Therapeutics Iii Exam 4 - Lectures 1-4 (Assessment Of Nutritional Status/parenteral Nutrition)

Front 1

A state induced by alterations in dietary intake or nutrient utilization resulting in changes in subcellular, cellular, and/or organ function that expose the individual to increased risks of morbidity and mortality and that can be reversed by appropriate nutritional support.

Back 1

Malnutrition

Front 2

What is the significance of hospital malnutrition?

Back 2

1. Increased morbidity and mortality
2. Increased infection risk
3. Decreased rate of wound healing
4. Worsened end organ response

Front 3

Risk factors for protein calorie malnutrition (PCM)

Back 3

1. Usual weight 20% above or below IBW
2. Recent loss of more than 10% usual weight
3. Excessive alcohol intake
4. Chronic diseases
5. NPO for more than 7-10 days
6. Increased metabolic needs
7. Protracted nutrient loss
8. Intake of anti-nutrient or catabolic drugs (steroids)
9. Protracted emesis

Front 4

What can metabolic stress result from?

Back 4

1. trauma
2. surgery
3. infection
4. tumor
5. chemotherapy
6. radiation therapy

Front 5

What are the metabolic effects of stress?

Back 5

1. Increased demand for protein synthesis
2. Increased demand for fuel substrates

Front 6

What are the effects of stress on nutritional status?

Back 6

Accelerates time-course of "nitrogen death." Adding stress to malnutrition makes it 10 times worse.

Front 7

What are some benefits of nutritional support?

Back 7

1. Reversal of weight loss
2. Restoration of immunocompetence
3. Suppression of gluconeogenesis
4. Enhanced tolerance for antineoplastic therapy

Front 8

What are some factors that contribute to malnutrition?

Back 8

1. age
2. alcohol or drug abuse
3. disease (cancer, diabetes, depression, GI disorders, HIV)
4. drug therapy
5. low socioeconomic status

Front 9

What are the major goals of nutritional assessment?

Back 9

1. To identify patients with or at risk of developing malnutrition, including problems arising from nutrient deficiencies, obesity, or impaired metabolism
2. To determine the risk of malnutrition-associated complications
3. To establish estimated nutrition needs
4. To establish baseline parameters to measure nutrition therapy outcomes

Front 10

A chronic condition resulting from a prolonged deficiency in total energy intake and/or utilization of food (protein and calories).

Back 10

Marasmus

Front 11

Define marasmus

Back 11

A chronic condition resulting from a prolonged deficiency in total energy intake and/or utilization of food (protein and calories).

Front 12

What are the characteristics of marasmus?

Back 12

1. marked weight loss (greater than 10% of well weight)
2. depleted fat stores
3. muscle wasting
4. visceral proteins usually spared
5. impaired cell-mediated immunity in severe cases
6. starved, cachetic appearance
7. usually ~85% of ideal body weight

Front 13

Condition common in patients who have adequate calorie intake, but a relative protein deficiency and who are catabolic.

Back 13

Kwashiorkor

Front 14

Define kwashiorkor

Back 14

Condition common in patients who have adequate calorie intake, but a relative protein deficiency and who are catabolic

Front 15

What are the characteristics of kwashiorkor?

Back 15

1. appears well-nourished, often obese
2. intake usually high calorie (mostly CHO or alcohol)
3. visceral proteins depleted
4. preservation of fat stores
5. hypoalbuminemia and edema
6. may have impaired immune function
7. may develop rapidly in response to protein deprivation with stress

Front 16

A form of severe protein-calorie malnutrition in chronically ill, starved patients who are undergoing hypermetabolic stress.

Back 16

Mixed marasmus/kwashiorkor

Front 17

Define mixed marasmus/kwashiorkor

Back 17

A form of severe protein-calorie malnutrition in chronically ill, starved patients who are undergoing hypermetabolic stress.

Front 18

What are the characteristics of mixed marasmus/kwashiorkor?

Back 18

1. decreased visceral protein synthesis
2. wasting of somatic protein and fat stores
3. decreased immunocompetence
4. increased incidence of infection
5. poor wound healing

Front 19

Define obesity

Back 19

BMI > 30 kg/m2

Front 20

Define overweight

Back 20

BMI > 25 kg/m2

Front 21

Formula for lean body mass

Back 21

Males: 50 kg + 2.3 kg for every inch over 5 feet tall
Females: 45.5 kg + 2.3 kg for every inch over 5 feet tall

Front 22

What is the formula for adjusted lean body weight and when is it used?

Back 22

Adjusted weight is used if the patient weighs more than 120% of the LBW.
Adjusted LBW = [(Actual weight - LBW) X 0.25] + LBW
*Use this for dosing

Front 23

When do we use lean body weight?

Back 23

-If actual body weight is less than calculated LBW or 100% to 120% of LBW, use actual body weight for dosing. If over 120%, use adjusted LBW.

Front 24

Formula for BMI

Back 24

kg/m^2
1 inch = 2.54 cm then convert to meters
1 kg = 2.2 lbs

Front 25

What is zinc's main function in the body?

Back 25

Zinc is a component of many enzymes and proteins. It has a role in gene expression and DNA and RNA synthesis.

Front 26

What can zinc deficiency be due to?

Back 26

1. inadequate intake
2. malabsorption
3. extensive losses
4. Crohn's disease
5. Fistulae
6. ulcerative colitis

Front 27

Signs and symptoms of zinc deficiency

Back 27

1. alopecia
2. dermatitis
3. diarrhea
4. impaired wound healing
5. immunosuppression
6. growth retardation

Front 28

Normal serum levels of zinc

Back 28

70-130 mcg/dl

Front 29

How do we estimate GI zinc losses

Back 29

2 + 17.1a + 12.2b
2 = urinary zinc loss
a = stool or ileostomy output in kg
b = small bowel fluid lost via fistula, etc., in kg

Front 30

Treatment of zinc deficiency

Back 30

40 mcg - 32 mg zinc/day

Front 31

Zinc RDA

Back 31

Males: 11 mg
Females: 8 mg
Pregnancy and Lactation: 11-12 mg

Front 32

What is the main function of copper in the body?

Back 32

Copper is an essential component of enzymes involved in iron metabolism

Front 33

Normal Serum Levels of Copper

Back 33

70-150 mcg/dl

Front 34

Predisposing factors to Copper Deficiency

Back 34

1. malabsorptive states
2. prolonged diarrhea
3. malnutrition
4. copper-free nutrition
5. ulcerative colitis
6. nephrotic syndrome

Front 35

Signs and Symptoms of Copper Deficiency

Back 35

1. anemia
2. hypercholesterolemia
3. neurologic abnormalities

Front 36

Copper RDA

Back 36

900 mcg/day

Front 37

Treatment of Copper Deficiency

Back 37

20-30 mcg elemental copper/kg/day

Front 38

Normal Serum Levels of Chromium

Back 38

1-3 ng/ml

Front 39

Treatment of Chromium Deficiency

Back 39

250 mcg chromium/day for 2 weeks

Front 40

Chromium RDA

Back 40

25-30 mcg/day

Front 41

Signs and Symptoms of Chromium Deficiency

Back 41

1. impaired glucose tolerance
2. lipid abnormalities

Front 42

Normal Serum Levels of Selenium

Back 42

0.10-0.34 mcg/ml

Front 43

Treatment of Selenium Deficiency

Back 43

100 mcg selenium/day for 24 days

Front 44

Signs and Symptoms of Iron Deficiency

Back 44

1. fatigue and weakness
2. nail changes
3. tachycardia
4. paresthesias

Front 45

Iron RDA

Back 45

Males: 8 mg/day
Females: 18 mg/day
Pregnant: 27 mg/day
Over 50: 8 mg/day

Front 46

Treatment of Iron Deficiency

Back 46

150-200 mg elemental iron daily for 3-6 months
(325 iron sulfate = 65 mg elemental iron)

Front 47

What is the main function of iron in the body?

Back 47

Iron is a vital component of most metabolic processes. It is important for oxygen transport, muscle iron storage, and cellular energy production.

Front 48

Reasons for Iron Deficiency

Back 48

1. inadequate intake
2. malabsorption
3. blood loss

Front 49

Vitamin deficiency is mostly commonly seen with which vitamins?

Back 49

1. folic acid
2. B12
3. Vitamin K

Front 50

What is the mechanism of Essential Fatty Acid Deficiency (EFAD)?

Back 50

Continuous infusion of hypertonic dextrose (without long-chain fatty acids, specifically, linoleic acid) causes an increase in circulating insulin levels causing an inhibition of lipolysis and fatty acid mobilization.

Front 51

What are some manifestations of EFAD?

Back 51

1. Dermatological including rash or dry, cracked, scaly skin
2. Hematological including thrombocytopenia or increased hemolysis
3. Alopecia
4. Impaired wound healing

Front 52

What biochemical parameter can assess EFAD?

Back 52

If triene:tetraene ratio is greater than 0.4, this indicates EFAD

Front 53

Prevention of EFAD during TPN

Back 53

Patients should receive at least 500 ml of 10% fat emulsion or 250 ml of 20% fat emulsion twice weekly during TPN. EFAD can easily be prevented with this regimen.

Front 54

Normal albumin levels

Back 54

3.5 - 5.0 grams/dl
*mild depletion 2.8-3.5 gm/dl
*moderate depletion 2.1-2.7 gm/dl
*severe depletion <2.1 gm/dl

Front 55

Advantages of albumin

Back 55

1. Good correlation with malnutrition with low albumin
2. It provides baseline and means to monitor
3. It is in common use
4. It is easy

Front 56

Disadvantages of albumin

Back 56

1. long half-life, so it is slow to reflect early changes
2. It is an insensitive indicator of protein-calorie malnutrition.
3. It also can be falsely elevated from administration of exogenous albumin.

Front 57

Factors resulting in increased albumin

Back 57

Dehydration, anabolic steroids, insulin, and infection

Front 58

Factors resulting in decreased albumin

Back 58

Overhydration, edema, kidney dysfunction, nephrotic syndrome, poor dietary intake, impaired digestion, burns, congestive heart failure, cirrhosis, thyroid/adrenal/pituitary hormones, trauma, sepsis

Front 59

Prealbumin Normal values

Back 59

20 – 40 mg/dl
Mild depletion is 10-20; moderate 5-10; and severe depletion is <5

Front 60

Albumin Half-life

Back 60

~20 days

Front 61

Prealbumin half-life

Back 61

~ 2 days

Front 62

Utilization of prealbumin

Back 62

Prealbumin rapidly responds to changes and sudden demands for protein synthesis (trauma, infection). It is altered in chronic renal failure, and falsely elevated due to decreased renal metabolism.

Front 63

Factors resulting in increased prealbumin

Back 63

Fe deficiency, pregnancy, hypoxia, chronic blood loss, and estrogens

Front 64

Factors resulting in decreased prealbumin

Back 64

Chronic infection, cirrhosis, burns, enteropathies, nephrotic syndrome, cortisone, and testosterone

Front 65

Transferrin Normal values

Back 65

200 – 400 mg/dl
Mild depletion is 150-200; moderate 100-150; and severe depletion <100

Front 66

Transferrin half-life

Back 66

7-10 days

Front 67

Transferrin utilization

Back 67

Low transferrin correlates with low albumin, but it has faster response to changes in nutritional status. It is more sensitive than albumin and convenient to follow weekly.
But, it is altered by transfusions, dilution, and Fe overload. It is decreased by infection, trauma, and acute stress. It is increased by Fe administration, pregnancy, and acute hepatitis.

Front 68

Factors resulting in increased transferrin

Back 68

Kidney dysfunction

Front 69

Factors resulting in decreased transferrin

Back 69

Cirrhosis, hepatitis, stress, surgery, inflammation, hyperthyroidism, cystic fibrosis, kidney dysfunction, zinc deficiency

Front 70

Which immune function tests are used to classify nutrition?

Back 70

1. Total lymphocyte count
2. Delayed hypersensivity reaction (no response = anergy which correlates with malnutrition)

Front 71

Factors Influencing Energy Requirements

Back 71

1. Basal metabolic expenditure
2. Physical activity
3. Stress
4. Maintenance versus anabolism
5. Environment

Front 72

What is RQ?

Back 72

RQ is indirect calorimetry and is equal to CO2 produced/O2 consumed. It is especially useful in obese, paralyzed, or stressed patients.

Front 73

RQ values

Back 73

RQ over 1 indicates lipogenesis or hyperventilation
RQ of 0.85 indicates mixed substrate oxidation
RQ less than 0.7 indicates fat or EtOH oxidation or ketogenic diet

Front 74

Calories needed per body weight (per kg)

Back 74

-healthy, normal nutrition status maintenance: 20-25 calories/kg/day
-malnourished or mildly metabolically stressed: 25-30 calories/kg/day
-critically ill, hypermetabolic: 30-35 calories/kg/day
-major burn injury: 35-40+ calories/kg/day

Front 75

NPC:N values

Back 75

Maintenance: 150:1
Stress: 90-120:1

Front 76

Estimated adult protein requirements

Back 76

Over 18: 0.8 grams/kg/day

Front 77

Amount of nitrogen in protein

Back 77

6.25 grams of protein provides 1 gram of nitrogen

Front 78

Nitrogen balance equation

Back 78

nitrogen intake - nitrogen output
Nitrogen intake is protein intake/6.25
Nitrogen output is 24 hour urinary urien nitrogen (UUN) + 4 (fudge factor) SO
Nitrogen balance = (protein intake/6.25) - (UUN + 4)

Front 79

What is the goal nitrogen balance?

Back 79

+2 to +5

Front 80

Daily fluid requirements

Back 80

Active adults: 35cc/kg/day
Sedentary adults: 30cc/kg/day
Elderly: 25cc/kg/day

Front 81

Reasons for increased fluid requirements

Back 81

1. Increased insensible losses (fever, excessive sweating, increased metabolism, hyperthyroidism)
2. Increased GI losses (vomiting, diarrhea, high-output fistula)

Front 82

Reasons for decreased fluid requirements

Back 82

1. Renal failure
2. Expanded extracellular fluid volume
3. Hypoproteinemia with starvation

Front 83

What percent of daily calories should be essential fatty acids?

Back 83

2-4%

Front 84

What percent of daily calories should be from fat?

Back 84

10-35%

Front 85

What effect does amphotericin B have on nutrients?

Back 85

decreased magnesium, zinc, and sodium

Front 86

What effect do thiazide diuretics have on nutrients?

Back 86

decreased potassium, magnesium, and zinc

Front 87

What effect do loop diuretics have on nutrients?

Back 87

decreased potassium, calcium, magnesium, and zinc

Front 88

What effect do glucocorticoids have on nutrients?

Back 88

decreased potassium and calcium

Front 89

What effect does spironolactone have on nutrients?

Back 89

increased potassium

Front 90

What effect does ticarcillin or piperacillin have on nutrients?

Back 90

increased sodium

Front 91

What are the main drugs that cause hyperglycemia?

Back 91

corticosteroids
furosemide
phenytoin

Front 92

What are the main drugs that cause hypoglycemia?

Back 92

anabolic steroids

Front 93

What effect do antineoplastics have on vitamins?

Back 93

folic acid antagonism and malabsorption (deficiency)

Front 94

What effect does isoniazid have on vitamins?

Back 94

vitamin B6 deficiency

Front 95

mEq per 24 hours of:
Sodium
Potassium
Calcium
Phosphorus

Back 95

Sodium: 60-100
Potassium: 60-100
Magnesium: 8-24
Phosphorus: 10-15

Front 96

What causes increased requirements of Na, K and Cl?

Back 96

1. vomiting
2. nasogastric suction
3. gastrostomy output

Front 97

What causes increased requirements of Na, K, and HCO3?

Back 97

1. diarrhea
2. ostomy losses
3. high-output fistula

Front 98

What causes decreased requirements of Na?

Back 98

1. congestive heart failure
2. ascites

Front 99

What causes decreased requirements of Na, K, Mg, Phos, and Cl?

Back 99

renal failure

Front 100

How many calories are in dextrose?

Back 100

3.4kcal/gram

Front 101

What is the maximum vein tolerance of parenteral nutrition?

Back 101

Peripheral: 600-900 mOsm/L
Central: ?

Front 102

How many calories are in fat?

Back 102

9kcal/gram
10% fat emulsion: 1.1cal/cc
20% fat emulsion: 2 cal/cc
30% fat emulsion: 3 cal/cc

Front 103

Advantages of Fat emulsions

Back 103

1. Can be infused via peripheral vein and possibly protective of peripheral vein
2. May be mixed with other nutrients

Front 104

What groups of people are fat emulsions especially useful in?

Back 104

1. fluid restricted
2. respiratory compromised
3. glucose intolerant patients

Front 105

Contraindications to fat emulsion

Back 105

1. severe liver failure
2. egg allergies
3. pathologic hyperlipidemias
4. acute pancreatitis associated with hyperlipidemia
5. lipoid nephrosis

Front 106

How many calories are in protein?

Back 106

4kcal/gram

Front 107

Hepatamine 8% indications

Back 107

Hepatamine 8% is an amino acid solution for use in hepatic failure. It has increased concentrations of branched chain amino acids and decreased concentrations or aromatic amino acids.

Front 108

Freamine HBC 6.9% indications

Back 108

Freamine HBC 6.9% is marketed for use in hypermetabolic patients. It has increased concentrations (approximately 45%) of the branched chain amino acids.

Front 109

Aminosyn HBC 7% indications

Back 109

Aminosyn HBC 7% is marketed for use in hypermetabolic patients. It has 45% branched chain amino acids (BCAA) by weight.

Front 110

Branchamin 4% indications

Back 110

Branchamin 4% is marketed for use as an additive to standard AA solutions to produce a final solution with increased concentrations of branched amino acids. It contains only branched chain amino acids in equimolar amounts.

Front 111

TrophAmine 6% and 10% indications

Back 111

TrophAmine 6% and 10% is marketed for use in neonates and infants. It includes taurine, formulated to normalize plasma amino acid profile to approximate that of a breast-fed infant.

Front 112

An amino acid solution for use in hepatic failure. It has increased concentrations of branched chain amino acids and decreased concentrations or aromatic amino acids.

Back 112

Hepatamine 8%

Front 113

Marketed for use in hypermetabolic patients. It has increased concentrations (approximately 45%) of the branched chain amino acids.

Back 113

Freamine HBC 6.9%
Aminosyn HBC 7%

Front 114

Marketed for use as an additive to standard AA solutions to produce a final solution with increased concentrations of branched amino acids. It contains only branched chain amino acids in equimolar amounts.

Back 114

Branchamin 4%

Front 115

Marketed for use in neonates and infants. It includes taurine, formulated to normalize plasma amino acid profile to approximate that of a breast-fed infant.

Back 115

TrophAmine 6% and 10%

Front 116

What individual electrolyte salt additives are available?

Back 116

Sodium as chloride, acetate, lactate, phosphate
Potassium as chloride, acetate, phosphate
Magnesium as sulfate
Calcium as gluconate, gluceptate, chloride
Phosphate as sodium, potassium

Front 117

Electrolyte incompatibilities

Back 117

1. Bicarbonate is not compatible with TPN solutions. (Acetate may be substituted 1 for 1 for bicarbonate)
2. Calcium and phosphorus can be in the same solution to a maximum sum of 45 mEq/L. (1 mmol Phos = 2 mEq Phos)

Front 118

What additional things can be added to TPNs?

Back 118

1. regular insulin
2. H2 antagonists
3. metoclopramide
4. albumin

Front 119

Define and list conditionally essential amino acids.

Back 119

Eight amino acids are generally regarded as essential for humans: phenylalanine, valine, threonine, tryptophan, isoleucine, methionine, leucine, and lysine. Additionally, cysteine (or sulphur-containing amino acids), tyrosine (or aromatic amino acids), histidine and arginine are required by infants and growing children. Essential amino acids are so called not because they are more important to life than the others, but because the body does not synthesize them, making it essential to include them in one's diet in order to obtain them. In addition, the amino acids arginine, cysteine, glycine, glutamine, histidine, proline, serine and tyrosine are considered conditionally essential, meaning they are not normally required in the diet, but must be supplied exogenously to specific populations that do not synthesize it in adequate amounts.