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General Surgery > Surgical Nutrition > Flashcards

Surgical Nutrition Flashcards

1
Q

The term for the initial period during the activation of stress hypermetabolism where there is a decrease in oxygen consumption, cellular shock, and fluid imbalance lasting 24 to 36 hours:

A

Ebb phase

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2
Q

The term for the adaptation of the body to the ebb phase of stress hypermetabolism where body temperature, metabolic rate, and nitrogen loss are increased:

A

Flow phase

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3
Q

Sepsis/surgery/trauma can increase the kcal requirement by:

A

20% to 40%

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4
Q

The percentage increase of the basal metabolic rate for every degree above 38°C:

A

10%

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5
Q

General method to calculate the calorie requirement for a burn patient:

A

25 kcal/kg/d + (30 kcal/d × %burn)

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6
Q

General method to calculate the protein requirement for a burn patient:

A

1 to 1.5 g/kg/d + (3 g × %burn)

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7
Q

Level of albumin that is a strong risk factor for morbidity/mortality after surgery:

A

<3.0 g/dL

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8
Q

Pregnancy can increase the kcal requirement by:

A

300 kcal/d

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9
Q

What fuel source does the brain use during progressive starvation?

A

Ketones

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10
Q

Most efficient form for the storage of calories:

A

Triglycerides

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11
Q

Amino acid that is the primary substrate for gluconeogenesis:

A

Alanine

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12
Q

Only amino acids to increase during stress:

A

Alanine and phenylalanine

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13
Q

Primary enzyme responsible for the transamination of amino acids (ammonia, α-ketoglutarate):

A

Glutamate dehydrogenase

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14
Q

Where does gluconeogenesis occur during late starvation?

A

Kidney

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15
Q

Name the places where glycogen is stored and the rough percentages:

A

One-third in liver and two-thirds in skeletal muscle

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16
Q

How long does it take to deplete glycogen stores during starvation?

A

24 to 36 hours

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17
Q

List obligate glucose users in the body:

A

Adrenal medulla, peripheral nerves, red blood cells, white blood cells

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18
Q

Carbohydrate digestion begins with this enzyme:

A

Salivary amylase

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19
Q

What is the protein requirement for an average healthy adult male?

A

1g protein/kg/cl;

20% from essential amino acids

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20
Q

Protein digestion begins with this enzyme:

A

Pepsin

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21
Q

1 g of nitrogen is contained in how many grams of protein?

A

6.25 g of protein contains 1 g nitrogen

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22
Q

Formula to calculate the nitrogen balance:

A

(Nin- Nout)=[(protein/6.25) - (24hour urine N + 4g)]

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23
Q

Name the branched chain amino adds:

A

Isoleucine, leucine, valine

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24
Q

Where are branched chain amino acids metabolized?

A

Muscle

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25
Q

List the nutrients included in immune-enhancing formulas:

A

Arginine,
glutamine,
w-3 fatty acids,
w-6 fatty acids

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26
Q

Where is iron absorbed?

A

Most in duodenum and some in jejunum

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27
Q

Where is vitamin B12 (cobalamin) absorbed?

A

Terminal ileum

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28
Q

Where are bile salts absorbed?

A

Terminal ileum

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29
Q

Where are fat-soluble vitamins absorbed?

A

Terminal ileum

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30
Q

Name the fat-soluble vitamins:

A

Vitamin A, D, E, K

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31
Q

Where is calcium absorbed?

A

Actively in the duodenum and passively in the jejunum

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32
Q

What vitamin increased the oral absorption of iron?

A

Vitamin C

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33
Q

Fuel for colonocytes:

A

Short-chain fatty acids (butyrate}

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34
Q

Fuel for small bowel enterocytes:

A

Glutamine

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35
Q

Primary fuel for cancer cells:

A

Glutamine

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36
Q

Term for an acute form of childhood protein-energy malnutrition characterized by anorexia, edema, enlarged liver with fatty infiltrates, irritability, and ulcerating dermatoses:

A

Kwashiorkor

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37
Q

Term for severe protein-energy malnutrition characterized by energy deficiency and characterized by extensive tissue/muscle wasting and variable edema:

A

Marasmus

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38
Q

How many kcal are there in a gram of dextrose?

A

3.4 kcal/g

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39
Q

How many kcal are there in a gram of oral carbohydrates?

A

4 kcal/g

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40
Q

How many kcal are there in a gram of protein?

A

4 kcal/g

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41
Q

How many kcal are there in a gram of EtOH?

A

7 kcal/g

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42
Q

How many kcal are there in a gram of fat?

A

9 kcal/g

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43
Q

List metabolic complications from TPN:

A

Acid-base abnormalities
Excessive glucose resulting in hyperosmolar nonketotic coma with resultant dehydration
Increasein C02 production
Lipogenesis with resulting fatty liver/hepatic abnormalities

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44
Q

Maximal glucose administration for TPN delivered through a central line:

A

3 g/kg/h

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45
Q

For an average healthy adult male, what percentage of calories should come from fat?

A

30%

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46
Q

Rate that should not be exceeded with fat infusion:

A

2.5 g/kg/d

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47
Q

Name an amino acid solution that contains an increased percentage of branched chain amino adds that is used in patients with encephalopathy:

A

HepatAmine 8% amino acid solution

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48
Q

The caloric value from the lipid propofol is stored in:

A

1 kcal/cc

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49
Q

Formula to calculate the ideal body weight for a man:

A

106 lb +6 lb for every inch over 5 ft

50
Q

Formula to calculate the ideal body weight for a woman:

A

105 lb + 5 lb for every inch over 5 ft

51
Q

List the rough percentage of calories from carbohydrates in TPN:

A

50% to 60%

52
Q

List the rough percentage of calories from proteins in TPN:

A

10% to 20%

53
Q

List the rough percentage of calories from lipids in TPN:

A

20%to 30%

54
Q

Electrolyte abnormalities found with refeeding syndrome:

A

Hypokalemia, hypomagnesemia, hypophosphatemia; occurs when feeding after prolonged malnutrition/starvation

55
Q

The best parameter to check for adequate nutritional status:

A

Prealbumin

56
Q

Half-life of retinol-binding protein:

A

12 hours

57
Q

Half-life of prealbumin:

A

2 to 3 days

58
Q

Half-life of transferrin:

A

8 to 9 days

59
Q

Half-life of albumin:

A

14 to 20 days

60
Q

Formula for the respiratory quotient:

A

RQ = CO2 produced/

O2 consumed

61
Q

Respiratory quotient for carbohydrate:

A

1

62
Q

Respiratory quotient for ethanol:

A

0.67

63
Q

Respiratory quotient for fat:

A

0.7

64
Q

Respiratory quotient during hyperventilation:

A

> 1.1

65
Q

Respiratory quotient to indicate lipogenesis or overfeeding:

A

> 1.0

66
Q

Respiratory quotient in starvation:

A

0.6 to 0.7 (fat is fuel source during starvation)

67
Q

Ideal respiratory quotient during mixed substrate oxidation:

A

0.85 to 0.95

68
Q

Respiratory quotient <0.82 indicates:

A

Occurrence ofprotein oxidation;

increase total energy intake by increasing carbohydrates and caloric intake

69
Q

Respiratory quotient >1 indicates:

A

Excessive calorie load; decrease carbohydrate intake and caloric intake

70
Q

List the effects seen with chromium deficiency:

A

Encephalopathy, hyperglycemia, neuropathy

71
Q

List the effects seen with cobalamin (B12) deficiency.

A

Beefy tongue, megaloblastic anemia, peripheral neuropathy

72
Q

List the effects seen with copper deficiency:

A

Pancytopenia

73
Q

List the effects seen with essential fatty adds deficiency:

A

Dermatitis, hair loss, thrombocytopenia

74
Q

List the effects seen with folate deficiency:

A

Glossitis, megaloblastic anemia

75
Q

List the effects seen with niacin deficiency:

A

Diarrhea, dermatitis, dementia (pellagra)

76
Q

List the effects seen with phosphate deficiency:

A

Encephalopathy, decreased phagocytosis, weakness

77
Q

List the effects seen with pyridoxine (B6) deficiency:

A

Glossitis, peripheral neuropathy, sideroblastic anemia

78
Q

List the effects seen with thiamine (B1) deficiency:

A

Cardiomyopathy,

peripheral neuropathy, Wernicke encephalopathy

79
Q

List the effects seen with zinc deficiency:

A

Hair loss, rash, poor healing

80
Q

List the effects seen with vitamin A deficiency:

A

Night blindness

81
Q

List the effects seen with vitamin D deficiency:

A

Rickets, osteomalacia

82
Q

List the effects seen with vitamin E deficiency:

A

Neuropathy

83
Q

List the effects seen with vitamin K deficiency:

A

Coagulopathy

84
Q

A 55-year-old female underwent a Hartmann procedure for Hinchey III perforated diverticulitis. On postoperative day 8, she had failed 3 attempts at extubation and was still on mechanical ventilator support. One possible reason to explain her difficult weaning is a respiratory quotient of:

A. 0.67 
B. 0.7 
C. 0.8 
D. 0.9 
E. 1.1
A

Answer: E.

The RQ is defined as the ratio of volume of carbon dioxide produced to the volume of oxygen used on oxidation of a nutrient. The RQ is nearly 1 for carbohydrates, 0.7 for fat, 0.8 for protein, and 0.67 for alcohol.

Respiratory failure requiring mechanical ventilation and difficulty with weaning patients can occur if excess glucose is provided, hence raising the RQ to greater than 1.

85
Q

Which electrolyte and acid-base abnormality is present in a neonate with intractable projectile vomiting from hypertrophic pyloric stenosis?

A. Hyperkalemic hypochloremic metabolic alkalosis

B. Hypokalemic hypochloremic metabolic acidosis

C. Hypokalemic hyperchloremic metabolic alkalosis

D. Hypokalemic hypochloremic metabolic alkalosis

E. Hypernatremic metabolic acidosis

A

Answer: D.

Persistent emesis causes progressive loss of fluids rich in hydrochloric acid, which causes the kidneys to retain hydrogen ions in favor of potassium.

Electrolyte abnormalities depend on the duration of symptoms in the affected infant.

Dehydration may result in hypernatremia or hyponatremia and prerenal failure.

86
Q

What is the major primary nutrient of colonocytes?

A. Acetoacetate 
B. Beta-transferrin 
C. Glutamine 
D. Arginine
E. Butyrate
A

Answer: E.

Compared with common fuels, butyrate is the principal fuel for colonocytes, followed by acetoacetate, glutamine, and glucose.

87
Q

What is the major primary nutrient of neoplastic cells?

A. Glutamine
B. Short-chainfatty acids 
C. Long-chain fatty acids 
D. Glucose
E. Arginine
A

Answer: A.

Glutamine is the most abundant amino acid in the human body.

It is necessary for nucleotide synthesis in rapidly dividing cells, which is why it is not only the major fuel source for the enterocyte but also for the neoplastic cells.

88
Q

A 25-year-old female driver ofan automobile sustained severe multiple traumatic injuries. She had an altered sensorium and required intubation. Etomidate was used for induction.

A noted side effect of this agent is associated with what electrolyte abnormality?

A. Hypomagnesemia
B. Hypokalemia
C. Hyperphosphatemia
D. Hyponatremia and hyperkalemia 
E. Hypernatremia and hypokalemia
A

Answer: D.

Etomidate has minimal effects on the cardiovascular system, making it an attractive induction agent in trauma patients.

However, even a single dose of etomidate is a major risk factor for the development of relative adrenal insufficiency for at least 24 hours after its administration.

Mineralocorticoid deficiency can cause sodium excretion and potassium retention as a result of hypoaldosteronism.

89
Q

Which of the following conditions is associated with hypovolemic hyponatremia?

A. Cirrhosis
B. Congestive heart failure
C. Nephrotic syndrome
D. Enterocutaneousfistula 
E. SIADH
A

Answer: D.

Cirrhosis, congestive heart failure, and nephrotic syndrome are all associated with hypotonic hypervolemia hyponatremia.

A variety of factors can contribute to the development of hyponatremia in patients with cirrhosis.

The most important factor is systemic vasodilation, which leads to activation of endogenous vasoconstrictors, including antidiuretic hormone (ADH); ADH promotes the water retention that is responsible for the fall in serum sodium.

Neurohumoral stimulation as a result of atrial underfilling causes ADH release in heart failure, leading to hyponatremia as well.

Intrinsic renal disease leads to salt wasting and impaired water balance in nephrotic syndrome. SIADH is associated with euvolemia, by definition.

GI fistulas cause loss of fluid and electrolytes, causing hypovolemic hyponatremia.

90
Q

Hypernatremia in a volume-depleted patient is best treated with what initial fluid choice?

A. Normal saline 
B. 0.25% saline
C. 3% saline
D. Lactated Ringer
E. No fluid should be given
A

Answer: A.

The main priority in this patient is volume replacement.

After this is accomplished, the sodium concentration can be decreased in the intravenous fluids.

Hypernatremia associated with hypovolemia occurs with Na loss accompanied by a relatively greater loss oftotal body water.

Common extrarenal causes include most of those that cause hyponatremia and volume depletion.

Either hypernatremia or hyponatremia can occur with severe volume loss, depending on the relative amounts of Na and water lost and the amount of water ingested before presentation.

Renal causes of hypernatremia and volume depletion include therapy with diuretics.

Loop diuretics inhibit Na reabsorption in the concentrating portion of the nephrons and can increase water clearance.

Osmotic diuresis can also impair renal concentrating capacity because of a hypertonic substance present in the tubular lumen of the distal nephron.
The most common cause of hypernatremia due to osmotic diuresis is hyperglycemia in patients with diabetes.

In patients with hypernatremia and hypovolemia, particularly in patients with diabetes with non-ketotic hyperglycemic coma, 0.45% saline can be given as an alternative to a combination of 0.9% normal saline and 5% D/W to replenish Na and free water.

Alternatively, extracellular fluid volume and free water can be replaced separately, using the formula given to estimate the free water deficit.

91
Q

A 60-year-old cancer patient has gastric outlet obstruction and presents with refractory vomiting. Which intravenous fluid is most appropriate for volume repletion?

A. Normal saline 
B. 0.45% saline
C. 3% saline
D. Lactated Ringer 
E. Freewater
A

Answer: A.

Similar to neonatal pyloric stenosis, the metabolic alkalosis of GOO in response to the administration of chloride is important; therefore, sodium chloride solution should be the initial IV fluid of choice.

Potassium deficits are corrected after repletion of volume status and after replacement of chloride.

92
Q

Routine lab work on a patient with small-bowel obstruction shows refractory hypocalcemia causing perioral numbness that is uncorrectable with calcium supplementation.

What other electrolyte level must be checked and corrected?

A. Sodium
B. Phosphate
C. Bicarbonate 
D. Magnesium 
E. Chloride
A

Answer: D.

Low magnesium concentrations may impair adenylate cyclase activity, leading to refractory hypocalcemia secondary to impaired secretion of PTH.

Remember to check and correct magnesium levels in the hypocalcemic patient as in post parathyroidectomy or post thyroidectomy.

93
Q

A patient with Crohn disease undergoes an ileocecectomy for perforation and subsequently has a prolonged postoperative ileus. What is the most common electrolyte abnormality associated with starting TPN?

A. Hypernatremia 
B. Hypokalemia
C. Hypophosphatemia 
D. Hypomagnesemia 
E. Hypochloremia
A

Answer: C.

The serum phosphorous level falls precipitously with refeeding due to a shift of phosphate from the extracellular to intracellular compartment, which is due to the huge demands for this ion for synthesis of phosphorylated compounds.

The result of this sudden massive reduction in phosphorous levels is a multitude of life-threatening complications involving multiple organs: respiratory failure, cardiac failure, cardiac arrhythmias, rhabdomyolysis, seizures, coma, red cell, and leukocyte dysfunction.

94
Q

A 77-year-old cachectic homeless man undergoes exploratory laparotomy with Graham patch repair for perforated gastric ulcer. He is extubated postoperatively, and enteral nutrition is started on POD #2. He then develops gross confusion, weakness and requires reintubation. What underlying electrolyte abnormalities are seen with this condition?

A. Hypophosphatemia, hyperkalemia, hypermagnesemia

B. Hypophosphatemia, hypokalemia, hypermagnesemia

C. Hypophosphatemia, hypokalemia, hypomagnesemia

D. Hyperphosphatemia, hyperkalemia, hypomagnesemia

E. Hyperphosphatemia, hypokalemia, hypomagnesemia

A

Answer: C.

This is another refeeding syndrome question.

Refeeding syndrome is seen with the introduction of nutrition in the malnourished patient.

Classic electrolyte abnormalities seen are hypophosphatemia, hypokalemia, and hypomagnesemia
along with hyponatremia and thiamine deficiency.

Introduction of nutrition and carbohydrates causes an increase in insulin, which drives the extracellular movement of potassium, phosphate, and magnesium into the intracellular compartment.

Permissive underfeeding is a reasonable option with this patient population.

95
Q

The best nutrition access method for a critically ill burn patient is:

A. Nasogastric
B. Nasojejunal
C. Parenteral
D. Percutaneous gastrostomy 
E. Witzeljejunostomy
A

Answer: B.

Guidelines published by a multitude of burn associations that are based on several trials recommend nasojejunal feeding in severely burned patients due
to complications associated with early enteral feeding by the nasogastric route.

Percutaneous and surgical feeding tubes are premature and usually unnecessary.

96
Q

A 30-year-old man who underwent Roux-en-Y gastric bypass for morbid obesity years prior returns to clinic for follow-up with numbness in his fingers and megaloblastic anemia. Which deficiency is likely to be seen?

A. B12 deficiency
B. Iron deficiency
C. Zinc deficiency
D. Selenium deficiency 
E. Chromium deficiency
A

Answer: A.

Vitamin B12 deficiency typically manifests with megaloblastic anemia and peripheral neuropathy.

Patients with a history of gastric bypass are especially susceptible to B12 deficiency due to impairment of the metabolism of B12, which is due to deficiency of intrinsic factor.

97
Q
  1. A 73-year-old man has EKG findings showing peaked T waves and decreased P waves. Which of the following is the first step in the management of this patient?
A. 10 U insulin and 50 g dextrose 
B. Kayexalate
c. Dialysis
D. Calcium gluconate
E. IV sodium bicarbonate
A

Answer: D.

The main symptoms of hyperkalemia occur when potassium levels are around 7 to 8 mEq/L or higher, which can result in muscle weakness and cardiac arrhythmias.

The classic EKG findings that will occur are peaked T wave abnormalities, which result from rapid repolarization and delay of depolarization from the high levels of potassium.

The quickest way to alleviate the effects of hyperkalemia is to give IV calcium to antagonize the effects of hyperkalemia
by restoring membrane excitability toward normal.

After stabilizing the cardiac membrane, correcting the hyperkalemia would be the next step.

98
Q

A 56-year-old female with metastatic breast cancer is found at home confused and complaining of abdominal pain. The patient’s serum calcium is found to be 15 mg/dL Which of the following is the most appropriate next step in management?

A. Bisphosphonates 
B. Dialysis
C. Fluid resuscitation 
D. Furosemide
E. Calcitonin
A

Answer: C.

Hypercalcemia can occur from neoplastic processes from either parathyroid-related protein {PTHrP) from classic squamous cell lung carcinoma and breast cancer or from resorption from the bony destruction of metastasis, which can be seen with metastatic breast cancer, multiple myeloma, and lymphoma.

The first step in management in the acutely symptomatic hypercalcemic patient is aggressive fluid resuscitation with normal saline.

99
Q 
A 45-year-old male with short gut syndrome on long-term TPN develops confusion, neuropathy, and hyperglycemia. A deficiency in which of the following is associated with these symptoms?
A. Copper 
B. Selenium
C. Chromium 
D. Zinc
E. Cobalamin
A

Answer: C.

Chromium deficiency is associated with symptoms including glucose intolerance, confusion, and neuropathy. Patients receiving long-term administration of TPN are at increased risk of developing deficiencies in trace minerals.

100
Q

A 48-year-old-man is transferred to the trauma bay with severe TBI and SAH. Neurosurgery is consulted, and no surgical intervention is indicated at this time, but it is recommended to maintain the patient’s serum Na >140. The patient is transferred to the ICU, where he is resuscitated with a total of 5 L-NS throughout the night. What metabolic derangements are likely to be seen with this patient?

A. Anion-gapped metabolic acidosis
B. Non-anion-gapped metabolic acidosis
C. Non-anion-gapped metabolic alkalosis 
D. Anion-gapped metabolic alkalosis
E. Respiratory acidosis
A

Answer: B. The fluid composition of NS is 154 mEq Na+ and 154 mEq Cl-.

Resuscitation with NS can result in excess chloride accumulation with a decrease in HC03 resulting in a normal anion-gap hyperchloremic metabolic acidosis.

Remember the calculation for anion gap is:
Anion gap = Na - (Cl+ HC03).

For gapped metabolic acidosis, remember the mnemonic MUDPILES.

101
Q 
A 70-kg man is receiving 100 g of protein per day. His urinary urea nitrogen is 26. What is his nitrogen balance?
A. Zero 
B. +7
c. +14
D. -14
E. Not enough information
A

Answer: D.

Nitrogen balance is calculated using the following equation: Nitrogen balance = Protein intake / 6.25 - (UUN + 4), where UUN = urinary urea nitrogen.

For the question, this equation would be: 100/6.25 - (16 + 4) = -14.

102
Q

Nutritional screening:

A. All patients should have nutritional screening.

B. Patients with inadequate nutrition screening should have nutritional assessment

C. Patients with moderate to severe malnutrition should have preoperative nutrition assessment.

D. Normal appearing patients do not need nutritional screening.

A

D. Normal appearing patients do not need nutritional screening.

103
Q

Patients undergoing surgery who are considered to have no specific risk of aspiration

A. Shall drink clear fluids until two hours before anesthesia.

B. Solids shall be allowed until six hours before anesthesia.

C. Preoperative anesthesia is unnecessary in most patients

D. Preoperative anesthesia is required in most patients.

A

D. Preoperative anesthesia is required in most patients.

104
Q

Oral nutritional intake:

A. Oral intake is usually given within 48h.

B. In general, oral nutritional intake shall be continued after surgery without interruption.

C. It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out with special caution to elderly patients.

D. Oral intake including clear liquids, shall be initiated within hours after surgery in most patients.

A

A. Oral intake is usually given within 48h.

105
Q

Perioperative nutritional therapy is given:

A. If patients are not able to have adequate oral intake in two days.

B. If it is anticipated that the patient will be unable to eat for more than five days perioperatively.

C. If patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days.

D. If oral intake cannot be maintained above 50%, enteral nutrition should be initiated.

A

A. If patients are not able to have adequate oral intake in two days.

106
Q

Indication for parenteral nutrition

A. Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as intestinal obstruction.

B. For administration of parenteral nutrition in all-in-one (three chamber bag or pharmacy prepared) should be preferred instead of multi-bottle system

C. Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN

D. All are correct.

A

D. All are correct.

107
Q

Nutrition care:

A. It is recommended to assess the nutritional status before and after major surgery

B. Standardised operating procedures (SOP) for nutritional support are recommended to secure an effective nutritional support therapy.

C. Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk.

D. Once nutritional assessment is done, the process is completely complied with.

A

D. Once nutritional assessment is done, the process is completely complied with.

108
Q

Intravenous omega fatty acid infusion:

A. Postoperative parenteral nutrition including omega-3-fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require parenteral nutrition

B. Once enteral nutrition is achieved you can still deliver the IV omega fatty acid infusion

C. IV omega fatty acid infusion may have side effects when given at above 50% of the total non-protein calorie requirement.

D. Intravenous omega fatty acid infusion may cause untoward side effects to cancer patients.

A

A. Postoperative parenteral nutrition including omega-3-fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require parenteral nutrition

109
Q

Preoperative nutrition therapy in high-risk patients:

A. Patients with severe nutritional risk shall receive nutritional therapy prior to major surgery even if operations including those for cancer have to be delayed. A period of 7-14 days may be appropriate.

B. A three-day perioperative build up may suffice for some of these patients.

C. Whenever feasible, the oral/enteral route shall be preferred.

D. Preoperatively, oral nutritional supplements shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery.

A

B. A three-day perioperative build up may suffice for some of these patients.

110
Q

High risk patients include:

A. A special group of high-risk patients are the elderly people with sarcopenia.

B. Immune modulating oral nutritional supplements including arginine, omega-3 fatty acids and nucleotides can be preferred and administered for five to seven days preoperatively to this group of patients

C. Parenteral glutamine supplementation may ve considered in patients who cannot be fed adequately enterally and, therefore, required exclusive PN

D. Low protein is required for these patients.

A

D. Low protein is required for these patients.

111
Q

Postoperative surgical care:

A. If tube feeding is indicated, it shall be initiated within 24h after surgery.

B. In most patients, a standard whole protein formula is appropriate.

C. For technical reasons with tube clogging and the risk of infection, the use of kitchen-made (blenderized) diets for tube feeding is not recommended in general.

D. All are recommended.

A

D. All are recommended.

112
Q

Which vitamin is not part of any commercially prepared vitamin solution, hence should be supplemented on a weekly basis?

A

Vitamin K

113
Q

Which deficiency manifests as dry, scaly dermatitis and loss of hair?

A

Essential fatty acid deficiency.

This is clinically apparent during prolonged parenteral nutrition with fat free solutions.

It is prevented by periodic infusion of a fat emulsion at a rate equivalent to 10-15% of total calories.

114
Q

Which deficiency is most common and manifests as dry, scaly dermatitis and loss of hair?

A

Zinc deficiency

115
Q

Which deficiency is associated with microcytic anemia?

A

Copper deficiency

116
Q

Which deficiency is associated with glucose intolerance?

A

Chromium deficiency

117
Q

Discuss refeeding syndrome.

A

Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding. This is characterized by hypokalemia, hypomagnesemia, hypophosphatemia, thiamine deficiency, salt and water retention leading to edema.

Symptoms include fatigue, lethargy, muscle weakness, fluid overload, cardiac arrhythmia, and hemolysis.

Management is through slow initiation in first week (50% of requirements based on dry weight), careful monitoring of fluid status, electrolytes, and cardiovascular function, vitamin and mineral supplementation.

118
Q

How does protein overfeeding present?

A

Azotemia
Hypertonic dehydration
Metabolic acidosis

119
Q

How does glucose overfeeding present?

A

Hyperglycemia
Hypertriglyceridemia
Hepatic steatosis

120
Q

How is overfeeding managed?

A

Insulin treatment, targeting normoglycemia

121
Q

Risk factors for overfeeding?

A
  • Extremes of size
  • Non-protein calories inadvertently excluded from nutritional computations (ie, glucose in IV fluids, lipid in propofol)
  • Errors in height or weight measurements, estimates, or calculations
  • Failure to account for clinical state (eg decreased energy needs from sedation and mechanical ventilation)
  • Use of parenteral nutrition

General Surgery (34 decks)

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