Nutrition II Flashcards
Complications – PN
Mechanical (catheter-related)
– Clotting of line
– Displacement
Infectious
– Catheter-related ___
– Solution contamination
– Bacterial translocation
sepsis
Bacterial Translocation
___ -dependent passage of bacteria or endotoxins from the ___ to extra-intestinal sites
___ organisms cause systemic infections
- Pneumonia
- Central line infections
- Abscesses
- Multi-organ dysfunction syndrome (MODS)
time
GI tract
Enteric
Complications – PN (cont.)
Metabolic
- Electrolyte imbalances
- Fluid imbalance
- Hyper- and hypo ___
– Liver function abnormalities:
* Steatosis (fatty liver)
* Intrahepatic cholestasis
* Cholelithiasis
glycemia
Baseline Monitoring – PN
Baseline
- CMP, Mg, Phos, Ca
- Hepatic function panel
- ___ / ___
- PT/INR
Q4-6H
- Finger sticks for ___
* Correct elevated glucose concentrations with insulin via
infusions and/or sliding scale
- Residuals, distention, vomiting, ___
- Prealbumin/CRP
- glucose
- aspiration
Ongoing Monitoring – PN
Daily
- Vital signs
- Intake/Output (stools)
- ___ (electrolytes, glucose, BUN/SCr)
- Feeding tube placement and patency
- May decrease frequency when stable
CMP
Ongoing Monitoring – PN
Twice Weekly
- Weight
- CBC
- Mg, Phos, Ca, ___ / ___
- ICU setting -> increase to ___
- prealbumin/CRP
- daily
Ongoing Monitoring – PN
Weekly
- Albumin, transferrin, nitrogen balance
- Liver function tests (alk phos, AST, ALT, LDH, bilirubin)
- ___
- PT/INR
- ___ ___ /Indirect Calorimetry
TG
Respiratory Quotient (RQ)
Refeeding Syndrome
- Constellation of fluid, micronutrient,
electrolyte, and vitamin ___ - Occurs within first few days of feeding a ___ patient
- Potentially life threatening
imbalances
starved
Clinical Findings of Refeeding Syndrome
- Hypo ___ , hypo ___ , hypo ___
- ___ distress
- Paresthesias
- Tetany
- Cardiac ___
- Hemolytic ___
- hypophosphatemia, hypomagnesemia, hypokalemia
- respiratory
- arrhythmias
- anemia
Risk Factors for Refeeding
- Rapid feeding, excessive ___ infusion
- Low BMI (less than __ - __ kg/m2)
- Excessive weight loss
- Insufficient caloric intake
- Low levels of ___ , ___ , or ___ prior to feeding
- Loss of subcutaneous fat or muscle mass
- High-risk comorbidities: ___ , anorexia nervosa, ___
- dextrose
- 16-18.5
- K, Phos, Mag
- alcoholism, Marasmus
Prevention of Refeeding Syndrome
Replete ___ before initiating feeds
Initiation recommendations (Day #1):
- Limit carbohydrates (dextrose) to ___ - ___ gm
- Limit fluids to ___ mL/day
- Provide adequate amounts of ___
- Provide approximately ___% of total caloric needs
- Advance calories/dextrose by 20-33% of goal every 1-2 days as tolerated
- Give ___ 100 mg daily x5-7 days
electrolytes
- 100-150
- 800
- electrolytes
- 50%
- thiamine
Essential Fatty Acid (EFA)
Requirements
- Estimated to be __ - __% of daily calories
- EFAs include __ and __ acids
4-10%
linoleic, linolenic
Essential Fatty Acid Deficiency (EFAD)
Mechanism:
- Continuous infusion of hypertonic dextrose will increase circulating insulin levels
- Inhibits ___ and fatty acid mobilization
Clinical onset:
- Several weeks on a fat-free PN regimen ( __ - __ days)
Symptoms:
- Dry scaly skin, brittle hair, lack of luster
lipolysis
10-14
Prevention of EFAD
Recommended minimum requirement is to provide approximately __ % of caloric intake as lipids
Prevention:
- Provide at least 500 mL of 10% fat emulsion over at least 3-5 hours __ weekly
– OR –
- Provide at least 250 mL of 20% fat emulsion over at least 5-9 hours __ weekly
- 4%
- twice
- twice
EN indications
“If the gut works, use it.”
* Oral consumption inadequate
* Oral consumption ___ :
– ___ obstruction
– Head and ___ surgery
– Dysphagia
– Trauma
– Cerebrovascular accident
– Dementia
- contraindicated
- esophageal
- neck
Advantages - EN
Provides GI ___
- Decreased chance for bacterial ___
- Stimulates biliary flow through biliary tract
Avoids risks associated with IVs
- Non-invasive tube placement at the bedside
- Line ___ , pneumothorax, etc.
More ___ than PN
Bolus feeds are more physiologic than continuous
Less stringent protocol for administration
Less expensive (depending on the formula)
- stimulation
- translocation
- infections
- physiologic
EN - decreased bacterial translocation
Time-dependent passage of bacteria or
endotoxins from GI tract to extra-intestinal
sites
Enteric organisms cause systemic infections
– Pneumonia
– Central line infections
– Abscesses
– Multi-organ dysfunction syndrome (MODS)
___ infectious morbidity and mortality w/ EN
decreased
Contraindications to EN
Mechanical obstruction
- Hernia, tumors, adhesions, scar tissue, etc.
Non-mechanical obstruction – ___
- No peristalsis, decreased perfusion, post-op, etc.
Intractable vomiting
Severe malabsorption
Severe GI hemorrhage
Certain types of __
- High output, proximal small bowel
ileus
fistulas
Routes of Administration – EN
___ (NG) / Orogastric (OG)
Nasojejunal (NJ) / Orojejunal (OJ)
- Dobhoff®
- Cortrak® / Corpak®
___ ; Percutaneous endoscopic gastrostomy (PEG)
- Surgical placement
___ ; PEG/PEJ
Nasogastric
gastronomy
jejunostomy
Determining Route of Access
Risk of aspiration
- If low risk – may utilize ___
- If high risk – ___ (post-pyloric) is preferred
Tolerance
- Vomiting – use ___
- Gastric residuals – use ___
Duration of therapy
- Long term – consider ___ or ___
- gastric
- jejunal
- jejunal
- jejunal
- PEG or PEJ
Bolus
Mimics ___
Administer > 200 mL formula over 5-10 min
- Maximum volume 300 – 400 mL
Used primarily for patients with ___
- Nursing facilities
- Ambulatory settings
Advantages
- More convenient for patients
- Requires minimal equipment (syringe)
- Less medication interactions
Disadvantages
- Cannot feed into ___
- Higher risk of ___ and intestinal side effects?
- meal
- gastrostomy
- small bowel
- aspiration
Intermittent
Administer > 200 mL formula over 20-30 minutes (gravity drip)
- __ - __ feedings per day
Advantage
- Helps __
Disadvantage
- More equipment required (requires use of reservoir bottle or bag)
- 4-8
- tolerance
Continuous Infusion
- Administer continuously over 12-24 hours/day
- Requires use of infusion pump
- Preferred method when feeding into the ___
Advantages
- Lower risk of gastric distention and ___
- Better tolerated by the patient
Disadvantages
- Problematic for ___ administration
- Requires infusion ___
- jejunum
- medication
- pump
Trickle or Trophic
___ continuous infusion at 10 – 30 mL/hr
Advantages
- Prevent mucosal ___ and bacterial __
- May shorten time on ___ and decrease mortality
Disadvantage
– Difficult to achieve sufficient ___ delivery
- slow
- atrophy, translocation
venetilator
calorie
Initiation & Advancement of Tube Feeding
- Initiate full strength at __ mL/h
- Advance 25 mL/h q 4-6 hrs as tolerated up to goal rate
- Check ___ q 4-6 hrs
- May hold for > 500 mL
- Dilution of formula has limited benefit (not recommended)
- 25
- residuals
Cyclic
- Administer over __ - __ hours/day
- Often infused ___
Advantage
- increased ___ for the patient
- 8-20
- overnight
- independence
EN – ICU Initiation Points
Achieve > __ - __ % goal calories within
first week (if not, consider PN)
- Do not initiate if ___ unstable (concern for intestinal ___ )
- Bowel sounds or flatus not needed for
initiation
- EN promotes gut ___
- 50-60
- hemodynamically
- ischemia
- motility
NPO Times
Minimize holding times
- Inadequate nutrient delivery
- May stimulate ___ development
Patients undergoing frequent surgical
procedures have ___ infections when
EN is not stopped for each procedure
- ileus
- fewer
Immune-modulating Contents (Impact 1.5)
- ___ : T lymphocyte function
- ___ : Antioxidant, immune support, and nitrogen retention
- ___ : Reduced inflammation,
arrhythmia incidence, ARDS, and
sepsis - ___: Selenium, ascorbic acid, and
vitamin E
- arginine
- glutamine
- omega-3 fatty acids
- antioxidants
Immune-modulating Formulation (Impact 1.5)
- Target Patient Populations: Major elective surgery, ___ , ___ , head or neck cancer, mechanically ___
- Use w/ Caution: Severe ___
- Benefits: Reduced time on ventilator, infectious morbidity, length of hospital stay
- trauma, burn, ventilated
- sepsis
EN Nutrient Composition
Protein
- Intact protein
* Requires complete digestion into smaller peptides
- Partially digested (peptide-based)
* ___ ; may be beneficial for pts with malabsorption, diarrhea
Fat
- Long-chain fatty acids
- ___ -chain fatty acids
* More water soluble; rapid hydrolysis, little or no
pancreatic lipase for absorption
Carbohydrates
– ___ polymers primarily used for tube feeding formulas
– Simple glucose used for oral supplements (higher in osmolality)
- Elemental
- medium-chain
- Glucose
Adjunctive Therapies- modular supplements
Pro-Stat
- 2 Tbsp (30 mL)
- __ g protein
- 72 kcal
- 3 g CHO
15 g
Adjunctive Therapies - glutamine
- May reduce hospital and ICU length of stay
- Reduces mortality in ___ patients
- No systemic effect when given by ___ route
- Will help maintain gut integrity
- 0.3 – 0.5 g/kg/day divided in 2 – 3 doses
- Do not supplement if already receiving glutamine via an immune-modulating formula (i.e., ___ )
- burn
- enteral
- Impact 1.5
Adjunctive Therapies - Probiotics
Microorganisms conferring potential health benefits to host:
- Inhibit pathogenic bacterial growth
- Block pathogen attachment
- Eliminate toxins
- Enhance host inflammatory response
Clinical efficacy data are mixed/lacking
May increase complications (e.g., ___ )
diarrhea
Vitamins and Trace Elements
- Used for antioxidant effects and/or repletion
- Vitamin E and vitamin C
- Trace elements (Selenium, zinc, copper, chromium, manganese)
- Beneficial in most ICU patients
- Emphasis on ___ , ___ , and ___ ___
- Consider organ dysfunction as previously discussed
- burn, trauma, and mechanically ventilated
Complications - GI
- High gastric ___
- ___
- Nausea/vomiting or ___ motility
- Consider prokinetic medications
- Metoclopramide, erythromycin may be given
Abdominal distention
- Diarrhea
- Check meds, formula
Constipation
– Check meds
- residuals
- aspiration
- decreasd
High Gastric Residuals
Lower cut offs do not protect patient from complications
Residuals
- < ___ mL: do not hold unless intolerance signs
- 200 to 500 mL: implement risk reduction measures to avoid ___
- Cutoffs may vary by site
- 500
- aspiration
Aspiration Risk Reduction
- Elevate ___ 30-45 degrees
- Administer as ___ infusion
- Change to post-pyloric delivery
- Consider ___ drugs or narcotic
antagonists
- HOB
- continuous
- prokinetic
Decreased Motility: Consider Prokinetic Agents
- ___ 10 mg IV/PO/feeding tube QID
- ___ base 250 – 500 mg PO/feeding tube TID or 3 mg/kg IV Q8hr
- ___ 8 mg via feeding tube QID
- ___ weight-based dosing IV x1
- metoclopramide
- erythromycin
- naloxone
- methylnaltrexone
Diarrhea
Formula
- Change to soluble ___ -containing or small ___ formulations
- Suspect Clostridium difficile colitis
- Consider other infectious etiologies
Evaluate medications:
- ____ medications
– Liquid formulations with sorbitol
– ___ regimen
– ___ ___ antibiotics
- fiber, peptide
- hyperosmolar
- bowel
- broad sprectrum
Hyperosmolar Medications
≥ ___ mOsm/kg
3000
Medications with Sorbitol
Complications - Metabolic
Hyper- or hypoglycemia
- Check meds, ___ regimen
- Stress
- Infection
Overhydration; dehydration
- Monitor fluid status
Electrolyte imbalance
- ___ is most common
- insulin
- hyponatremia
Glycemic Control in ICU
Goal blood glucose (BG)
- ≤ ___ mg/dL
NICE-SUGAR Study
- ____ mortality with tight glycemic control
- Higher rate of hypoglycemia with tight control
- 180
- increased
Complications - Mechanical
- ___ of feeding tube
- Tube ___ (abdominal X-ray “KUB”)
Rhinitis
- Reposition daily
- Use smaller bore tube
- Change from NG to ___
Sinusitis
- clogging
- malposition
- OG
Complications - Medication Related
- ___ feeding tubes
- Drug-tube feed ___
- clogged
- interactions
General Guidelines for Medication
Delivery via Enteral Feeding Tubes
- ___ medications are preferred whenever possible.
- If using oral dosage forms, crush the tablet to a fine powder (or empty capsule contents) and mix in water.
- Do not crush ___ -released or ___ coated formulations!!
- Administer each medication separately.
- Ensure adequate flushing with water between each medication.
- Dilute ___ medications or those irritating to the gastric mucosa in at least 30 mL of water before administering
- liquid
- sustained, enteric
- hypertonic
Liquid Medications Preferred
Avoid ___ formulations due to risk of clogging tube:
– Syrups
– Mineral oil
– Granules
Can sometimes crush tablets or open
capsules
- Dilute in __ - __ mL of sterile water
viscous
15-30
Unclogging the Tube
- 1 ___ tab + 1 ___ cap + 10 mL warm sterile water
- place slurry into feeding tube
- clamp tube for 15-30 min
- flush when complete
- sodium bicarb
- pancreatic enzyme
Drug/Tube Feed Interactions
antibiotics (4)
anti-retrovirals (3)
other (4)
hold tube feed
- wait ___ hour
Give med
- wait ___ hours
Resume feed
- 1
- 2
Monitoring – Gastrointestinal
- Gastric ___
- Emesis
- Check q __ - __ hrs
- ___ daily (frequency, volume)
- Bloating/distention
- Bronchial/tracheal aspirate
- residuals
- 4-6
- stools
Monitoring – Metabolic
- I/Os; bowel movements
- ___ : 2-3 times per week
- Serum electrolytes, glucose, BUN/SCr [CMP]: ___ until stable -> twice weekly -> weekly
- Mg, Phos, Ca, triglycerides, LFTs: ___
- Albumin, prealbumin/CRP, nitrogen balance: ___
- weight
- daily
- weekly
- weekly
Monitoring – Mechanical
- Feeding tube ___
- Feeding tube __
- placement
- patency
Special Considerations and Disease States
Acute Renal Failure
- Use a normal EN formula unless electrolyte profile dictates otherwise
Hemodialysis/Continuous Renal Replacement Therapy
- CRRT: ___ protein requirement to prevent nitrogen deficit (max 2.5 g/kg/day)
- HD: 0.8-1.2 g/kg/day protein
- Loss of ___ micronutrients ( ___ , ___ , ___ )
– ___ accumulates due to it being cleared renally (falsely high)
- increased
- water-soluble, selenium, zinc, thiamine
- prealbumin
- falsely
Special Considerations and Disease States
Hepatic Failure
- Traditional nutritional assessment tools are ___ due to presence of ascites, intravascular volume depletion, edema, portal hypertension, and hypo-albuminemia
- Standard enteral formulations for most liver disease patients
- ___ ___ ___ ___ formulations (BCAA) for encephalopathic patients refractory to other treatments
- inaccurate
- Branched chain amino acid
Special Considerations and Disease States
Pulmonary Failure
Fluid- ___ , calorically dense formulations
- ___ - ___ kcal/mL
- Monitor ___ closely
- Component of adenosine triphosphate (ATP) and 2,3-disphosphoglycerate (2,3-DPG):
essential for normal ___ function
- restriction
- 1.5-2.0
- phosphate
- diaphragmatic
Special Considerations and Disease States
Acute Pancreatitis
Metabolic changes
– ↑ protein ___
- inability of exogenous glucose to inhibit ___
– ↑ energy expenditure
– ↑ ___ resistance
– ↑ dependence on ___ oxidation for energy
EN vs. PN
– Recovery and resumption of oral intake often occurs within 3-7 days, not requiring __
- catabolism
- gluconeogenesis
- insuline
- fatty acid
- PN
Special Considerations and Disease States
Acute Pancreatitis (cont.)
Protein requirements
- ___ - ___ g/kg/day
- Consider adding ___
Glucose
- Safe, same maximum as other patients
Lipid infusions
- Safe if ___ levels are within normal limits -> monitor closely
Parenteral nutrition does NOT affect ___ secretion and function
- 1.2-1.5
- glutamine
- TG
- pancreatic
Special Considerations and Disease States
Burn
Metabolic changes
– ↑ basal metabolic rate and ___ loss
- Glycolysis, proteolysis, lipolysis
Nutritional requirements
- High in protein ( __ - __ g/kg/day) and calories
- ___ feeding with EN
Supplements
- Adult multivitamin
- If TBSA >10%: Ascorbic acid, Zinc, Vitamin E, Selenium
- If TBSA >20%: oxandrolone/growth hormones
- Vitamin D (if deficient); Vitamin A (if on corticosteroids)
- nitrogen
- 2-2.5
- early
