Nutrition - Walroth Flashcards
Ideal Body Weight Calculation
Male: 50kg + (2.3 x inches over 60)
Female: 45.5kg + (2.3 x inches over 60)
Nutrition Body Weight Calculation
IBW + 0.25(ABW-IBW)
when to use nutrition body weight
when actual body weight is 130% or more of IBW
risk factors for malnutrition
- 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
when should nutritional risk be determined
within 48 hours of hospitalization
what are the screening tools for nutritional risk? **
NUTRIC
NRS-2002
What is the NURTIC score range and who is considered high risk?
range 0-10
high risk 6-10 (or 5-9 without IL-6)
how to determine protein status?
prealbumin!!! also get a CRP!!!
what is the normal serum concentration of prealbumin? ***
15-40mg/dL
What is CRP
C-Reactive Protein: always check with prealbumin!! it is an inflammatory marker
what is a normal CRP value?
<1mg/dL
(if elevated, decreases in prealbumin are due to inflammation)
( if normal, decreased in prealbumin indicate malnutrition)
marasmus definition
not eating at all; decreased total intake; wasting of skeletal muscle and fat
kwashiorkor definition
adequate calorie intake; protein malnutrition. ex) burn patients
marasmus treatment
provide well-balanced substrate and vitamin B
kwashiorkor treatment
provide carbs followed by high protein
what is the UUN
urinary urea nitrogen (measure of urinary excretion of nitrogen) from protein catabolism
What is the nitrogen balance goal?**
+3 to +5 grams
How to calculate N in
24 hour protein intake (g) divided by 6.25
how to calculate N out
UUN (g) + 4g
what is the BEE
basic energy expenditure- bare minimum amount of calories needed to maintain life
what is the REE
resting energy exposure
what is the TEE
total energy expenditure
How to calculate TEE**
TEE = REE x stress/activity factors
what is a maintenance activity factor?
1.2 to 1.3
what is a severe/ thermal burn activity factor?
2
what is the nutritional/caloric requirement for a non-stressed and non-depleted patient?
20-25 kcal/kg/day
what is the nutritional/caloric requirement for a trauma/stress/surgery/critical care/burn patient?***
25-30 kcal/kg/day
how to calculate TEE
REE x1.2
what is the RQ?
Respiratory Quotient; for energy production, oxygen is consumed and CO2 is produced
What is the normal RQ range??***
0.85-0.95 (monitor once weekly)
what is an RQ >0.95 mean?
Overfeeding
What does an RQ <0.85 mean?
Underfeeding
What does TEE indicate?
total energy expenditure = minimum caloric intake requirements in Kcal/day
What is a maintenance amount of protein?
0.8-1 gm/kg/day
How much protein/day is needed in a floor patient?
1-1.5 gm/kg/day
how much protein/day is needed in an ICU patient
1.5-2 gm/kg/day
What is the standard distribution of non-protein calories?
70% dextrose (carbs)
30% fat
May need to use 100/0 during sepsis and bloodstream infections
What are the indications for PN?
- 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
Peripheral PN dextrose concentration
Restrict total osmolarity to <900 mOsm/L
how many kcals per g of protein
1 g protein = 4 kcal
how many kcal per g of dextrose (max?)
1 g dextrose = 3.4 kcal
max of 4-5 mg/kg/min due to vein irritation
how many kcal per gram of lipids?
1g lipids = ~10 kcal
what is max lipids/day in adults?
max 2.5gm/kg/day
propofol
10% lipid solution (1.1 kcal/mL)
IV fat emulsion administration
10-20% fat emulsions can be administered via peripheral vein
emulsions >30% must be incorporated into TPN (administered centrally)
IV fat emulsion complications
infectious risk- limit hang time to 12 hours
can be increased to 24 hours if part of a 3 in 1 (TNA)
Guidelines for initiation of PN
- 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
Guidelines for cessation of PN
decrease rate by 1/2 every 2 hours until rate <50mL/hr, then discontinue
Max infusion rate for cycling PN
max ~200 mL/hr
normal cycling PN regimens
total caloric requirements infused over 12-18 hours per day. Max of 200 mL per hour
What is the max calcium and phosphorus concentration?
Ca (mg/dL) x Phos (mg/dL) >150
how much vitamins do adults and pediatric patients >40kg receive per day?
10mL/day of injectable multivitamin
Should iron be added to PN?
No; can destabilize IV fat emulsion and induce infectious risk
What medications can be added to PN?
famotidine for GERD
regular insulin only (may stick to the bag)
What is the range for maintenance IV fluids?***
30-40mL/kg/day
What labs need done at baseline for PN?
- CMP, Mg, Phos, Ca
- Hepatic function panel
- Prealbumin/CRP
- PT/INR
What monitoring needs done Q4-6H for PN?
- glucose finger sticks
- residuals, distension, vomiting, aspiration
daily monitoring PN
vitals, intake/output, CMP, tube placement
twice weekly monitoring PN
weight, CBC, mg, phos, Ca, prealbumin/CRP (daily in ICU)
weekly monitoring PN
albumin, transferrin, nitrogen balance, LFTs, triglycerides, PT/INR, respiratory quotient
what are the clinical findings of refeeding syndrome
hypophosphatemia, hypomagnesemia, hypokalemia
When is oral consumption contraindicated?
Esophageal obstruction
head and neck surgery
dysphagia
trauma
cerebrovascular accident
dementia
what are the advantages of enteral nutrition
- GI stimulation (decreased bacterial translocation)
- Avoid IV risk (line infections and pneumothorax)
- more physiologic
- less expensive
what are contraindications to EN?
- mechanical obstruction (hernia, tumor, adhesion, etc.)
- ileus
- intractable vomiting
- severe malabsorption
- Severe GI hemorrhage
- proximal small bowel fistula
what route of EN is best for patients with higher aspiration risk?
jejunal
what does bolus administration of EN look like?
> 200mL of formula over 5-10 minutes
max volume of 300-400mL
for gastrostomy patients
what does intermittent administration of EN look like?
- > 200 mL of formula over 20-30 minutes (gravity drip)
- 4 to 8 feedings per day
- better tolerance; more equipment needed
what does continuous infusion of EN look like?
- administered over 24 hours using kangaroo pump
- preferred for administration into the jejunum
- better tolerance (lower risk of aspiration) but harder to administer medications
what does trickle/trophic EN look like
slow continuous infusion at 10-30mL/hour
prevent mucosal atrophy and bacterial translocation
- difficult to achieve sufficient calorie delivery
how to initiate tube feeding
- full strength at 25mL/hour
- increase by 25 mL/hr every 4-6 hours
- check residuals every 4-6 hours
what does cyclic EN look like?
administer over 8-20 hours per day
- increased independence
how many kcals/mL and g of protein in jevity
~1 kcal/mL and ~45 g/L
how how many kcals/mL and g of protein in impact 1.5
1.5 kcal/mL, ~95 g/L
is immune-modulating (contains glutamine)
how many kcals/mL and g of protein in glucerna
1.2 kcal/mL and 60 g/L (less carbs than the other formulations)
how many kcals/mL and g of protein in Nepro
1.8 kcal/mL and 80 g/L (less volume needed)
what is Pro-Stat
protein supplement; 30mL contains 15g of protein and 72 kcal
What is glutamine?
- 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
Gastric residuals
> 500mL - hold tube feeds
200-500 mL - implement risk reduction to avoid aspiration
What are the aspiration risk reduction measures?
- elevate head of bed to 30-45 degrees
- administer continuous infusion
- change to post-pyloric delivery
- use of prokinetic drugs or narcotic antagonists
What are the prokinetic agents
metoclopramide 10mg QID
erythromycin 250-500mg TID
Naloxone 8mg QID (feeding tube only)
methylnaltrexone (weight based dosing)
considerations for patients with diarrhea
- need a formulation with fiber (NOT impact 1.5)
- check for C.diff
- look for hyperosmolar meds, liquids with sorbitol, bowel regimen, broad antibiotics
guidelines for medication delivery via enteral tube **
- 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
can buccal and sublingual tablets be given via feeding tube?
NO – they can still be administered PO
how to unclog feeding tube
1 sodium bicarb tab, 1 pancreatic enzyme capsule, 10mL of warm sterile water
place into tube, clamp, and leave for 15-30 minutes
What drugs should tube feeds be held for?
antibiotics, anti-retrovirals, levothyroxine, phenytoin, warfarin
- hold for one hour before and 2 hours after
how often should electrolytes, glucose, CMP, LFTs, and albumin/prealbumin/CRP be monitored
weekly
considerations for acute renal failure and EN
0.8-1.2 g/kg/day protein
falsely high prealbumin due to accumulation and renal elimination
considerations for acute pancreatitis
requires 1.2-1.5 g/kg/day protein
consider addition of glutamine
considerations for burn patients
start tube feeds within 12 hours
need high protein 2-2.5g/kg/day and more cals
may need adult multivitamin and trace metals
