Nutrition and Specific Disease States Flashcards
role of fiber in diabetes
slows down gastric emptying to reduce spike in blood sugar, reduces LDL and increases satiety
Is fiber recommended in gastroparesis
No
Probiotics mechanism of action
when probiotics reach the ileum/colon, endogenous bacteria consume and ferment pre biotics and produce short chain fatty acids which increases bacterial mass and enzyme activity
Uses for probiotics
help reduce flatulence, bloating, abdominal pain
What is the recommended fiber intake daily
20-35/day
detriments of too much protein
pre-renal azotemia, kidney stones, increased risk of osteoporosis
______ based sterols lower cholesterol absorption and are recommended as cholesterol lowering agents
soy based
Are immune modulating enteral formulas with omega 3 fatty acids and antioxidants recommended for Acute Respiratory Distress Syndrome or Severe Acute Lung Injury?
No
Which EN formulas should be considered for patients with traumatic brain injury
Formulas containing fish oil, arginine, omega 3 fatty acids with DHA (immune modulating)
What causes high creatinine loss
diarrhea, high output fistula or ostomy losses
Which populations are immune modulating EN formulas appropriate for per ASPEN
SICU
an amino acid which functions in immune function, wound healing, synthesis of nitrous oxide and plays roles in respiratory and cardiac function
arginine
hydroxy beta methylbutyrate (HMB) protein is shown to
increase lean muscle mass
HMB protein has been studied in which populations
AIDS, ALS and muscular dystrophy
symptoms of fatty acid deficiency
scaly rash, color spots, alopeica, dull/easily plucked hair, xerosis, follicular hyperkeratosis
Patients with liver cirrhosis are at risk for what deficiencies
fat soluble vitamins (ADEK) and thiamine
what is the recommended modality of artificial nutrition for an open abdomen
EN, when the peritoneum is left open and the viscera are protected with a temporary dressing
what type of EN feeding tube is recommended for gastroparesis in the setting of postprandial nausea and vomiting
jejunostomy
what mode of artificial nutrition is recommended in hyperemesis gravidarum
EN in conjunction with anti-emetic therapy
what are 3 parameters for assessing EN efficacy in pregnancy
maternal dry weight gain, fetal growth, nitrogen balance
what items should be labeled on an enteral product
Patient Name Product Name Strength Additives Volume Expiration Date and Time
advantages of a ready to hang enteral formula
decreases risk of infection (less to handle)
longer hanging time
decreased RN time
disadvantages of ready to hang EN formula
decreased individualization
could be accidentally be administered into IV tubing (sentinel event)
what is the most likely source of EN formula contamination
organisms on the hands of healthcare workers
what are 2 potential points of contamination of EN formulas
preparing and dispensing
in order to ensure feeding tube patency flush the tube how often for continuous/intermittent feedings
every 4-6 hours
in order to ensure feeding tube patency when giving medications flush ___ to ___mL of formula before/after each med using a ____ to ___mL syringe
15-30mL of water with a 50-60mL syringe
why shouldn’t small syringes be used to flush tubes
may cause rupture from too much pressure
if a fiber rich formula is being used, what is the recommended French size range
10-12 French
advantages of an open enteral feeding system
can be more individualized with the volume
reduces waste
what is the hang time for an open enteral feeding system
8-12 hours
what are the disadvantages of an open enteral feeding system
uses bags
only 8-12 hour hang time
higher risk of contamination than RTH
requires additional RN time
to minimize infections, enterally fed patients (open system) should have bags and tubing changed
every 24 hours
in a closed system enteral feeding what is the hang time/how long can it last after being opened
48 hours
what is the optimal storage temperature for EN formulas to prevent microbial growth and contamination
39 degrees F, 4 degrees C
the most likely formula to become contaminate is
blenderized
SIBO can cause
enteritis, marked diarrhea, abdominal cramps, hypoalbuminemia, protein catabolism, cachexia, fever, sepsis
what are potential causes of SIBO
altered GI anatomy, Roux-en-Y bypass, ileal resection
is PN in patients for chemo/radiation recommended for routine use per ASPEN
no, can cause infectious complications and no clinical improvement
ASPEN recommends thorough assessment of a cancer patients _________ and only use PN when ___ and ____ for __ to __ days
nutrition status
malnourished AND unlikely to use gut in 7-14 days
what is the preferred nutrition method for patients with cancer and a functional GI tract
enteral nutrition
PN as a primary treatment for ulcerative colitis has shown _____ benefit
NO
a patient with a high output ostomy of 3 liters, with an elevated BUN/Cr should have a treatment plan of while on PN
increased sodium fluids
sodium loss from a high output fistula can be up to
100 mEq/L
a high BUN:Cr ratio indicates
volume depletion
patients with ____ and ____ disease are more prone altered protein metabolism due to decreased excretion of urea
hepatic/renal disease
In a patient with elevated ammonia what is used for treatment and prevention
reduce total amino acids
restrict protein in refractory encephalopathy
(TRUE/FALSE) Nutrition support is understood to be a therapy to attenuate the metabolic response to stress, prevent metabolic oxidative stress, and modulate the immune response.
TRUE.
**What are the nutrition requirements for TBI?
- ENERGY: IC, if unable use 140% x the Harris-Benedict equation.
- PROTEIN: 1.3 to 1.5 g/kg/d
- Early nutrition is key, start EN ASAP
- Supplementation with zinc and IGF-1 has been shown to improve outcomes after TBI.
Define hyponatremia. What can it contribute to?
- Serum sodium less than 135 mg/dL.
- Contributes to worsening cerebral edema, intracranial pressure elevations and death from herniation
Define SIAD. How does it relate to TBI? What is the primary treatment?
- SIAD = Syndrome of Inappropriate Anti-Diuresis
- TBI is a common cause of SIAD, which results in euvolemic hyponatremia
- FR is primary treatment
Define CSW (Cerebral Salt Wasting). How does it relate to TBI? What is the treatment/management?
- A rare hypovolemic hyponatremia characterized by increased natriuresis (excretion of sodium in the urine).
- Like SAID, CSW is usually transient after TBI
- CSW is a diagnosis of exclusion
- Managed with IV Sodium supplemention
Define diabetes insipidus.
- A hypernatremic state characterized by a deficiency in vasopressin (neurogenic- most common type), lack of response to vasopressin (nephrogenic), OR accelerated degradation of vasopressin (gestational).
- BASICALLY: DAMAGE TO THE HYPOTHALAMUS OR POSTERIOR PITUITARY, usually as a result of rotational forces sustained in MVC, reduces central vasopressin production leading to neurogenic diabetes insipidius after TBI.
- Supplementation of salt-free water and replacement of vasopressin can reduce serum sodium to normal levels
(FILL IN THE BLANKS)
As with hyponatremia, hypernatremia should be corrected NO FASTER than X to X mEq/L/d to avoid worsening of cerebral edema.
- 10 to 12 mEq/L/day
- (relates to previous 3 conditions: SIAD, CSW, Diabetes insipidus).
What medications (4) used in TBI treatment have been shown to reduce measured energy expenditure?
- Proproanolol
- Reduced by 5 to 18%
- Morphine
- Reduced up to 8%
- Pentobarbital (used to reduce intracranial pressure)
- Reduced up to 32%
- NMBAS (also used to reduce intracranial pressure)
At present, which pharmaconutrients lack the available information to recommend specific dosing strategies for patients with TBI?
-
L-arginine
- Clinical research has not found that arginine supp in trauma and TBI improves outcomes
-
Glutamine
- Low plasma glutamine concentration at ICU admission is an independent risk factor for post-ICU morality in critically ill patients; but early provision of glutamine did not improve outcomes in large-scale study
-
Omega-3 FA
- No clinical data available
-
Antioxidants
- Ascorbic acid and alpha-tocopheral levels; not enough information
**What are the nutrition recommendations for energy and protein for patients with SCI (spinal cord injury?)
- ** ENERGY: IC first, or 15% less than Harris-Benedict equation (no validated predictive equation best determines the SCI energy expenditure)
- PROTEIN: 1.5 to 2.0 g/kg/d (immediately following a SCI)
**What are the general energy recommendations for weight maintenance for quadriplegic patients?
** 20 to 22 kcal/kg/d OR 55 to 90% of the Harris-Benedict equation.
**What are the general energy recommendations for weight maintenance for paraplegic patients?
** Energy recommendations are increased slightly to 22 to 24 kcal/kg/d OR 80 to 90% of the Harris-Benedict equation)
**What is the protein intake for patients in long-term care after a SCI?
**Healthy patients; 0.8 to 1.0 g/kg/d
If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.
**Healthy patients; 0.8 to 1.0 g/kg/d
If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.
**
EN start within 24 to 48 hours of admission.
**What are the energy requirements for patients with acute stroke?
- **IC is the gold standard; no equation has been validated to precisely determine the energy expenditure for the stroke population.
- Based on available data, the energy requirements following an ischemic stroke are likely close to estimated BMR via Harris-Benedict equation or Penn-State equation.
- Patients with hemorrhagic stroke, especially SAH, have elevated energy needs as compared with estimates of BMR.
**What are the protein requirements for patients following an acute stroke?
** Recommended protein goals range from 1.0 to 1.5 g/kg/d
If hypernatremia protocols aim for serum sodium ranges of 140 to 150 mg/dL to minimize cerebral edema, what should you recommend?
A concentrated enteral formula with 1.5 to 2.0 kcal/mL may be appropriate to provide less water. Then advancing to a standard formula as the patient progresses.
Explain the level 1 dysphagia diet.
PUREED (homogenous, very cohesive, and pudding-like in texture, requiring very little chewing ability.
Explain the level II dysphagia diet.
MECHANICALLY ALTERED
- Cohesive, moist, semisolid foods, requiring some chewing
Explain the level III dysphagia diet.
SOFT FOODS that requiring more chewing; most advanced dysphagia diet.
(TRUE/FALSE)
Although overeating creates risks for SCI patients, poor intake may increase the risk of pressure ulcers. When pressure ulcer incidence was examined in SCI patients, a higher percentage of underweight patients developed pressure ulcers compared to healthy weight, overweight or obese patients with SCI.
TRUE.
Monitoring weekly weight changes throughout the rehab program is useful in guiding adjustments in energy requirements.
Explain implication of nutrition status in patients with ALS.
- ALS = Lou Gehrig’s disease; a rapidly progressing, degenerative motor neuron disease that results in significant muscle weakness and atrophy
- 75% of ALS patients will experience bulbar involvement (includes muscles that control speech, swallowing, and chewing, that can lead to substantial weight loss)
- Malnutrition is an independent prognostic factor of ALS survival; 8-fold increase in poor nutrition status
- Early nutrition interventions has been shown to maintain good nutrition status for a longer period of time.
- PEG placement earlier in the disease process is more effective at preserving nutrition status for a longer period of time.
- ***It is recommended that PEG is placed whle forced vital capacity is more than 50% of predicted value or when patients has dysphagia or a BMI less than 20 or loses 5 to 10% of UBW.
**What are the energy requirements for patients with ALS?
- **Mifflin St. Jeor and Harris-Benedict equations have been shown to be the most accurate methods, with HB being the most practical
- Some research supports increasing the calculated resting energy expenditure by 10%
- Others: recommend energy needs to be 120% greater than BMR by IC and 130% x HB equation.
- As the ratio of organ mass to muscle mass increases, patients may require 34 to 35 kcal/kg/d
**What are the protein requirements for patients with ALS?
** Ranges from 0.8 to 1.2 g/kg/day
Explain the ketogenic diet.
- Well documented use for therapy in controlling seizures in the pediatric population
- To decrease seizures, a 4:1 ratio of fat to CHO and protein is recommended; which can be titrated down as the disease state stabilizes.
- Note many medications contain CHOs and must be taken into account when calculating diet.
Explain the modified Atkins diet.
- A 1:1 ratio fat to protein and CHO can be used once a patient’s seizure frequency is more stable.
- Shown to reduce seizures in adults and adolescents with drug-resistant epilepsy.
Limited information is known about nutrition and Parkinson’s disease. What is the overall pattern with body weight patterns in Parkinsons?
- In the beginning stages of the disease, body weight increases, likely due to a decrease in motor function.
- As the disease progresses, weight loss occurs. It is theorized that the metabolic rate increases because of worsening rigidity and dyskinesia.
Explain the relationship between carbidopa/levodopa drug therapy and protein intake.
- The medication and protein compete for transport in the SI and blood-brain barrier.
- Fluctuations in absorption in leveodopa can affect motor function, and this drug therapy. has been associated with decreased intake of protein.
- Higher levodopa requirements have been associated with increased constipation, and diet mgmt is recommended.
Define sepsis.
- Life-threatening organ dysfunction caused by a dysregulated host response to infection.
- The systemic response to infection
Define septic shock.
- Refers to a subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
- Associated with hemodynamic instability, which is primarily refractory hypotension with systolic peak pressure less than 90 mmHg, mean arterial pressures less than 65 mmHG or a drop of greater than 40 mmHg from baseline.
The metabolic response to sepsis is in many ways similar to the response that follows major surgery or trauma. What are both responses characterized by?
- Increases in energy expenditure
- Protein catabolism
- Oxidation of stored lipids alson with significant alterations in the body’s ability to metabolize CHOs
In what ways is appropriate nutrition therapy during sepsis and severe infections essential?
- Plays a key role in modulating the inflammatory response
- Maintaining immune function
- Abrogating skeletal muscle catabolism
- Improving wound healing
- Maintaining GI and pulmonary mucosal barrier function
What is the glucose target for patients with sepsis?
No greater than 180 mg/dL.
(TRUE/FALSE)
Following the onset of sepsis, glycogen stores are depleted within hours and endogenous lipid and protein become the major source of oxidative energy substrate.
TRUE.
Related to catabolic hormones stimulating glycogenolysis and gluconeogenesis.
However, oxidation of lipid from endogenous adipose stores is impaired during sepsis.
Why does sepsis result in hyperglycemia?
Sepsis results in hyperglycemia secondaryto alterations in:
- Endogenous glucose production
- Decreased glucose uptake
- Insulin resistance
Gluconeogenesis increases with progressive organ failure
(TRUE/FALSE)
Although protein breakdown and synthesis both continue to occur at acclerated rates during sepsis, patients remain in generalized net-negative N balance for variable periods even after the inciting insult has been resolved.
TRUE.
The acceleration of peripheral muscle protein breakdown noted in sepsis is accompanied by diminished AA uptake by muscle. Excreted in increased amounts in the urine during sepsis.
(TRUE/FALSE)
Mammalian species have no “storage” of protein and that any protein utilized during catabolic stress of any kind comes at the expense of other tissues that are more labile.
TRUE.
Explain hepatic reprioritization.
- During sepsis, hepatic uptake of AAs and hepatic protein synthesis are increased, which allows a substrate for gluconeogenesis and production of acute-phase protein.
- However, the increase in hepatic protein synthesis is NOT uniform
- Although serum concentrations of positive acute-phase proteins (such as haptoglobin and CRP), increase in response to stress, synthesis of negative acute-phase proteins, such as albumin and prealbumin, falls.
(FILL IN THE BLANK)
As the systemic response to sepsis progresses, protein catabolism XXXX, and the failure of synthetic processes to keep up with the breakdown rate results in XXXX of skeletal protein.
- INCREASES
- SEVERE LOSSES
What does prolonged catabolism of skeletal protein result in?
- Compromises respiratory function
- Impaires wound healing
- Exacerbates immunosuppression
- Accelerates the loss of strength and endurance necessary for recovery
- Increases ventilator-dependent time and ICU stay
- Increases thromboembolic disease
- Increase recovery time
- Increases mortality incidence.
(TRUE/FALSE)
**SCCM/ASPEN recommend that clinicians evaluate weight loss and nutrition history prior to admission, level of disease severity and GI function.
**TRUE
(TRUE/FALSE)
Practitioners are often concerned that EN may increase ischemic injury during states of decreased perfusion of the splanchnic organs in septic patients, especially if the patient is receiving vasoactive medications.
TRUE.
Lab evidence provides support for the OPPOSING VIEW: namely that EN provides protection and even enhances perfusion during septic states.
What are some approaches to maintaining visceral perfusion?
- Adequate resuscitation
- Glycemic control
- Correction of acidosis
- Correction of electrolyte abnormalities
- Minimizing the use of anticholinergic medications, narcotics and other medications that decrease intestinal motility
- Instituting EN, even at low rates, within the first 24 to 48 hours of the onset of SIRS or sepsis
**What are SCCM/ASPEN recommendations related to nutrition support in a critically ill septic patient?
**ASPEN/SCCM guidelines recommend trophic feeding (10 to 20 kcal/hr or 500 kcal/d) for the initial phase of sepsis, advancing as tolerated after 24 to 48 hours to greater than 80% of target energy goal over the first week.
**What are the SCCM/ASPEN recommendations related to PN in a critically ill septic patient?
**When a patient is in the acute phase of severe sepsis, the ASPEN/SCCM guidelines suggest NOT using exclusive PN or supplemental PN in conjunction with EN regardless of patient’s degree of nutrition risk.
Obviously, if the gut is deemed unreliable, PN may be selected.
What is the 3-armed approach to management of sepsis?
- Source control
- Early antibiotic administeration
- Resuscitation
Define hypotensive.
Mean arterial pressure less than 65 mmHg
(TRUE/FALSE)
There is a single laboratory/hemodynamic parameter signaling the successful resuscitation of the critically ill patient in shock.
FALSE.
There is NOT; Generally, clinicians use the trends in hemodynamic parameters, including mean arterial pressures, central venous pressures, and vasopressor requirements, in conjunction with urine output, arterial base deficit, serum lactate and venous oxygen saturations, to determine the relative success of resuscitation.
Define NMI (nonocclusive mesenteric ischemia.
- A uncommon compklication following the early initiation of enteral feeding in the underresuscitated patient
- It is a low flow state that most commonly affects the distribution of the superior mescenteric artery, which can result in irreversible ischemia and necrosis of the associated small and large bowel.
**When does SCCM/ASPEN recommend initiation of enteral support in critically ill septic patients?
**SCCM/ASPEN guidelines recommend that critically ill patients receive EN therapy within 24 to 48 hours of making the diagnosis of severe sepsis/septic shock, as soon as resuscitation is complete and the patient is hemodynamically stable.
Feeding immediately after the initial dx of sepsis yields a distinct set of problems.
How should GI intolerance be continually reassessed?
- Abdominal distention
- Increased gastric residual volumes
- Increased NG output
- Abdominal pain
- Diarrhea
(TRUE/FALSE)
Impaired gastric and proximal GI motility can be addressed efficiently through the placement of postpyloric feeding tubes.
TRUE.
They can be done successfully at bedside in more than 80% of patients.
What are two prokinetic agents?
- Erythromycin: acts on motilin receptors, resulting in increased motility, although its use may be limited by tachyphylaxis (short/rapid drug intolerance)
- Metoclopramide: a 5-HT(4) receptor agonist, works via cholinergic stimulation and is most effiacious in the proximal gut
No single prokinetic agent will have uniform success in the ICU, and the factors contributing to GI dysmotility in each patient must be considered.
**What are the energy requirements for patients with sepsis/septic shock?
- **Increases of 20 to 60% over basal expenditure
- Range of 20 to 30 kcal/kg/d is considered safe for critically ill patients (excluding the morbidly obese)
**What are the CHO recommendations related to energy expenditure in critically ill septic patients?
- **CHO administeration should supply 50 to 60% of the total energy prescription to avoid exceeding the maximum contribution of glucose oxidation and contributing to excess lipogenesis.
- Glucose admin. rates greater than 4 to 6 mg/kg/min result in excess lipogensis and lead to hyperglycemia.
**In critical care and sepsis patients, the amount of ILES should not exceed XXXXX, if XXXX.
- **1.0 g/kg/d
- if soybean oil is the source of lipid.
Guidelines for enteral lipid delivery are similar to those for parenteral lipid provision. The usual lipid goal of 1.0 g/kg/d can be liberalized when enteral lipids include lipid substrates containing omega-3 FAs, MCTs, and SCFA. And a mixture of lipid fuels should be delivered whenever possible.
(TRUE/FALSE)
**Conflicting data prevented the ASPEN/SCCM guidelines from making a recommendation for use of anti-inflammatory lipid formulas at this time.
TRUE.
**What are the SCCM/ASPEN guidelines for protein in sepsis?
** 1.5 to 2.0 g/kg/d (possibly even up to 2.5 g/kg/d in selected cases).
(TRUE/FALSE)
**ASPEN/SCCM guidelines recommend use of an arginine/fish oil formula only in surgical ICU patients and do NOT recommend their routine use in patients with sepsis alone.
**TRUE.
(TRUE/FALSE)
**SCCM/ASPEN guidelines recommend that clinicians supplement severely ill ICU patients with enteral or parenteral glutamine.
FALSE.
It is NOT recommended.
**Does SCCM/ASPEN have specific guidelines for supplementing zinc, selenium, or antioxidants in sepsis?
**NO
There is not a definitive recommendation.
The literature suggests clinicians provide at least the RDA of antioxidants vitamins and trace elements to critically ill patients throughout hospitalization.
Define SIRS.
Systemic Inflammatory Response Syndrome (SIRS)
- Entails the presence of 2 out of 4 abnormal systems
- Heart Rate
- Respiratory Rate
- Temperature
- WBC count
- When 2 of these are met, the local injury of trauma or burn is producing a systemic reaction.
Name some counter-regulatory hormones.
- Epinephrine
- Norepi
- Glucagon
- Cortisol
Named as such because they oppose the effects of insuling and other anabolic hormones. The responsiveness of tissues, especially skeletal muscle, to insulin is severly blunted.
Name the 3 effective treatment strategies of SIRS.
- Delivery of oxygen to vital tissues
- Source control (control of bleeding, necrotic, and infected tissues)
- Provision of nutrition support.
Define mucosal acidosis.
A measure of reduced intraoperative splanchnic perfusion, is associated with:
- Exaggerated local and systemic immune responses
- Increased intestinal permeability
- Increase in septic complications
- A trend toward increased multiorgan dysfunction syndrome
Define postprandial hyperemia.
The presence of luminal nutrients increases GI blood flow.
(TRUE/FALSE)
Clinical and laboratory evidence suggests that EN is contraindicated with the use of vasopressive agents.
FALSE.
IT IS NOT contraindicated. Use of EN in such patients should be conservative, with the EN advanced only when the patient demonstrates tolerance. Following adequate resuscitation, EN may protect the GI tract, especially the mucosa, from relatively low levels of ischemia.
(TRUE/FALSE)
Malnutrition related to stress or trauma differs from starvation-related malnutrition in that the former stems from increased resting energy expenditure and tremendous mobiliation of protein deposits.
TRUE.
It is driven by systemic inflammation. This systemic inflammation can drive catabolism to the severity of affecting cardiac mass and function. Which can continue for weeks to months after the patient is discharged from the ICU.
Noted as “acute-disease” or “injury-related malnutrition” to acknowledge this phenomenon.
**ASPEN/SCCM guidelines recommend assessment using XXXXX or XXXXX to identify patients who would benefit from nutrition therapy.
- NRS-2002 (Nutrition Risk Screening)
- Attempts to account for both preexisting malnutrition (ie: weight loss, decreased food intake) AND severity of illness (ie: type of injury, APACHE II score)
- NUTRIC (Nutrition Risk in Critically Ill)
- Focus on severity of illness.
What are the 3 main categories for surgical ICU patients?
- Postoperative major elective surgery
- Major injury (ie: burns and trauma)
- Serious sepsis
(TRUE/FALSE)
Body weight measured in the ICU is not a valid indicator of body cell mass.
TRUE.
Ideally, weight changes should be monitored weekly. Acute weight changes are most likely due to fluid shifts, as 1 L of fluid equals 1 kg body weight.
(TRUE/FALSE)
Fluid shifts and increased permeability change the proportion of fluid to protein, effectively altering the measured concentration of serum proteins. Therefore, in patients with acute illness, inflammation, or injury (such as in the early postoperative period and in trauma and burn patients), transport proteins cannot reliably be regarded as a marker of nutrition status, but can only be interpreted as a marker of severity of illness and inflammation.
TRUE.
Albumin, prealbumin, transferrin, and retinol-binding protein, are negative acute phase response proteins.
**How should energy needs be calculated in trauma patients?
**ASPEN/SCCM guidelines recommend using IC to measure resting energy expenditure in the critically ill, surgical, injured and burn patients, when it is available.
Describe the “PEPuP protocol.”
- Driven by the bedside nurse
- Uses daily volume based goals, liberalizes the GRV threshold, and initiates protein supplementation with motility agents on Day 1 of a patient’s ICU stay.
- Increased protein delivery by 14% and energy by 12% in trial.
Once a PEG tube is placed, how long do you have to wait until TF is initiated?
May be used for feeding within 2 hours; instead of the routine 24-hour delay.
**What is the current recommendation for stressed patients (including those with burns), for protein?
- **20 to 25% of total nutrient intake by provided by protein
- Equates to ~ 1.5 to 2.0 g/kg/d, with the higher range to promote N equilibrium
- 2.0 g/kg/d IBW has been suggested for obese patients (BMI equal or greater than 30)
- In patients with large surface area burns, 3 to 4 g/kg/d may be required.
(TRUE/FALSE)
It has been suggested that ICU patients receiving continuous renal replacement therapy (CRRT) should receive 2.0 to 2.5 g/kg/d to overcoe protein losses in the dialysate.
TRUE.
What is the minimum amount of dextrose necessary to maintain CNS function?
120 g/day
What are isomotic fluids (such as NS and lR) used for?
- Isomotic fluids or balanced electrolyte solutions are typically used for fluid and electrolyte replacement
- When these are used as maintenance, 5% dextrose will be added as an energy source (for protein sparing, prevention of ketosis and maintanence of stable glucose levels).
What is the Parkland formula?
- Most commonly used method to determine adult fluid resuscitation requirements
- Used for patients with greater than 15% TBSA second- and third-degree burns.
- (4 mL LR for X body weight (kg)) X (TBSA)
- One half of this total amount is administered in the first 8 hours after the burn
- The remaining amount is given over the next 16 hours, followed by maintenance fluids.
- Inhalation injury results in additional fluid needs and is often estimated as another 10% of TBSA.
(FILL IN THE BLANK)
Monitoring urine output is an essential part of providing fluid to thermal injury patients, as adequate hydration should result in a minimum of XXXX.
- 0.3 to 0.5 mL/kg/hour
What are the vitamin/mineral recommendations for burn patients with less than 20% TBSA and burn patients undergoing delayed reconstructive patients?
A daily MVI
