Week 2: Temperature Alteration, Nutrition, And Pre-Op Management Flashcards
1
Q
What is a Nutric score?
A
- design to quantify risk for malnutrition and critically ill patients for adverse effects that may be modified by nutritional therapy
- The higher the score the greater the likelihood they will require aggressive nutritional therapy
2
Q
Who needs nutritional support?
A
- those with inadequate bowel syndromes
- those with severe prolonged hypercatabolic state
- those requiring prolonged therapeutic bowel rest
- those with severe protein calorie malnutrition with a treatable disease who have lost 25% of body weight
3
Q
Before starting nutrition: lab work
A
- BMP, magnesium, phosphorus, liver function, EKG (for those severely at risk for refeeding syndrome)
- pre-albumin/plasma albumin: not much significance in the hospitalized patient, does not reflect nutrition status but more critical illness
4
Q
Contraindications to enteral feedings - absolute
A
- intestinal obstruction
– ongoing splanchnic ischemia
– small bowel fistulas that cannot be bypassed by the feeding tube
– hemodynamic instability
– *enteral nutrition may worsen ischemia due to hypo perfusion of the gut and lead to necrosis and bacterial overgrowth
5
Q
Contraindications to enteral feedings – relative
A
- Active G.I. hemorrhage
– early stages of short bowel syndrome
– severe malabsorption
6
Q
How to tell if someone is malnourished?
A
- usually labs will tell you, bodyweight, electrolytes, fluid
- albumin/pre-albumin are not accurate here
- hypokalemia, hyperphosphatemia, hypoglycemia
- need to correct abnormal plasma electrolytes before initiation of feeding
7
Q
Refeeding syndrome
A
- significant risk for fluid overload, CHF, EKG changes, confusion, muscle issues
– low concentrations of predominately intracellular ions (phosphate, magnesium, and potassium) in addition to abnormalities in glucose metabolism, sodium levels, and water balance are associated with morbidity and mortality - plasma electrolytes and glucose should be measured before feeding and any deficiencies must be corrected during feeding
8
Q
What to do when there is marked phosphatemia in refeeding syndrome after initiation of feeding?
A
Intake should be reduced to 500 kcal per day for 48 hours
9
Q
Anorexia nervosa
A
- restriction of energy intake relative to requirements leading to a significantly low body weight
- intense fear of gaining weight or becoming fat
- or even persistent behavior that interferes with weight gain
10
Q
Bulimia nervosa
A
- recurrent episodes of binge eating
- binge eating characterized by both of the following: eating in a discrete period of time and amount of food is definitely larger than what most individuals would eat and a lack of self-control over eating during the episode
- recurrent compensatory behaviors in order to prevent gain, such as vomiting, laxatives, diuretics, fasting, or excessive exercise
- behaviors must occur at least once a week for three months
11
Q
Signs and symptoms of anorexia and bulimia
A
- depends on severity
– abdominal pain (vague), electrolyte imbalance is, poor dentist in/tooth erosion, low bodyweight (anorexia), rapid weight loss, socially withdrawn, poor eye contact
12
Q
Diagnostics of anorexia and bulimia
A
Electrolyte imbalance s (low potassium common), metabolic alkalosis (from severe vomiting), EKG (low-voltage, nonspecific T-wave changes)
13
Q
Complications of anorexia and bulimia
A
- The primary CNS area affected acutely in emergency departments, especially with weight loss, is the hypothalamus
- hypothalamic dysfunction is reflected in problems with thermal regulation, sleep, autonomic cardioregulatory imbalance
14
Q
Treatment for anorexia and bulimia
A
- A nurturant-authoritative approach using biopsychosocial model
- antidepressants, counseling, bio feedback
15
Q
How to make a diagnosis of malnutrition?
A
A diagnosis of malnutrition is made if the patient has two or more of the following criteria:
- insufficient energy intake
– weight loss
– loss of muscle mass
– loss of subcutaneous fat
– localized or generalized fluid accumulation
– decreased functional status
16
Q
Complications of enteral feedings
A
- usually due to the solution
– diarrhea is the most common complication, need to slow down the rate
– nasal damage, aspiration, discomfort, clogging of tubes are others
17
Q
Risk factors for delayed gastric emptying
A
- gastroparesis
- diabetes
– gastric outlet obstruction
– ileus (postop) - trauma
- sepsis
– medications affecting gastric motor function (ex: opioids)
18
Q
Medications to improve gastric emptying
A
- Prokinetic medications such as metoclopramide and erythromycin either alone or combined
- they are safe to use when QTC intervals are monitored and used for up to seven days
19
Q
How to determine route for parenteral nutrition support
A
- less than two weeks use peripheral vein
- Greater than two weeks use central vein
20
Q
When to initiate parenteral nutrition
A
- initiate after seven days for well-nourished, stable adults patients who are unable to receive significant oral or enteral nutrition
- initiate within 3 to 5 days in those who are nutritionally at risk and unlikely to achieve desired oral intake or enteral nutrition
- initiate as soon as possible in feasible patients with baseline moderate or severe malnutrition in those in which oral intake or enteral nutrition or not possible/sufficient
21
Q
Complications of parenteral nutrition support
A
- catheter related: pneumothorax, central line associated bloodstream infection, thrombosis, embolism
– metabolic: refeeding syndrome, glucose abnormalities (hyper/hypoglycemia), hyperlipidemia (hyperlipidemia), liver dysfunction, abnormalities of serum electrolytes and minerals, vitamin mineral deficiencies (ex: brittle bones) - circulatory: volume overload
- gallbladder associated: cholelithiasis, gallbladder sludge
22
Q
Basics of determining TPN requirements
A
- water: 1500 mL for the first 20 kg bodyweight +20 mL for every kilogram over 20
- Energy: estimate 25-30 kcal/kg/day to sustain weight
- Protein: 1.2-1.5 g/kg/day; if in moderate to severe distress then 2.5 g/kg/day
23
Q
Nitrogen balance
A
- The means of assessing how a patient is responding to nutritional therapy
- Intake = output: N equilibrium (no change in body protein, normal state of adult)
- intake > output: positive N balance (increase in total body protein, normal status and growth (including pregnancy), and an adult recovering from a loss of protein in response to trauma or malnutrition
- intake < output: negative N balance (net loss of body proteins, this is never normal, but reflects either a response to trauma or infection, or an intake that is inadequate to meet the needs or replace tissue proteins
24
Q
Geriatric changes to temperature alteration: homeostenosis
A
- decreased sensation of cold, shivering intensity, thermogenesis, vasoconstriction, sweating response, vasodilation, ability to raise cardiac output
25
Q
Hyperthermia versus fever
A
Hyperthermia - defect in temperature regulation – can exceed 41°C (106°F) - absent diurnal variation Fever – normal thermal regulatory system – commonly diurnal variation
26
Q
Hyperthermia syndromes: heat exhaustion
A
- symptoms: flu like with fever, usually less than 39°C, muscle cramps, nausea and vomiting, dizziness, malaise, irritability
- NO Significant neuro impairment
- volume depletion WITHOUT hemodynamic compromise
- management: volume repletion, general supportive measures, cooling measures not necessary
27
Q
Hyperthermia syndromes: heat stroke
A
- life-threatening
Symptoms: extreme elevation and temperature >/= 41°C, SEVERE neuro dysfunction (delirium, coma, seizures) anhidrosis common (inability to produce sweat) - severe volume depletion WITH hypotension
- management: volume resuscitation, cooling to reduce temperature to 38°C, supportive care, NO role for antipyretics
- try to get patients temperature down to 39°C within roughly 30 minutes
28
Q
Drug induced hyperthermia: malignant hyperthermia
A
- uncommon, inherited disorder
- response to halogenated inhaled anesthetic agents
- excessive release of calcium in skeletal muscles
- symptoms: muscle rigidity, hyperthermia, depression of consciousness, rise in EtCO2, AKI, neuro changes (range from agitation to comatose), autonomic dysfunction (including BP changes and arrhythmias)
- management: discontinue offending agent, dantrolene, prevention
29
Q
Drug-induced hyperthermia: neuroleptic malignant syndrome (NMS)
A
- drugs implicated: antipsychotics (Haldol, risperidone), anti-emetics (Reglan, metoclopramide), CNS stimulants, others (lithium TCA overdose), dopaminergics (discontinuation of these drugs – levodopa, amantadine, bromocriptine)
- associated with drugs that influence dopamine-mediated transmission
- symptoms: GRADUAL onset, hyperthermia, muscle rigidity, AMS, autonomic instability
- labs: CK/CPK (> 1,000), WBC can be 40,000 with a left shift on differential
- management: discontinue/resume offending agent, volume resuscitation, dantrolene, bromocriptine
