Nutrition Flashcards by Ra Ma

Basic daily energy requirement

25-35 kcal/kg/day

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Daily protein requirement

0.8-1.5 g/kg/day (of which 0.13-0.24 g nitrogen/kg/day)

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Daily free water requirement

30-35 mL/kg/day

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Daily sodium requirement

1-2 mmol/kg/day

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Daily potassium requirement

1 mmol/kg/day

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Daily chloride requirement

1 mmol/kg/day

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Magnesium and Calcium requirement

0.1 mmol/kg/day

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Phosphate requirement

0.4 mmol/kg/day

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List 7 advantages of commencing early feeding in the ITU

Reduction in:
Overall complications
Readmissions
Length of stay
Infections/sepsis/antibiotic use
Pressure ulcers
Ventilation days
?Mortality

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Describe the advantages of post pyloric feeding

Reduction in ventilator-associated pneumonia
Useful in gastric outlet obstruction

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At what point should you consider starting TPN

Day 8 of starvation as reduced mortality as compared with early TPN on day 3

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How can you combat the fatty acid deficiency inherent to TPN?

Make up 3% of TPN calorie delivery with linoleic acid

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Which compounds are affected by refeeding syndrome?

Reduction in:
Phosphate
Magnesium
Potassium
Glucose
Thiamine
Vitamins

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What features should prompt for TPN use?

Non functioning GI tract
Ileus/poor absorption
Proximal high output / enterocutaneous fistula
Short gut syndrome
Oral mucositis

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What is “trophic enteral feed”?

A slow feed used in conjunction with TPN designed to prevent gastric atrophy
Usually run at 10-30mL/hr

What percentage of nutrition should be supplied by EN before discontinuing TPN?

50%

What are the disadvantages of TPN?

High Cost
No maintenance of GI Tract
Risks inherent to CVC
Specific risks of TPN:
- Large fluid load
- Liver function derangement
- Cholestasis
- Trace element deficiency (esp. copper, zinc, chromium)
- Fatty acid deficiency
- Hypovolaemia from osmotic diuresis
- Hypercarbia
- Hyperchloraemic metabolic acidosis
- HONK
- Hyperglycaemia (during infusion)
- Hypoglycaemia (during withdrawal)
- Hypernatraemia
- Hypophosphataemia
- Lipidaemia

What percentage of muscle mass is lost per day on the ICU?

1-2%/day

List the names of some formulas used to estimate calorie requirement in the critically unwell (4)

Pre-calculated:
- ACCP
- ESPEN

Formulaic (all include age, gender and weight):
- Schofield equation (includes stress factor)
- Ireton Jones equation (trauma/burns)
- Penn State equation (temp, MV)
- Harris Benedict equation (IBW Heigh)

What factors increase your metabolic requirements in ITU?

Burns
Trauma
Surgery
Fever
Pain
Physiotherapy

What factors decrease your metabolic requirements in ITU?

Hypothermia
Ventilation
Sedation
Paralysis

What are the advantages of TPN?

Can be used with EN contraindicated
Can be patient specific

What are the advantages of EN?

Cheap
Maintenance of the GI tract
- Structure and function
- Maintenance of immune functions
- Decreased bacterial translocation
Decreased stress ulceration
Decreased hypoglycaemia
No CVC required
Generally safer

What are the disadvantages of EN?

Often intolerant in ITU setting (e.g. burns, sepsis, trauma etc) Results in undernutrition May require prokinetics Misplaced NG tube can be disastrous Diarrhoea Nausea/Vomiting

What are the international guidelines of feeding in ITU?

ESPEN - all patients to receive nutritional support within 24-48 hours, use PN if EN contraindicated ASPEN - Early EN if possible, if not, no nutritional support for 7 days, commence PN thereafter

What did the CALORIES trial show (NEJM 2014)

Looked at early EN vs early PN (both initiated within 36 hours and continued for 5 days) No difference in 30 day mortality 50% of both groups failed to achieve nutritional goals

What are your calorie goals in critical illness

Increased mortality if <25% or >65% calorie goals Aim for 60-65% requirement Approx 16 kcal/kg/day

What are the disadvantages of post-pyloric feeding?

Difficult to site line (needs endoscopy) Increased tube blockage Increased tube displacement Alters the gastric phase of digestion Increased diarrhoea

What are the sequelae of refeeding syndrome?

Life threatening arrhythmias Increased O₂ consumption Neuromuscular disturbance

How should you treat refeeding syndrome?

Identification of at risk groups Slow initial feed (50% estimated requirement for 2 days) Slowly increase by 200-400 kcal/day Aggressive electrolyte correction Thiamine supplementation

What is refeeding syndrome?

Metabolic disturbance which occurs as a result of the commencement of nutrition in people who are malnutritioned