Nutrition Flashcards
IBW equation
male: 50 +(2.3 x in over 60)
female: 45.5 + (2.3 x in over 60)
nutrition body weight equation
NBW = IBW + 0.25(wt-IBW)
when to use nutritional body weight
if actual body weight > 130% IBW
nutrition support has switched to what
nutrition therapy
when do we start enteral nutrition
as early as possible
all pts within 48 hours
malnutrition risk factors (8)
20% below IBW
invol weight loss >10% within 6 months
NPO > 7 days
gut malfunction
mechanical vent
increased metabolic needs: trauma/burn, high dose steroids
alcohol / substance abuse
nutrient losses: chronic disease states
what level of weight loss would be a risk factor for malnutrition
> 10% weight loss in 6 months
where are pts most at risk for malnutrition
ICU
what is NUTRIC
nutritional risk assesment score for ICU patients
NUTRIC high risk score
6-10
5-9 w/o IL-6
how to check protein status
weight
tricep skin fold
arm muscle circum
physical appearance
what is anthropometrics
protein stores
what is the best protein to measure
pre-albumin
prealbumin range
15-40 mg/dL
normal albumin level
3.5-5
if prealbumin low is pt malnourised?
not exactly, need to look at other factors
if prealbumin is decreased, what is CRP if pt is malnourished
CRP normal, <1
if prealbumin is decreased and patient just has inflammation what is CRP
elevated
what is protien-calorie nutrition called and what is it
Marasmus
decrease intake of food
some chronic dx pts
what is protien malnutrition called and what pts is this
Kwashiorkor
trauma / burn pts, catabolic and breaking down proteins
what is UUN
urinary urea nitrogen
measure of nitrogen released from protein catabolism
85-90% total excretion
what increases UUN
stress
increased protein catabolism
where do we lose nitrogen other than urine
sweat, feces, respirations, GI
what do we measure UUN for ?
measure the protein repletion adequacy
ideal nitrogen balance goal
+3 to +5 grams
nitrogen balance equation
(N in) - (N out)
n in = protein (g) / 6.25
n out = 24 hr UUN + 4
trauma/stress/surgery
critically ill
burns kcal
(hospital patients)
25-30 kcal/kg/day
TEE equation
REE x 1.2
goal RQ
0.85-0.95
mixed substrate
what RQ is overfeeding
> 0.95
what RQ is underfeeding
RQ <0.85
protein requirement for floor pt (mild to moderate stress)
1-1.5
NPC is what
non protein calories
carbs and fat
goal distribition for non-protein calories
70/30
70 from dextrose
30 from fat
patient with diabetes non protein calorie distribution
60/40
50/50
lower carbs
100/0 used when
100 percent from dextrose
used in bloodstream infection / sepsis
parenteral nutrion is given how
IV
parenteral nutrion other names
TPN, 3 in one, PN, TNA
parenteral nutrition indications
anticipated NPO > 7 days
can’t absorb nutrients through gut
small bowel/colonic ileus
small bowel resection
intractable vomit/diahrrhea
IBD
enterocutaneuous fistulas
hyperemesis gravidum (pregnancy sick)
peripheral PN, osmolarity restriction
total osmolarity < 900 mOsm/L
when do we do peripheral?
not much, should be short term and switched to central line
NICU is all peripheral
advantages and disadvantages of central line
adv: hypertonic, more calories
disad: infection risk, thrombus, air embolus, pneumothorax
CVC (central venous catheter) insertion sites
subclavian (SC)
inter jugular (IJ)
femoral
whats a PICC
peripherally inserted central catheter
longer term access
whats a triple lumen
three ports
one port used for TPN
where is subclavianh
chest
where is internal jugular
neck
where is femoral
groin
1 gram of protein = kcal
4 kcal
1 gram of carb = kcal
3.4 kcal
what do we use for carb source
D70W but dilute it so no more than 10%
maximum carb per min
4-5 mg/kg/min
1 g lipid = kcal
10 kcal
what do we need to check for with intralipid
soybean
egg allergy
glycerin
what do we need to check for with smof lipid
fish allergy
soybean allergy
SMOF lipid contents
soybean oil
medium chain triglycerides
olive oil
fish oil
types of fat lipids
SMOF lipid
intralipid
which lipid should we give most pts
SMOF lipid
max lipid per day
2.5 g/kg/day
how much lipid in propofol
1.1 kcal/mL
subtract from lipid requirements
risk with IV lipid and length we can hang
infection, pathogens can grow
only hang 12 hours by itself or 24 hours in TPN
TPN types
3 in 1 (carb, prot, fat)
2 in 1 (carb and protein, fat sep)
premix (no lipids)
whats an in line filter
filters TPN
catches pathogens, particulates
filter sizes for 3 in 1 and 2 in 1
3 in 1: 1.2 micron
2 in 1: 0.22 micron
premix TPN called what
Clinimix/Clinimix E
whats in Clinimix
dextrose, amino acid
no fat but compatible
electrolytes (E)
Can Clinimix be given peripheral
yes
who cant get ClinimixE
CrCl < 50
cant process electrolytes
CrCl formula
(140 - age) x IBW / 72 x SCr
x 0.85 if female
how do we titrate PN
start at 25% flow rate goal and titrate to final within 24 hours
what should we check when we are initiating PN
check blood glucose q4-6 h
before each increase
how do we adjust rate if BG >200
> 200 continue same rate x 4 hr
if still > 200 then start insulin
how do we stop TPN
decrease rate by half every 2 hours until < 50 mL/hr then discontinue
what is cycling PN
transitioning to EN/PO
patients want free time from pump
infusion over 12-18 hours
max rate for cycling PN
200 mL/hr
what electorlytes should we avoid in TPN for pt with renal dx
mag, phos, potassium
what electrolytes should we watch for in acid base disorder
acetate and chloride
what electrolytes do we need to avoid precipitate
calcium and phos
Ca x Phos > 150 BAD
what electrolytes go in a TPN
calcium
phos
mag
potassium
sodium
chloride
acetate
what vitamins go in a TPN
thiamin
riboflavin
niacin
folic acid
pnathotenic acid
pyroxidine
cyanacobalmin
biotin
ABCDEK
what product has all vitamins
multivitamin 12
which weight pts get adult multivitamin
> 40 kg
consideration with multivitamin 12
VIt K, warfarin
do we need trace elements
YES
who shouldnt get trace elements
liver dysfunction (liver disease or LFTS >2 x ULN)
supplement zinc and selenium seperately
CKD ( caution, check serum)
what is not part of trace elements in PN
iron
- destabilizes fat
- infection
can we give meds in TPN
no, only famotidine
NO PPIS
what kind of insulin can be added to TPN
regular only
MIVF
30-40 mL/kg/day
how much sodium goes in bag
77 mEq/L
how much potassium goes in bag
0.5-1 mEq/kg
how much calcium in bag
10 mEq/day
how much mag in bag
8 mEq/day
how much phos in bag
phos conv
0.3 mMol/kg
1 mMol phos = 1.4 mEq
how much acetate / chloride
2/3 chloride
1/3 acetate
LESS BASE
which ions are already balanced
calcium
magnesium
positive ions
potassium
sodium
negative ions
chloride
acetate
phos
how do we balance ions and decide acid /base
balance positives and negatives
convert phos to mEQ
subtract negs from pos
2/3 acid 1/3 base
mechanical complications of parenteral nutrition
line clotting
displacement
infectious complications of parenteral nutrition
sepsis
solution contamination
bacterial translocation
what is bacterial translocation and what can it cause
GI bacteria move to extra intestinal
can cuase pnemonia, central line infection, abcess
metabolic complications of parenteral nutritioon
imbalances
hyper/hypo glycemia
liver abnormalities
what do we need to baseline monitor in parenteral nutrition
CMP
mag
phos
calcium
hepatic function panel
prealbumin/CRP
PT/INR
glucose
how often do we get prealbumin/CRP
twice weekly
how often do we get triglycerides and respiraotry quotient
weekly
daily monitoring items parenteral nutrition
vital signs
ins/outs
CMP (electrolytes, glucose, BUN/SCr)
feeding tube placement
twice weekly monitoring parenteral nutrition
weight
CBC
Mag, phos, calcium
prealbumin/CRP
weekly monitoring parenteral nutrition
albumin, transferin, nitrogen balance
LFTs
triglycerides
INR
RQ/ indirect calorimetry
refeeding syndrome clinical findings
hypophosphatemia *** most likely
hypomagnesia
hypokalemia
resp. distress
arrythmias
anemia
how do we prevent refeeding syndrome in high risk?
dextrose
fluids
calories
limit dextrose to 100-150
limit fluids to 800 mL/day
calories 50%
provide adequate electrolytes
essential fatty acids are how much of daily calories
4-10%
what are essential faty acids
linoleic and linolenic acids
when does essential fatty acid deficiency happen
after 10-14 days on a fat free PN
what happens in essential fatty acid deficiency
inhibits lipolysis and fatty acid mobilization
how do we prevent essential fatty acid deficiency
give fat emulsion twice weekly
500 mL 10% or 250mL 20%
oral nutrition contraindications / enteral indiacations
esophageal obstruction
head / neck surgery
dysphagia
trauma
cerebrovascular accident
dementia
advantage of enteral nutrition
decreased chance of bacterial translocation
stimulates the GI
avoids IV line risks, pneumothorax
bolus is more physiologic
infectious morbidity and mortality is decreased with what kind of nutrition
enteral
enteral nutrition contraindications
mechanical obstruction
ileus
intractible vomiting
severe malabsorption
GI bleed
fistula
types of enteral nutrition tubes
naso/oro gastric
naso/oro jejunal
PEG/PEJ
when to use jejunal over gastric
most pts
risk aspiration
vomiting, gastric residuals
when to use PEG/PEJ
long term
ways to confirm placement of tube
auscultation
abdominal x ray
cortrak
4 ways to administer enteral nutrition
bolus
intermittent
continuous
trickle
what is bolus enteral feeding
mimics meals
primarily PEG tubes
200-400 mL over 5-10 min
bolus feeds adv and disadv
adv: easy, onhly need syringe
dis: can’t feed to small bowel, higher risk aspiration
intermittent feeding given over what time and how much
20-30 mins
>200 mL
intermittent feeding adv and disadv
adv: helps tolerance
dis: more equipment
continuos infusion given how
over 12-24 hours per day
continuous infusion preferred tube
jejunum
continuous infusion adv and disadv
adv: lower risk aspiration, better tolerated
dis: med admin hard, need infusion pump (kangaroo)
trickle feed used why
stimulate the gut
prevent mucosal atrophy and bacterial translocation
shorten ventilator time
trickle feed infusion rate
10-30 mL / hour
not enough to meet calorie goals
initiation goal in enternal nutirtion
50-60% of goal calories within firrsst week
do not initiate if hemodynamically unstable (heart, lung, brain)
what is Impact formula used for
in ICU, immune support
trauma, burn, intubated, surgery, cancer
what is protien in tube feeds made of
intact protein: requires digestion
partially digested - elemental, beneficial for pts with diarrhea
what is fat in tube feeds made of
long chain and medium chain fatty acids
tube feed carbs are made of
glucose polymers
who shouldnt get glutamine
if getting Impact, immune formula
who benefits from glutamine
burn patients (reduce mortality)
do probiotics help with diarrhea?
could cause more
GI complications with enteral
aspiration
N/V
decreased motility
diarrhea
constipation
when can we hold for residuals
> 500 mL
how to prevent aspiration
elevate head
continuous infusion
prokinetic agent
what prokinetic agents can we use with decreased motility
metoclopramide
erythromycin
naloxone
methylnaltrexone
what if pt is having diarrhea
change to soluble fiber containing or small peptide formulations
check for c diff
evaluate the meds
what kinds of meds cause diarrhea
hyperosmolar
sorbitol liquids
bowel regimen
broad spectrum antibiotics
most common electrolyte disturbance
hyponatremia
blood glucose goal in ICU
< 180
what dosage form preferred via enteral tubes
liquid
how to give capsule/tablet with enteral tube
crush tablet, open capsule and mix in water
which meds can we not crush
sustained or enteric coated
SL/buccal
hazardous
can meds be given together in feeding tube
no, give seperately
what to do in between meds with enteral tube
flush with water
how do we give hypertonic meds with enteral feed tube
dilute them in at least 30 mL of water before
what kinds of dosage forms to avoid in enteral
syrups
mineral oil
granules
correct flushing method to avoid tube clog
flush 15-30 ml water before and after admin
flush 5-10 in between
how to unclog the tube
slurry
10 mL warm sterile water + 1 bicarb tab + 1 pancreatic enzyme
clamp tube for 15 mins and flush
what meds interact with tube feed
fluoroquinolone
itraconazol
tetracyclines
penicillin
didanosine
-virs
levothyroxine
phenytoin
theophilline
warfarin
how to give meds that interact with tube feeds
hold tube feed
wait 1 hr
give med
wait 2 hr
resume feed
(will need to adjust feed rate)
in acute renal failure how much protein do they need
up to 2.5 g/kg/day
pts in hemodialysis need how much protein
0.8-1.2 g/kg/day less
pulmonary failure considerations
monitor phos closely
fluid restriction
acute pancreatitis considerations
can feed enterally
need more protein (1.2-1.5 g/kg/day)
parenteral nutrition does not affect pancreatic secretion and function
burn pt considerations
increased metabolic rate
start tube feeds in 12 hours
need more protein and calories
supplement vitamins
