Skildum: GI case

Question 1

Why evaluate nutritional status of a trauma pt?

Answer 1

Malnutrition delays wound healing.

Rapidly replenishing a malnourished pt can cause life threatening complications (i.e. Refeeding syndrome)

Question 2

What is refeeding syndrome?

Answer 2

hyperglycemia
glucosuria
dehydration
hyperosmolar coma

Question 3

How do you evaluate the nutritional status of a pt?

Answer 3

Pt hx

PE: Chelosis- vit deficiencies,
BMI, muscle tone in fingers

Labs: 
24 hour urine/BUN
albumin
total protein
Fe

Question 4

What impact does trauma have on nutritional requirements?

Answer 4

Pt needs more N for HEALING!

Protein synthesis
Trauma→ hypercatabolism→ needs more calories

Missing 70% of gut→ let it rest

Question 5

How does trauma affect metabolism?

Answer 5

trauma>
hormonal changes>
rapid INCREASE in metabolism

Question 6

How can nutrition be delivered?

Answer 6

Enteral
Parenteral (central line-TPN, peirpheral- PPN)

*higher conc of glucose w/out osmotic effect

Question 7

What are complications of parenteral nutrition?

Answer 7

TPN requires close monitoring

Damage to veins from needle

Infectious complications (fat emulsifications are common sources of infection)

Metabolic complications (Re-feeding syndrome)

Question 8

What are the three components of human energy expenditure?

Answer 8

1. BEE= this is the energy you expend when you’re BEEing a bump on a log (AKA supine, after sleep, before eating, under stringent conditions)
2. Thermic Effect (energy expended in digesting and absorbing food)
3. Energy from physical activity

Question 9

How does BMR differ from BEE?

Answer 9

Usually slightly higher and accounts for upright posture, being non-fasted.

Question 10

What are our energy needs measured in?

Answer 10

kcal/day

Question 11

What is REE/BMR based on ?

Answer 11

age, gender, size

Question 12

What modifies REE/BMR?

Answer 12

pregnancy
activity
sepsis
trauma

Question 13

How does severe stress affect TEE?

Answer 13

TEE= 1.2- 1.6(this number can change) xREE

FYI
mild stress 1.2
fever 1.1

Question 14

How much protein, carbs and FA are needed in a person recovering from trauma?

Answer 14

2x protein required in trauma recovery

fatty acids are “calorically dense”

ω3 and ω6 fatty acids–> eicosanoids

Question 15

How much vitamins, minerals and electrolytes are needed?

Answer 15

Micronutrients may be depleted!

Burns–> copper depletion

Question 16

What is the goal of TPN?

Answer 16

Swamp out pool of AA to maintain protein pool in skeletal muscle in the organs

Question 17

How do you evaluate the effectiveness of a nutrition program?

Answer 17

Calculate the pt’s N balance

If it’s positive: net gain of protein

Negative: net LOSS of protein

Question 18

How do you calculate N balance?

Answer 18

Total the urinary urea N excreted over 24 hrs

NB= N intake (g) - urinary urea N (g) - 3 (g)

N intake: dietary, TPN, PPN
N excreted in urine: Urinary urea N
N excreted other: Urine, feces, sweat, sloughing skin cells

Question 19

Normal N loss factor (through feces, sweat, sloughing of skin cells) is 2 g. How does it change for parenteral feeding or enteral feeding?

Answer 19

3g for parenteral feeding

4 g for enteral feeding

Question 20

What if a pt recovering from trauma has a slightly negative N balance?

Answer 20

That’s okay for the short term, though ideally a positive N balance is best.

Question 21

A 24 year old female is brought to the emergency room 20 minutes after sustaining multiple serious fractures in a car accident.

The patient’s blood glucose concentration is 180 mg/dL (normal 70-100 mg/dL).

What provides the carbon for the patient’s elevated blood glucose concentration?

Answer 21

Hepatic glycogenolysis

Question 22

A 42 year old male is in the ICU following surgery to set a compound fracture in his leg. The patient is eating while he recovers. One day after surgery, four hours after his last meal, his blood glucose concentration is 165 mg/dL.

What explains the patient’s elevated blood glucose concentration?

Answer 22

Muscle proteolysis

Question 23

Which of the markers below would decrease in a patient recovering from trauma if the patient were in negative nitrogen balance for a prolonged time?

Answer 23

Transthyretine
AST
ALT