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PHRM 864 > Nutrition - Walroth > Flashcards

Nutrition - Walroth Flashcards

1
Q

Ideal Body Weight Calculation

A

Male: 50kg + (2.3 x inches over 60)
Female: 45.5kg + (2.3 x inches over 60)

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2
Q

Nutrition Body Weight Calculation

A

IBW + 0.25(ABW-IBW)

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3
Q

when to use nutrition body weight

A

when actual body weight is 130% or more of IBW

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4
Q

risk factors for malnutrition

A
  • 20% below IBW
  • involuntary weight loss >10% within 6 months
  • NPO >10 days (or >7 days)
  • gut malfunction in ICU
  • mech vent in ICU
  • increased metabolic needs (trauma or burn)
  • alcohol or substance abuse
  • chronic disease states
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5
Q

when should nutritional risk be determined

A

within 48 hours of hospitalization

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6
Q

what are the screening tools for nutritional risk? **

A

NUTRIC
NRS-2002

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7
Q

What is the NURTIC score range and who is considered high risk?

A

range 0-10
high risk 6-10 (or 5-9 without IL-6)

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8
Q

how to determine protein status?

A

prealbumin!!! also get a CRP!!!

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9
Q

what is the normal serum concentration of prealbumin? ***

A

15-40mg/dL

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10
Q

What is CRP

A

C-Reactive Protein: always check with prealbumin!! it is an inflammatory marker

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11
Q

what is a normal CRP value?

A

<1mg/dL
(if elevated, decreases in prealbumin are due to inflammation)
( if normal, decreased in prealbumin indicate malnutrition)

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12
Q

marasmus definition

A

not eating at all; decreased total intake; wasting of skeletal muscle and fat

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13
Q

kwashiorkor definition

A

adequate calorie intake; protein malnutrition. ex) burn patients

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14
Q

marasmus treatment

A

provide well-balanced substrate and vitamin B

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15
Q

kwashiorkor treatment

A

provide carbs followed by high protein

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16
Q

what is the UUN

A

urinary urea nitrogen (measure of urinary excretion of nitrogen) from protein catabolism

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17
Q

What is the nitrogen balance goal?**

A

+3 to +5 grams

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18
Q

How to calculate N in

A

24 hour protein intake (g) divided by 6.25

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19
Q

how to calculate N out

A

UUN (g) + 4g

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20
Q

what is the BEE

A

basic energy expenditure- bare minimum amount of calories needed to maintain life

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21
Q

what is the REE

A

resting energy exposure

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22
Q

what is the TEE

A

total energy expenditure

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23
Q

How to calculate TEE**

A

TEE = REE x stress/activity factors

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24
Q

what is a maintenance activity factor?

A

1.2 to 1.3

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25
Q

what is a severe/ thermal burn activity factor?

A

2

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26
Q

what is the nutritional/caloric requirement for a non-stressed and non-depleted patient?

A

20-25 kcal/kg/day

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27
Q

what is the nutritional/caloric requirement for a trauma/stress/surgery/critical care/burn patient?***

A

25-30 kcal/kg/day

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28
Q

how to calculate TEE

A

REE x1.2

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29
Q

what is the RQ?

A

Respiratory Quotient; for energy production, oxygen is consumed and CO2 is produced

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30
Q

What is the normal RQ range??***

A

0.85-0.95 (monitor once weekly)

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31
Q

what is an RQ >0.95 mean?

A

Overfeeding

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32
Q

What does an RQ <0.85 mean?

A

Underfeeding

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33
Q

What does TEE indicate?

A

total energy expenditure = minimum caloric intake requirements in Kcal/day

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34
Q

What is a maintenance amount of protein?

A

0.8-1 gm/kg/day

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35
Q

How much protein/day is needed in a floor patient?

A

1-1.5 gm/kg/day

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36
Q

how much protein/day is needed in an ICU patient

A

1.5-2 gm/kg/day

37
Q

What is the standard distribution of non-protein calories?

A

70% dextrose (carbs)
30% fat

May need to use 100/0 during sepsis and bloodstream infections

38
Q

What are the indications for PN?

A
  • NPO > 7 days
  • inability to use the gut: ileus, small bowel resection, intractable vomiting/diarrhea, malabsorptive states
  • fistulas
  • IBD
  • Hyperemesis gravidum
  • mucositis due to bone marrow transplant
39
Q

Peripheral PN dextrose concentration

A

Restrict total osmolarity to <900 mOsm/L

40
Q

how many kcals per g of protein

A

1 g protein = 4 kcal

41
Q

how many kcal per g of dextrose (max?)

A

1 g dextrose = 3.4 kcal
max of 4-5 mg/kg/min due to vein irritation

42
Q

how many kcal per gram of lipids?

A

1g lipids = ~10 kcal

43
Q

what is max lipids/day in adults?

A

max 2.5gm/kg/day

44
Q

propofol

A

10% lipid solution (1.1 kcal/mL)

45
Q

IV fat emulsion administration

A

10-20% fat emulsions can be administered via peripheral vein
emulsions >30% must be incorporated into TPN (administered centrally)

46
Q

IV fat emulsion complications

A

infectious risk- limit hang time to 12 hours
can be increased to 24 hours if part of a 3 in 1 (TNA)

47
Q

Guidelines for initiation of PN

A
  • check blood glucose every 4-6 hours and before each increase in rate
  • If BG >200, continue at the same rate for 4 hours and re-check
  • If BG >200 again, consider insulin
48
Q

Guidelines for cessation of PN

A

decrease rate by 1/2 every 2 hours until rate <50mL/hr, then discontinue

49
Q

Max infusion rate for cycling PN

A

max ~200 mL/hr

50
Q

normal cycling PN regimens

A

total caloric requirements infused over 12-18 hours per day. Max of 200 mL per hour

51
Q

What is the max calcium and phosphorus concentration?

A

Ca (mg/dL) x Phos (mg/dL) >150

52
Q

how much vitamins do adults and pediatric patients >40kg receive per day?

A

10mL/day of injectable multivitamin

53
Q

Should iron be added to PN?

A

No; can destabilize IV fat emulsion and induce infectious risk

54
Q

What medications can be added to PN?

A

famotidine for GERD
regular insulin only (may stick to the bag)

55
Q

What is the range for maintenance IV fluids?***

A

30-40mL/kg/day

56
Q

What labs need done at baseline for PN?

A
  • CMP, Mg, Phos, Ca
  • Hepatic function panel
  • Prealbumin/CRP
  • PT/INR
57
Q

What monitoring needs done Q4-6H for PN?

A
  • glucose finger sticks
  • residuals, distension, vomiting, aspiration
58
Q

daily monitoring PN

A

vitals, intake/output, CMP, tube placement

59
Q

twice weekly monitoring PN

A

weight, CBC, mg, phos, Ca, prealbumin/CRP (daily in ICU)

60
Q

weekly monitoring PN

A

albumin, transferrin, nitrogen balance, LFTs, triglycerides, PT/INR, respiratory quotient

61
Q

what are the clinical findings of refeeding syndrome

A

hypophosphatemia, hypomagnesemia, hypokalemia

62
Q

When is oral consumption contraindicated?

A

Esophageal obstruction
head and neck surgery
dysphagia
trauma
cerebrovascular accident
dementia

63
Q

what are the advantages of enteral nutrition

A
  • GI stimulation (decreased bacterial translocation)
  • Avoid IV risk (line infections and pneumothorax)
  • more physiologic
  • less expensive
64
Q

what are contraindications to EN?

A
  • mechanical obstruction (hernia, tumor, adhesion, etc.)
  • ileus
  • intractable vomiting
  • severe malabsorption
  • Severe GI hemorrhage
  • proximal small bowel fistula
65
Q

what route of EN is best for patients with higher aspiration risk?

A

jejunal

66
Q

what does bolus administration of EN look like?

A

> 200mL of formula over 5-10 minutes
max volume of 300-400mL
for gastrostomy patients

67
Q

what does intermittent administration of EN look like?

A
  • > 200 mL of formula over 20-30 minutes (gravity drip)
  • 4 to 8 feedings per day
  • better tolerance; more equipment needed
68
Q

what does continuous infusion of EN look like?

A
  • administered over 24 hours using kangaroo pump
  • preferred for administration into the jejunum
  • better tolerance (lower risk of aspiration) but harder to administer medications
69
Q

what does trickle/trophic EN look like

A

slow continuous infusion at 10-30mL/hour
prevent mucosal atrophy and bacterial translocation
- difficult to achieve sufficient calorie delivery

70
Q

how to initiate tube feeding

A
  • full strength at 25mL/hour
  • increase by 25 mL/hr every 4-6 hours
  • check residuals every 4-6 hours
71
Q

what does cyclic EN look like?

A

administer over 8-20 hours per day
- increased independence

72
Q

how many kcals/mL and g of protein in jevity

A

~1 kcal/mL and ~45 g/L

73
Q

how how many kcals/mL and g of protein in impact 1.5

A

1.5 kcal/mL, ~95 g/L
is immune-modulating (contains glutamine)

74
Q

how many kcals/mL and g of protein in glucerna

A

1.2 kcal/mL and 60 g/L (less carbs than the other formulations)

75
Q

how many kcals/mL and g of protein in Nepro

A

1.8 kcal/mL and 80 g/L (less volume needed)

76
Q

what is Pro-Stat

A

protein supplement; 30mL contains 15g of protein and 72 kcal

77
Q

What is glutamine?

A
  • reduces mortality in burn patients
  • helps maintain gut integrity
  • 0.3 to 0.5 g/kg/day
  • do not use in patients receiving impact 1.5
78
Q

Gastric residuals

A

> 500mL - hold tube feeds
200-500 mL - implement risk reduction to avoid aspiration

79
Q

What are the aspiration risk reduction measures?

A
  • elevate head of bed to 30-45 degrees
  • administer continuous infusion
  • change to post-pyloric delivery
  • use of prokinetic drugs or narcotic antagonists
80
Q

What are the prokinetic agents

A

metoclopramide 10mg QID
erythromycin 250-500mg TID
Naloxone 8mg QID (feeding tube only)
methylnaltrexone (weight based dosing)

81
Q

considerations for patients with diarrhea

A
  • need a formulation with fiber (NOT impact 1.5)
  • check for C.diff
  • look for hyperosmolar meds, liquids with sorbitol, bowel regimen, broad antibiotics
82
Q

guidelines for medication delivery via enteral tube **

A
  • liquid preferred
  • crush tablets to a fine powder and mix in water
  • DO NOT CRUSH SR or EC formulations
  • administer separately
    dilute hypertonic meds in 30 mL of water
83
Q

can buccal and sublingual tablets be given via feeding tube?

A

NO – they can still be administered PO

84
Q

how to unclog feeding tube

A

1 sodium bicarb tab, 1 pancreatic enzyme capsule, 10mL of warm sterile water
place into tube, clamp, and leave for 15-30 minutes

85
Q

What drugs should tube feeds be held for?

A

antibiotics, anti-retrovirals, levothyroxine, phenytoin, warfarin
- hold for one hour before and 2 hours after

86
Q

how often should electrolytes, glucose, CMP, LFTs, and albumin/prealbumin/CRP be monitored

A

weekly

87
Q

considerations for acute renal failure and EN

A

0.8-1.2 g/kg/day protein
falsely high prealbumin due to accumulation and renal elimination

88
Q

considerations for acute pancreatitis

A

requires 1.2-1.5 g/kg/day protein
consider addition of glutamine

89
Q

considerations for burn patients

A

start tube feeds within 12 hours
need high protein 2-2.5g/kg/day and more cals
may need adult multivitamin and trace metals

PHRM 864 (9 decks)

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