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IMS: Nutrition > Nutrition for the Critically Ill > Flashcards

Nutrition for the Critically Ill Flashcards

1
Q

Consequences of Impaired Nutrition

in a

Non-critical Patient

A
  • ↑ incidence nosocomial infections
  • longer hospital stay
  • ↑ mortality
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2
Q

Malnutrition

Immune Effects

A
  • ↓ production of complement and Ig
  • ↓ cellular immunity
  • impaired WBC function
    • chemotaxis
    • phagocytosis
    • oxidative burst
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3
Q

Malnutrition

Wound Healing Effects

A
  • Impaired inflammatory phase
    • d/t WBC function
  • Impaired proliferative phase
    • d/t collagen synthesis
  • Impaired remodeling phase
    • d/t collagen turnover
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4
Q

Malnutrition

Muscle Mass Effects

A
  • progressive loss of muscle mass and tone
  • loss of respiratory muscles ⟾ ventilator dependence
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5
Q

Malnutrition

in

Hospitalized Patients

A

30% of hospitalized patients malnourished.

Causes:

  • Anorexia
    • cancer
      • radiation/chemo
    • sepsis
    • liver disease
  • Poor intake due to GI problems
    • obstruction
    • ileus
  • Bowel pathology
    • scleroderma
    • inflammatory bowel disease
    • s/p gastric resection
  • Excessive loss
    • protein losing enteropathies
    • GI fistulas
  • Iatrogenic causes
    • hospital food served without assistance
    • NPO status for tests
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6
Q

Hypercatabolic State

A

Associated with stress from:

  • Injury
    • burns
    • trauma
      • With a TBI → [norepi] x7 of normal
  • Sepsis
    • infection
    • inflammation

Due to neuroendocrine response & inflammatory cytokines:

  • Neuroendocrine response
    • Epi
    • Glucagon
    • Steroids
  • Cytokines
    • IL-1, IL-2, IL-6
    • TNF
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7
Q

Burn Injury

A
  • BEE is 140% above baseline s/p injury
  • Remains elevated at 110% for up to 1 year after injury
  • Proportional to extent of burn
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8
Q

Role of Cytokines

A
  • ↑ in sepsis, burns, and tissue injury
    • produced by inflammatory cells (e.g. macrophages)
    • enterocytes may be a source
  • Results in:
    • proteolysis in muscle
    • sustained levels → multiple organ failure
    • fever exacerbates proteolysis & muscle wasting
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9
Q

Role of GI Tract

A
  • Intestinal ischemia or disuse → release of inflammatory mediators
  • Leads to SIRS
    • fever, hypotension, increased CO
  • Lethal immunosuppression
  • Apoptosis of enterocytes
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10
Q

Intestinal Sequelae from Injury

A

Trauma → hemorrhagic shock → intestinal injury

  • Damage to gut immune system
    • decreased IgA
  • Enterocyte damage leads to systemic release of:
    • CRP
    • IL-6
    • intestinal fatty acid binding protein
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11
Q

Elevated Energy Requirements

A

Resting Energy Requirement:

25 kcal/kg/day + 1 gm protein/kg/day.

  • Walking, minor surgery → 1.3x
  • Major surgery → 1.5x
  • Major trauma → 1.7x
  • Sepsis → 2x
  • Burns > 20% BSA → > 2x
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12
Q

Nutritional Assessment

A
  • Dietary hx
    • support system
  • Clinical exam
    • muscle tone
    • skin turgor
    • neurologic assessment
  • Respiratory Quotient
    • ratio of CO2:O2
    • used to monitor feeding
    • depressed in sepsis
  • SOFA score → sepsis related organ failure assessment score
  • APACHE score → acute physiology and chronic health score
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13
Q

Biochemical Assessments

A
  1. Serum albumin
    • 1/2 life of 14-18 days
    • < 3.0 gm/dL abnl
    • may change d/t fluid shifts
    • measure of severity of underlying infection
      • prognostic indicator
  2. Pre-albumin
    • 1/2 life of 3-5 days
    • 16-35 mg/dL nl
    • may change d/t fluid shifts
    • synthesis may ↓ in favor of CRP or fibrinogen
  3. Transferrin
    • 1/2 of 7 days
    • < 200mg/dL abnl
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14
Q

Carbohydrate

Nutritional Support

A
  1. Benefits:
    • protein/AA sparing
    • hepatic gluconeogenesis suppressed
  2. Toxicity:
    • excess carbs → HLD → liver toxicity
    • CO2 production
    • hyperglycemia
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15
Q

Lipid

Nutritional Support

A
  1. Major source of calories
    1. ↑ lipolysis by steroids, catecholamines, glucagon, cytokines
    2. ↓ lipolysis by insulin
  2. Metabolism impaired in stress
  3. 1/3 of daily caloric replacement should be lipids
  4. Toxicity:
    • excess accumulation in liver → ⨂ reticuloendothelial system
    • elevated TAG levels
      • pancreatitis
      • pulmonary failure
  5. Max fat infusion
    • 2 g/kg/day in adults
    • 4 g/kg/day in infants
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16
Q

Protein Requirements

A

Baseline daily requirement = 0.8 gm/kg/day

  • Post-op → 1-1.5
  • Sepsis → 1.5-2
  • Multiple trauma on vent → 1.5-2
  • Major burn → 2-3
17
Q

Electrolyte Replacement

A
  • sodium 50 mEq
  • potassium 20-40 mEq
  • calcium 0.2-0.3 mEq/kg/day
  • magnesium 0.35-0.45 mEq/kg/day
  • phosphate 30-40 mmol/day
    • deficiency ​⟾ refeeding syndrome
      • weakness, encephalopathy
  • chromium
    • ​deficiency ​⟾ hyperglycemia
18
Q

Enteral Feeding

A
  • Preferred method
  • Via NG, gastric, or jejunostomy tube
  • Preserves:
    • mucosal integrity
    • hepatic substrate supply
    • gut immune function
      • IgA
      • ↓ infectious complications (e.g. C. diff)
    • Benefits can be achieved by trophic feedings (10 ml/hr)
  • Complications:
    • 30% fail to meet nutritional goals
    • stopped for residual volume in stomach
    • held for surgical or radiologic procedures
    • aspiration risk
    • diarrhea/fluid loss
  • Start within 48 hrs unless hemodynamically unstable
    • Instability can lead to bowel necrosis
19
Q

Parenteral Feedings

(PPN)

A
  • via peripheral line
  • unable to meet all nutritional needs
  • short-term use
20
Q

Total Parenteral Feedings

(TPN)

A
  • requires a central line
  • hyperosmolar
    • contains dextrose > AA and lipids
  • can provide all required nutrients long term
  • complications:
    • hyperglycemia
    • volume overload
    • electrolyte abnl
    • elevated CO2
    • hepatic dysfunction
    • cholestasis
    • acalculous cholecystitis
    • impaired intestinal immunity
    • metabolic bone disease
    • catheter complications
      • hemothorax, pneumothorax, sepsis, thrombosis, DVT
21
Q

Guidelines for Nutritional Support

A
  • Protein most important
  • Early enteric nutritional support beneficial
    • start within 24-48 hrs in ICU patient
    • start within 4-6 hrs for burn pt
  • Glutamine supplement w/o benefits
  • EN safer than PN if gut working
    • EN to stomach as safe as to intestine
    • EN should be held in unstable pt on pressors d/t inc. risk of bowel ischemia
  • PN if EN not possible
    • BGL 140-180
    • monitor phosphate
22
Q

Adipose Tissue

A
  • Hormonal and endocrine mediators produced:
    • Leptin
    • TNF
    • Resisten
    • Adiponectin

↓ adipose ⟾ ↑ longevity & ↓ tumors

IMS: Nutrition (15 decks)

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