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ASPEN Clin 2 Readings > Trauma, Surgery and Burns > Flashcards

Trauma, Surgery and Burns Flashcards

1
Q

Which of the following is the most important benefit to starting early EN after trauma?
A) Addressing protein-energy malnutrition before it is severe
B) Preventing negative nitrogen balance
C) Modulating the immune process and supporting the GI tract
D) Preventing sever hyperglycemia

A

C

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2
Q

Why does negative nitrogen balance occur despite adequate energy provision?

A

Due to counterregulatory hormone and cytokine changes which occur during traumatic insult

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3
Q

What is blunted during the traumatic response?

A

Insulin signalling, especially in skeletal muscle

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4
Q

What blunts insulin during the traumatic response?

A

Epinephrine, glucagon and growth hormones are elevated - increasing glycogenolysis, lipolysis and increased free fatty acids

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5
Q

How does early EN attenuate the hormonal milieu conducive to hyperglycemia in the traumatic state?

A

Will attenuate the cytokine storm and the counter-regulatory hormone system, but will only truly normalize once the injury or the metabolic stress has been resolved.

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6
Q

For routine colon surgery, which of the following components of Enhanced Recovery After Surgery (ERAS) protocols will contribute to improved outcomes?
A) Keeping the patient NPO after midnight to avoid aspiration on induction of general anesthesia
B) Providing glucose-rich supplementation 6 and 2 hours prior to surgery
C) Using high-dose oral protein supplements
D) Using probiotics to restore normal intestinal flora after surgery

A

B

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7
Q

What are the perioperative principles to improve outcomes in elective colon surgery?

A
  • Avoiding starvations
  • Limiting IV fluids
  • Increasing mobility
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8
Q

What are the outcomes of patients consuming 800 ml of CHO-rich liquid (providing 100 g of CHO) at midnight and 400 ml 2 hours prior to the surgical intervention?

A
  • Faster recovery
  • Fewer infections
  • No increased aspirations
  • Decreased insulin resistance
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9
Q 
Which of the following is NOT thought to benefit burn and wound healing?
A) Vitamin C supplementation
B) Calcium
C) Protein delivery of 1.5-2 g/kg/day
D) Zinc supplementation
A

B

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10
Q

What are the two tenants that must be addressed when treating patients who are admitted to surgical wards and ICU?

A

1) Negative nitrogen balance, will suffer from weight loss, weakness, and long duration of rehab prior to returning to baseline.
2) Early administration of nutrition and nutritional supplementation as patient is going to OR

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11
Q

How may the severity of body injury be assessed?

A
  • Injury severity score
  • Glasgow Coma Scale
  • Total Body Surface Area burn affected
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12
Q

What is SIRS?

A

Systemic Inflammatory Response Syndrome

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13
Q

When is SIRS indicated?

A

When 2/4 of the following are abnormally present:

  • Heart rate
  • Resp. rate
  • Temperature
  • WBC
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14
Q

Discuss the inflammatory response

A
  • Our tissues demand more oxygen, therefore resp., heart, and ventilation rate will increase to meet this demand.
  • Rapid shift to energy mobilization by counterregulatory hormones
  • Circulating levels of insulin are elevated, with resistance and blunted response in skeletal muscle
  • This hormonal milieu will only be resolved once the injury or metabolic stress is resolved
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15
Q

(T/F) NS should be initiated on Day 1 to 3

A

F

Depends, and we should consider beginning within 24 hours of admission by analyzing risk:benefits (e.g. bowel necrosis)

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16
Q

What are the counter-regulatory hormones? Why are they called this?

A

Epi, norepi, glucagon and cortisol
Will counteract the anabolic effects of insulin and other anabolic hormones (re-call that insulin still remains elevated)

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17
Q

What are the 3 strategies of SIRS?

A
  • Oxygen delovery
  • Source control
  • Nutrition support
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18
Q

(T/F) Eary NS is to meet protein and energy goals

A

F

Address the modulation of the immune function

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19
Q

What are the splanchnic arteries?

A

The arteries which supply the visceral organs with blood

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20
Q

What happens during significant insults, such as sepsis or haemorrhage?

A

Significant reduction in splanchnic blood flow and increase in oxygen consumption

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21
Q

How does the presence of luminal nutrients improve blood flow?

A

Increase Gi blood flow through splanchnic arteries, known as post-prandial hyperaemia

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22
Q

Inadequate splanchnic blood flow is though to play a pivotal role in what?

A

The development of multi-organ dysfunction

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23
Q

Increased blood flow associated with EN protects the gut despite ______

A

the risk of bowel necrosis

–> Avoid feeding in hemodynamically unstable or low-flow state

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24
Q

Differentiate the malnutrition from starvation and the malnutrition from stress and trauma

A

The former results in an increased energy expenditure and tremendous mobilization of protein deposits, which is driven by systemic inflammation
–> Will occur over the first few hours to days after the patient is admitted, but may continue for week or months after the patient is discharged from the ICU

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25
Q

What is linked to malnutrition linked to in the hospital setting?

A
  • Immunosuppression
  • Impaired wound healing
  • Increased hospital costs
  • Longer hospital stays
  • Increased mortality
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26
Q

What does the NUTR-2002 scoring system focus on?

A

Accounts for pre-existing malnutrition and severity of illness

27
Q

What does the NUTRIC scoring system focus on?

A

The severity of the illness

28
Q

Protein losses in the post-op surgical patient?

A

-5% of body protein during the first 2-weeks post-op

29
Q

Protein losses in the critically ill following trauma or illness?

A

-20% of total body protein is metabolized in the critically ill patient in the first 3 weeks following trauma/illness

30
Q

Is body weight usually a valid indicator in the ICU patient?

A

No, as there is often significant accumulation of edema, should be collected by historical weight information, such as through family

31
Q

How should the clinician prescribe nutrition therapy for a complex burn patient?

A
  • Provide nutrition support which addresses increased protein and energy needs
  • Provide a product with a high-bioavailability of protein, with a non-protein energy:nitrogen ratio of 100:1 or less
  • Consider immune-modulated formula, with omega-3s and with arginine and/or glutamine
  • Discontinue EN when 75% of needs can be met orally, and provide high-energy protein supplements
32
Q

Protein % and g/kg/day in burn patients ?

A

20-25% of energy

2.5 g/kg/day in the early post-burn course, and 4 g/kg/day during the extended flow period

33
Q

Give risks of overfeeding

A
  • Hepatic steatosis
  • Hyperglycemia
  • Pulmonary compromises
34
Q

Give risks of underfeeding

A
  • Poor wound healing
  • Impaired organ function
  • Altered immunologic status
  • Increased risk of mortality
35
Q

When are estimating energy needs less accurate?

A
  • Obese
  • Underweight
  • Patients with acute or chronic liver diseases
36
Q

When can a PEG tube be used for feeding after insertion?

A

Within 2 hours

37
Q

How is protein lost during major injury?

A

Primarily through the wound exudate and urine for the first 10 days following injury

38
Q

is catabolism reversed in the provision of energy and protein?

A

No, but the protein synthetic rate is partially responsive to amino acid infusion.

39
Q

What may excess protein administration cause?

A

Azotemia

40
Q

Why is nitrogen balance difficult to assess in the critically ill patient?

A

Difficult to quantify all protein losses - such as through stool, wounds, abdominal drains, urine, dialysate

41
Q

In the hyper-metabolic patient, where does the majority of of oxidized glucose derived from?

A

Amino acid substrates via gluconeogenesis, where this endogenous production is not suppressed by insulin signalling (i.e. through administering a CHO load - which may aggravate hyperglycemia)

42
Q

Why is adipose tissue mobilized in the hypercatabolic, critically-ill patient?

A
  • Alterations in cytokine and hormonal mediators

- Enhanced mobilization of TGs despite increased levels of plasma glucose and insulin

43
Q

What have multiple studies concluded about providing the critically-ill patient with high-concentrations of omega-3 FA from fish oil?

A

-Decreased infection rates, hospital length of stay and mortality

44
Q

Why are there significant shifts in fluid and electrolytes status?

A
  • Resuscitative fluid delivery

- Fluid compartmental shifts

45
Q

In thermal burn patients, how can adequate hydration become reflected in the urine?

A

Should observe a minimum of 0.3-0.5 ml/kg/h

46
Q

Along with increased levels of ROS, what is found to be depleted in patients after surgery, trauma, burns, sepsis and long-term PN?

A

Vitamins C and E (antioxidants)
ASPEN supports use of antioxidants due to mortality benefit
Provide, at minimum, the RDA

47
Q

When is a daily multivitamin recommended?

A

When burns are <20% TBSA

48
Q

Multivitamin provision when burns are >20% of TBSA?

A
  • Multivitamin
  • 20,000 IU Vit A
  • 220 mg zinc
  • 500 mg Vitamin C BID
49
Q

Why are large doses of vitamin C preferred to be given through tube feeding?

A

As they may induce nausea and vomiting

50
Q

When comparing EN to PN, how does PN disadvantage the critically ill patient?

A
  • Increase metabolic stress response
  • Alterations in gut flora
  • Gut atrophy
  • -> Contributing to systemic immuno-compromise
51
Q

Is the presence of bowel sounds or passing of flatulence required to initiate EN?

A

No

52
Q

When should PN be considered?

A

When EN has failed to advance to meet 60% of target goal energy for 7-10 days

53
Q

When may PN be immediately initiated?

A
  • Have pre-existing severe malnutrition
  • Cannot receive EN
  • Are expected to undergo major upper Gi surgery
54
Q

Why may the critically ill not tolerate gastric feeds?

A

Due to delayed gastric emptying, and may be predisposed to risks of aspiration and regurgitation

  • Higher presence of gut dysmotility within the ICU
  • Consider small-bowel feeding
55
Q

Which patients are considered high risk, and may benefit from small-bowel feeding?

A
  • Undergone major intra-abdominal surgery
  • Previous episode of aspiration or emesis
  • Persistant GRVs > 500 ml
  • Unable to protect airway, or who require prolonged supine position
56
Q

When may nightly cycling of EN be considered?

A

When patient is meeting more than 60% of energy goal through oral route

57
Q

What is early post-op feeding (whether through oral or enteral route) associated with?

A
  • Reduced complications
  • No increase in anastomotic leaks
  • Only small increases in N/V
58
Q

What is the overarching objective of ERAS? Why?

A

-Decrease insulin resistance

As insulin resistance has been shown to increase complications, infections, hospitalizations and mortality

59
Q

What are the objectives of ERAS?

A
  • Avoid starvation
  • Decrease physiological stress of surgery
  • Limit post-op IV fluids
  • Optimize pain control, GI function and mobilization
60
Q

What are the components of ERAS?

A
  • Provide solid meals up to 6 hours prior to surgery
  • 800 ml CHO rich liquid at midnight
  • 400 ml CHO rich liquid 2 hours prior to surgery
61
Q

How does the practitioner prescribe nutrition therapy for a complex trauma patient?

A
  • Insertion of feeding tube, and administration of immune enhancing formula with 24 hours of admission
  • Reach 50% of energy goal within 24 to 48 hours
  • Nutrition goals should be met within the first week of admission
62
Q

When may post-pyloric feeds benefit the patient?

A

-When patients are scheduled for many surgery/interventions, and we want to reduce to post-op NPO time required by aneasthesia

63
Q

ASPEN recommendation on immunonutrition?

A

Recommend the use of continuously administered immunonutrition formulations with supplemental w-3 fatty acids and arginine in post-op and trauma ICU patients.

64
Q

(T/F) ASPEN recommends adding glutamine to EN for the critically ill patient

A

F

ASPEN Clin 2 Readings (6 decks)

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