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62 Cards in this Set
- Front
- Back
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When assessing nutritional status what things are you looking for?
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Overt wasted appearance
Assess fat/muscle status Pitting edema, ascites Coarse, easily pluckable hair Glossitis Bleeding gums Cheilosis Angular fissures at corners of mouth Dermatitis Dry flaky skin Neuromuscular irritability |
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"Calorie deficient" malnutrition
Chronic inadequate caloric intake Severe fat & muscle wasting on PE Relative preservation of visceral protein stores Gradual tx key to prevent "refeeding syndrome” Relatively good prognosis |
Marasmus
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"Protein deficient" malnutrition
Acute inadequate protein intake during stress Normal or above normal fat & muscle stores Hair easily pluckable Pitting edema Skin breakdown Delayed wound healing Poor prognosis |
Kwashiorkor
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Combined protein-energy malnutrition
Acute stress experienced by chronically starved patient Careful tx to prevent complications of over/under feeding |
Marasmic-kwashiorkor
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Increases carbon dioxide production
metabolic complications |
Overfeeding
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Decreases immunocompetence
Increases risk of infection |
Underfeeding
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These drugs have a catabolic effect on body's nutrition?
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High dose steroids
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What are the specific stressors associated with metabolic stress?
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Sepsis (infection)
Surgery Trauma Burns (a subset of trauma) |
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Involves most metabolic pathways
Accelerated metabolism of LBM Negative nitrogen balance Muscle wasting Hypercatabolism |
Metabolic Response to Stress
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Usually the first 24-48 hours
Immediate response: Hypovolemia & tissue hypoxia Decreased cardiac output Decreased oxygen consumption Lowered body temperature decrease Insulin & increase glucagon levels |
Ebb Phase
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Follows fluid resuscitation and improved O2 transport
Increased cardiac output begins Increased body temperature Increased energy expenditure Total body protein catabolism begins Increase glucose production, FFAs, circulating insulin, catecholamines, glucagon, & cortisol |
Flow Phase
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What is the only thing, metabolically speaking, that decreases and stays decreased with sepsis?
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Amino acid uptake from both luminal and circulating sources, leading to gut mucosal atrophy
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Causes energy metabolism to shift to protein as a primary fuel
The body needs glucose, so protein is used for gluconeogenesis Increase in hepatic amino acid uptake for protein synthesis “Acute phase proteins” are made instead of visceral proteins This protein needs to come from somewhere…muscle is a good source! |
Hormonal and Cell mediated response to stress
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What is necessary for fluid & sodium conservation to support blood volume?
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Aldosterone
Corticosteroid that causes the kidney to retain sodium Antidiuretic hormone Stimulates renal tubular water absorption |
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In the hormonal stress response, what is necessary to stimulate metabolism?
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ACTH (adrenocorticotropic hormone)
Acts on adrenal cortex to release cortisol Mobilize amino acids from skeletal muscle Catecholamines Epinephrine & norepinephrine from renal medulla Stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis |
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Occurs when a patient is very stressed
See increased production of cytokines Protein mediators secreted by macrophages in response to tissue damage, infection, inflammation, and some drugs and chemicals Hormone regulators of the immune system Stimulate production of inflammatory mediators associated with shock & sepsis |
Acute Phase Response
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Cytokine Action
Increased catabolism of LBM Causes anorexia Activates the hypothalamic-pituitary-adrenal axis |
TNF
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Cytokine Action
Mediates the acute phase response Associated with fever, hypotension, inflammation, protein catabolism |
IL-1
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Cytokine Action
Release of hepatic acute phase proteins |
IL-6
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decreased energy expenditure, use of alternative fuels, decreased protein wasting, stored glycogen used in 24 hours
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Starvation
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fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system, and RBCs
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Late Starvation
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describes the inflammatory response that occurs in:
Infection Pancreatitis Ischemia Trauma/burns Shock Major organ injury |
Systemic Inflammatory Response Syndrome (SIRS)
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Multiple organ dysfunction syndrome is common
Ileus (lack of peristalsis) Enteral feeding may preserve gut function TF may help prevent bacterial translocation Hypermetabolism & hypercatabolism |
SIRS Complications
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Out of control cytokines
Gut hypothesis Bacterial translocation across the intestine Gets into the bloodstream Contributes to sepsis Shown in animal models—less evidence in humans Enteral nutrition may be beneficial |
Causes of Multiple Organ dysfunction syndrome (MODS)
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insufficient tissue perfusion that results in cellular hypoxia
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Shock
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What are the four major types of shock?
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Cardiogenic
Acute MI (“pump failure”) Obstructive Seen in pulmonary embolism or cardiac tamponade Hypovolemic Loss of blood volume Distributive Abnormal peripheral circulation…seen in sepsis or anaphylaxis |
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What are two characteristics often seen with shock?
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Hypotension
Low mean arterial pressure Need an MAP > 60 mm Hg to perfuse coronary arteries, brain, & kidneys |
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How do you TX shock?
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Depending on the type of shock, pts may be treated with
Fluid resuscitation Vasopressors Induce vasoconstriction to elevate MAP Examples: phenylephrine (Neosynephrine), norepinephrine (Levophed), epinephrine Inotropic agents ncrease cardiac contractility Examples: dobutamine, isoproterenol |
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If a patient has increased creatinine, and albumin than it is probably not safe to do what?
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Tube feed
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is nutritional support via placement through the nose, esophagus, stomach, or small intestine (duodenum or jejunum)
“Tube feedings” Must have functioning GI tract Exhaust all oral diet methods first |
Enteral Nutrition
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What conditions often require enteral nutrition?
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Impaired ingestion
Inability to consume adequate nutrition orally Impaired digestion, absorption, metabolism Severe wasting or depressed growth |
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Enteral Nutrition Access:
Short-term: up to 3 or 4 weeks Normal GI function Bolus, intermittent, or continuous infusions |
Nasogastric route
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Enteral Nutrition Access:
Short-term: up to 3 or 4 weeks Gastric motility disorders, esophageal reflux, or persistent nausea and vomiting |
Nasoduodenal or nasojejunal route
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Enteral Nutrition Access:
Nonsurgical technique Preferred for longer than 3 to 4 weeks |
Percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ)
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What is the standard formula for enteral nutrition?
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Lactose-free, 1kcal/mL
Some have fiber, some don't Concentrated standard formula: 1.5-2kcal/ml, for fluid restriction |
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When would you use a high nitrogen formula in enteral nutrition?
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Increased protein requirements: burns, fistulas, sepsis, trauma
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This is an enteral nutrition formula:
Some still use the term “elemental” Low in fat, supplemented with MCT Possible that long-term use may lead to essential fatty acid deficiency—need to monitor Protein fragments: dipeptides, tripeptides, or oligopeptides |
Chemically-defined formulas
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What enteral formula is used in the following conditions?
Kidney disease Liver disease Glucose intolerance/diabetes Pulmonary failure Immunosuppression Wound healing These formulas are expensive & efficacy is controversial in some cases |
Disease-specific
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This is an enteral formula:
Individual macronutrients Protein Carbohydrate Fiber supplements are available too Fat Occasionally combination products are used |
Modular formulas
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What are the four types of enteral infusion?
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Bolus
Intermittent Continous Cyclic |
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You use this only if the gut is not functional or the patient has failed a trial of enteral nutrition?
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Parenteral nutrition
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The following conditions often times require what?
Gastrointestinal incompetence Short bowel syndrome with major resection Severe acute pancreatitis after failed enteral trial Severe IBD Small bowel ischemia Bowel obstruction Intestinal atresia (absence of normal opening of the intestine) Severe liver failure Major GI surgery Critical illness with poor enteral tolerance or accessibility |
Parenteral nutrition
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Hypokalemia, hypophosphatemia, and hypomagnesemia
Cardiac and pulmonary complications from fluid overload Carbohydrate intake should be conservative Intake of intracellular electrolytes should be adequate |
Refeeding Syndrome
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PN infused via peripheral vein must have an osmolarity of?
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< 900 mOsm/L
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This must run concurrently with PPN to prevent venous sclerosis and phlebitis
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IV fat emulsion
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The osmolarity of CPN is?
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> 900 mOsm/L
Blood is ~ 200-300 mOsm/L |
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Ideal catheter tip location for Central PN is?
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SVC
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What are the components of PN?
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Protein
Carbohydrate Fat Additives Electrolytes Vitamins Trace elements Medications & specialized nutrients |
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For Cabohydrate, how much is too much?
Calculate the maximum oxidative rate Sometimes called the maximum glucose infusion rate For adults: ? |
5 mg/kg/minute
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For Cabohydrate, how much is too much?
Infants & children can handle much more What are the numbers? |
Infants & children can handle much more
Preterm infants: 6-8 mg/kg/min Infants: up to 13 mg/kg/min Children: 5-7 mg/kg/min? |
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Provide at least ? of total calories as fat to meet essential fatty acid requirements
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4-6%
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Patients with what allergies may not tolerate IV fat emulsion?
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Soy or Eggs
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How much PN fat do you provide for an Adult patient?
For a pediatric patient? |
Adults:
Typically, <30% total kcals Maximum: 2.5 g/kg or 60% total energy delivery Pediatrics: Infants: minimum 0.5-1 g/kg (EFA reqm’ts) Max 2-3 g/kg (some publications say 4 g/kg) Children & teens: minimum 1 g/kg Max 2.5-3 g/kg |
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Serum TG > ? mg/dL has been associated with pancreatitis
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500
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How do you measure fluid requirements for adults?
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30-40 mL/kg age 18-64
30 mL/kg age 55-65 25 mL/kg > age 65 |
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How do you measure fluid requirements for pediatric patients?
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For infants & children:
1-10 kg: 100 mL/kg 11-20 kg: 1000 mL plus 50 mL/kg for each kg above 10 kg >20 kg: 1500 mL plus 20 mL/kg for each kg above 20 kg Low birth weight (LBW) infants: 125-150 mL/kg |
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What are four typical additives made to PN?
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Electrolytes
10 mL MVI-13 (13 vitamins) daily - KNOW THIS!!! Trace elements Medications |
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Other PN additives:
Essential for fat metabolism Long-term PN patients are at risk for deficiency Weight-based dosing for kids Give 1-3 g/day for adults |
Carnitine
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What medications are often given via PN?
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Insulin
H2 blockers Metaclopramide Heparin Steroids (hydrocortisone) |
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Non-ICU Glucose Management
If “random” glucose is consistently > 150-180 mg/dL, start q 6 hr FSBG checks Administer sliding scale insulin if BG is > 180 mg/dL Add directly to PN: ½ the previous day’s dose |
Patients without known diabetes
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Non-ICU Glucose Management
Must have good control prior to initiation of PN Start with lower dextrose PN; may need to start with insulin in PN on day one Monitor FSBG q 6 hrs with sliding scale coverage Goal glucose while PN is infusing is <180 mg/dL |
Patients with known diabetes
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Select this nutrition over this nutrition if it is safe to feed the gut
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Select enteral nutrition over parenteral nutrition if it is safe to feed the gut
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