180 mg/dL

Electrolytes imbalances–> hyponatremia is the most common
Fluid imbalance

72
Q

Aspiration

A

Elevate the head of the bed by 30-45 degrees
Post pyloric delivery
Continuous tube feed at smaller volume
Prokinetics: metoclopramide or erythromycin, naloxone, methylnaltrexone

73
Q

Nausea/vomiting

A

metoclopramide or erthyromycin

74
Q

Diarrhea

A

Change to fiber-containing or small peptide
Consider C.diff
Evaluate medications: hyperosmolar meds, liquid formulations containing sorbitol, bowel regimen, broad spectrum antibiotics

PHRM 864 Exam 3 (9 decks)

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