Nutrition Obesity and parenteral/enteral Flashcards
What are the components of the body’s expenditure?
Total - TEE (100%)
60-65% - RMR/REE
-bodily functions at rest
25-30% - AEE
-burned during physical activity
5-10% - DIT
-digesting/absorbing nutrients and storage
What is indirect calorimetry
measure has exchanges (O2, VO2, N) to calculate estimated total energy expenditure
What are the equations for estimated caloric needs
schofield
harris-benedict
mifflin-st jeor**
Ireton-jones (hospitalized pts)
What are the ASPEN guidelines
insufficient energy intake
weight loss
loss of muscle mass
loss of subQ fat
local/generalized fluid accumulation
diminished functional status
What are some examples of when to use enteral nutrition?
-altered mental state or neurologic disorders
-prolonged assisted ventilation
-high metabolic need (burns)
-swallowing dysfunction
-malnutrition/high risk due to poor intake/unintentional weight loss
What are the long term feeding tube options?
large bore tubes
-faster
-easy med admin
-more invasive
PEG tube
-endoscopic insertion
-internal bumper
G/J tube
-surgical insertion
-balloon anchor
What are the short term tube options?
nasogastric
-easily inserted and confirmed with X-ray
orogastric
-nasal/sinus fracture
-uncomfortable
-easily dislodged
nasoduodenal/jejunal
-continuous feeding only
-increased reflux/aspiration risk
What are the CI to enteral nutrition?
Global - hemodynamic instability
physical GI issues:
-inflammation/ischemia
-perforation
-bleeding
-obstruction
-short bowel syndrome (<100cm)
Functional GI issues:
-ileus
-intractable N/V
What are the enteral nutrition complications?
aspiration (lying flat worse)
malposition
infection
fluid imbalance
clogging
GI intolerance
skin issues - hypergranulation
sinusitis
What are the indications for parenteral nutrition
malnourished or at risk
CI to enteral
insufficient bowel function
ex) some stages of UC, bowel obstruction
How is peripheral parenteral nutrition typically given
supplement oral intake
dextrose or amino acids
typically short term (<14 days)
How is central/total parenteral nutrition given
supplies all daily nutritional needs
>14 days
What are the pros and cons to central nutrition
pros:
-less phlebitis
-no need for routine placement
-more durable
cons:
-required specialized skill for placement
-more invasive
What are the contraindications to parenteral nutrition
sound nutritional status
infant with <8sm small bowel
critical cardiovascular or metabolic conditions
patient able to receive enteral nutrition
lack of therapeutic goal
What are some complications of parenteral nutrition?
Catheter related sepsis
glucose
hepatic
electrolytes
volume overload
metabolic bone disease
adverse reaction to lipid emulsions
gallbladder
What are some appropriate adjustments to formula based on disease states?
burns/post op: increase protein
renal disease: decrease protein
cardiac disease: tight fluid control
fever/sepsis: increased metabolism to consider
What is refeeding syndrome?
serious complication due to electrolyte and fluid shifts; potentially fatal
effects:
-hypophosphatemia
-sodium/fluid imbalance
-metabolic changes
-low thiamine
-hypokalemia
-hypomagnesemia
What is the pathogenesis of refeeding syndrome
starvation drops the metabolic rate and causes increased glucagon and decreased insulin - body in catabolism to maintain homeostasis
When feeding begins again, insulin increases and glucagon decreases; body starts using up micronutrients that outpaces the rate of replacement
insulin pushes glucose and potassium OUT of serum into cells, and phosphate and Mg follow; fluid shifts via osmosis
Describe phosphate in refeeding syndrome
involved in nearly all cellular processes
enzyme function
refeeding - cells rapidly pulling and metabolizing phosphate from serum
Describe sodium/fluid balance in refeeding syndrome
increased glucose in serum
kidneys hold on to sodium/water to maintain balance
decreased renal output
if fluid repletion is initiated, fluid overload can occur - CHF
Describe glucose in refeeding syndrome
hyperglycemia - insulin production, feeds intracellular processes described previously
can cause osmotic changes, ketoacidosis, respiratory failure due to increased CO2 production
Describe thiamine in refeeding syndrome
needed for breakdown of carbs
Wernicke’s encephalopathy
Korsakoff syndrome
Describe Potassium in refeeding syndrome
membrane potentials
potassium-sodium gates
refeeding - potassium rushes into cells aided by sudden insulin increase
abnormal electrochemical membrane potential - cardiac arrhythmia/arrest
Describe magnesium in refeeding syndrome
Needed for normal enzyme function and production of ATP
Refeeding - rapid movement of Mg from serum into cells
deficiency can cause cardiac and neuromuscular complications `
Describe obesity hypoventilation syndrome
like sleep apnea but awake (90% comorbid)
alveolar hypoventilation
central adiposity
hypersomnolence
loud snoring
dyspnea
hypercapnia
weight loss
pos airway pressure
What are the classes of obesity with BMIs?
Class 1: 30-34.9
Class 2: 35-39.9
Class 3: 40+
*don’t say morbidly obese
What is the classification and staging system for obesity?
Edmonton obesity staging system
-obesity related risk factors
-physical symptoms
-psychologic symptoms
-functional limitations
What is the SMART goal setting technique
Specific
Measurable
Achievable
Realistic
Time-based
What is the pharmacotherapy for obesity
GLP-1 agonists:
-may cause pancreatitis
-CI if hx of medullary thyroid CA
Phentermine
-CI if hyperthyroidism, CVD, drug abuse
-controlled substance
Naltrexone/buproprion
-opioid antagonists
orlistat
-anal seepage
describe devices and surgeries for obesity
BMI >40 or >35 + serious comorbidity
Changes in microbiome, hunger, satiety
Roux-en-Y
sleeve gastrectomy
duodenal switch
lap-band
intragastric balloon
cellulose/citric acid hydrogel
