1
Q
what is the first step in refeeding management?
A
correct deficiencies of potassium, phosphorus, magnesium
2
Q
When a patient is at risk for refeeding syndrome, initiate dextrose at ____ or initiate kcal provision at ___ kcals/kg.
A
initiate with 100-150 grams dextrose or 10-20 kcals/kg
3
Q
total body water females + elderly
A
50% of LBM
4
Q
total body water males <70 years old
A
60% of LBM
5
Q
ECF (extracellular fluid)
A
1/3 TBW
6
Q
ICF (intracellular fluid)
A
2/3 TBW
7
Q
water gain (sensible)
A
800-1500 ml from oral fluid, 500-700 ml from solid food
8
Q
water gain (insensible)
A
250 ml from water oxidation
9
Q
water loss (insensible)
A
600-900 ml via lungs/skin
9
Q
weight/age based fluid requirement 18-55 years old
A
35 ml/kg
9
Q
water loss (sensible)
A
800-1500 ml urine, 0-250 ml GI
10
Q
weight/age based fluid requirement 56-75 years old
A
30 ml/kg
11
Q
weight/age based fluid requirement >75 years old
A
25 ml/kg
12
Q
holliday-segar method for fluid (adults)
A
1500 ml fluid for first 20 kg, then add:
</= 50 years: 20 ml/kg remaining
>50 years: 15 ml/kg remaining
13
Q
factors that increase fluid needs
A
fever, vomiting, NGT output, ostomy/fistula output, hyperventilation (10-60%), excessive sweating, burns
***fluid needs increase by 12.5% for each 1 degree above normal (fever)
14
Q
factors that decrease fluid needs
A
fluid overload, HF, renal failure, SIADH, ascites, anasarca
15
Q
estimating minimal adult IV fluid needs
A
1000 ml urine output, add 500 ml for insensible loss, add net GI loss or subtract net GI gain
16
Q
maintenance fluids
A
hypotonic (1/2 NS)
17
Q
resuscitation fluids
A
isotonic (0.9% NS, LR, plasmalyte)
18
Q
electrolyte losses in the stomach
A
Na: 60
Cl: 130
K: 15
HCO3: 0
19
Q
electrolyte losses in the duodenum
A
Na: 140
Cl: 80
K: 5
HCO3: 0
20
Q
electrolyte losses in the pancreas
A
Na: 140
Cl: 75
K: 5
HCO3: 115
21
Q
electrolyte losses in the bile
A
Na: 145
Cl: 100
K: 5
HCO3: 35
22
Q
electrolyte losses in the ileum
A
Na: 140
Cl: 104
K: 5
HCO3: 30
23
electrolyte losses in the colon
Na: 60
Cl: 40
K: 30
HCO3: 0
24
gastric fluid loss replacement
1/2 NS + 10-20 meq KCl/L
25
small bowel fluid loss replacement (duodenum, pancreas, bile, ileum)
balanced crystalloid (LR, plasmalyte), bicarb or acetate based customized fluid, 0.9% NS
26
normal serum sodium
135-145
27
normal serum potassium
3.5-5
28
normal serum chloride
98-108
29
normal serum CO2
23-30
30
normal serum calcium
9-10.5
31
normal serum phosphorus
2.5-4.5
32
normal serum magnesium
1.7-2.4
33
measure plasma osmolality
2 x (serum Na) + (glucose) / 18 + BUN / 2.8
<280 mOsm/kg = hypotonic
>280 mOsm/kg = isotonic
34
Na correction in hyperglycemia
((glucose -100) x 0.016) + Na
35
urine osmolality
>100 mOsm/kg = inappropriate renal dilution
<100 mOsm/kg = appropriate renal dilution (excessive water intake, polydipsia, beer potomania, low solute intake)
36
anti-diuretic hormone (ADH)
increases water reabsorption in the kidneys
- pain, stress r/t surgery causes a sustained release of ADH in the first 1-2 days post op causing Na to drop
37
hypertonic hyponatremia treatment
insulin, dc mannitol
38
hypotonic hypovolemic hyponatremia treatment
isotonic fluids (0.9% NS, LR), dc diuretics, steroids
39
euvolemic hyponatremia treatment
fluid restrict +/- loop diuretics, isotonic fluids, NaCl tablets, urea, concentrate PN
40
hypervolemic hyponatremia treatment
Na and fluid restriction, diuretics, concentrate PN
41
free water deficit
TBW x ((current Na-140)/140)
42
what regulates entry of potassium into the cell?
Na-K-ATPase pump
43
what is responsible for an intracellular shift of potassium?
insulin, catecholamines, alkalosis
44
what is responsible for an extracellular shift of potassium?
glucagon, acidosis, aldosterone
*acidosis = high serum potassium
45
10 meq of IV potassium increases serum potassium by ___
0.1 meq/L
46
management of hyperkalemia
K cocktail if potassium is > 6 meg/L or ECG changes, cellular incorporation (insulin +/- D50, sodium bicarbonate, albuterol), increase elimination (furosemide, HD, Na polystyrene sulfonate)
47
what increases calcium levels?
vitamin d, PTH
48
what decreases calcium levels?
calcitonin, phosphorus, pH
49
peripheral calcium supplement
calcium gluconate
1 gram = 4.65 meq Ca
50
central calcium supplement
calcium chloride
1 gram = 13.6 meq Ca
51
hypercalcemia
acute: malignancy
chronic: hyperparathyroidism
treatment: hydration +/- loop diuretics, calcitonin (rapid onset), biphosphonates (slower onset), steroids
52
magnesium
absorbed in the jejunum and regulated by the kidney, enzyme cofactor, calcium channel blocker, neuromuscular transmission, CV tone, metabolism
53
long term PPI use (years) effects the active transport/absorption of ___ in the GI tract
magnesium
54
parenteral magnesium dosing
serum mg: 1-1.5 mg/dl = 8-32 meq, up to 1 meq/kg
serum mg: < 1 mg/dl = 32-64 meq, up to 1.5 meq/kg
55
parenteral magnesium infusion rate
56
parenteral phosphorus dosing
serum P: 2.3-3.7 = 0.08-0.16 mmol/kg
serum P: 1.5-2.2 = 0.16-0.32 mmol/kg
serum P: <1.5 = 0.32-0.64 mmol/kg
57
parenteral phosphorus infusion rate
58
loss of night vision
vitamin a
59
angular stomatitis, cheilosis
riboflavin (vitamin b2), pyridoxine (vitamin b6), niacin, iron
60
glossitis (inflammation of the tongue/magenta color)
riboflavin, pyridoxine, niacin, folate, iron
61
poor nail blanching
vitamin a or c
62
PPN Osmolality calculations
AA (1 gram = 10 mOsm)
Dextrose (1 gram = 5 mOsm)
IV lipids (1 gram = 0.71 mOsm)
electrolytes (1 meq = 1 mOsm)
63
pinch off syndrome
CVC compressed between the clavicle and the first rib, catheter malposition
64
thrombotic occlusions
formation of thrombus within surrounding or at the tip of the catheter
push-pause flushing method helps prevent
65
fibrin sheath
tail extends from the catheter tip but is drawn inward blocking the opening of the catheter lumen on aspiration, resulting in an ability to infuse fluids but inability to withdraw blood
66
crohn's disease key features
transmural, small bowel involvement, fistulas, granulomas, skip lesions, 25-30% have no bleeding
67
ulcerative colitis key features
mucosal disease, starts from rectum up, colonic involvement only, bleeding common
68
sites of absorption: duodenum
iron, folate, calcium, fat soluble vitamins
69
sites of absorption: lower jejunum
water soluble b vitamins
70
sites of absorption: terminal ileum
vitamin b12, bile salts
71
sites of absroption: ileum
magnesium
72
sites of absorption: colon
short chain fatty acids
73
autonomy
right of individuals to make their own decisions
74
beneficence
doing the right thing for the patient
75
nonmaleficence
doing no harm
76
justice
acting fairly, providing similar treatment to patients in similar situations
77
protein:nitrogen
6.25 grams protein = 1 gram nitrogen
78
manifestations of essential fatty acid deficiency
scaly dermatitis, alopecia, poor wound healing, thrombocytopenia, triene to tetraene ratio of more than 0.2
79
sodium maintenance dosage
1-2 meq/kg/day
80
potassium maintenance dosage
1-2 meq/kg/day
81
calcium maintenance dosage
10-15 meq/day
82
magnesium maintenance dosage
8-20 meq/day
83
phosphorus maintenance dosage
20-40 mmol/day
84
celsius to fahrenheit conversion
(C x 1.8) + 32
85
base component
HCO3
86
acid component
PCO2
87
arterial blood gas normal values
pH: 7.4 (7.35-7.45)
PCO2: 35-45
PO2: 80-100
HCO3: 22-26
88
respiratory acidosis
PCO2 is elevated (>40 mmHg)
89
respiratory alkalosis
PCO2 is reduced (<40 mmHg)
90
metabolic acidosis
HCO3 is <24
91
metabolic alkalosis
HCO3 is >24
92
medicare guidelines to cover home EN
> 3 months, non-function or disease of the structures that normally permit food to reach the small bowel, dysphagia, esophageal cancer, gastroparesis, disease of the small bowel which impairs digestion/absorption, sole source of nutrition
93
nutritionally at risk child
- weight for length, weight for height <10th percentile, -1.28 z score
- bmi for age/gender <5th percentile, -1.64 z score
- increased metabolic requirements
- impaired ability to ingest/tolerate oral feeding
- documented inadequate provision of or intolerance to nutrients
- inadequate weight gain or significant decrease in usual growth percentile
94
low birth weight
<2500 grams
95
very low birth weight
<1500 grams
96
extremely low birth weight
<1000 grams
97
micronate
<750 grams
98
pediatric bmi classifications
<5th percentile: underweight
5th-85th percentile: normal
85th-95th percentile: overweight
>95th percentile: obese
99
protein requirements 0-3 mos
1.5 grams/kg
100
protein requirements 4-12 mos
1.5 grams/kg
101
protein requirements 13-36 mos
1.1 grams/kg
102
protein requirements 4-13 yrs
0.95 g/kg
103
protein requirements 4-18 yrs
0.85 grams/kg
104
fluid requirements children (holliday-segar)
1-10 kg: 100 ml/kg
10-20 kg: 1000 ml + 50 ml/kg >10 kg
>20 kg: 1500 ml + 20 ml/kg >20 kg
105
EN initiation and advancement guidelines (infants)
bolus: initiate at 25% and divide by # of preferred feeds, increase volume by 25% daily
pump: initiate at 1-2 ml/kg/hr and advance by 0.5-1 ml/kg/hr every 6-24 hrs to goal
106
vitamin d in infants
supplement 400 IU/day in those exclusively breastfed
107
iron in infants
fortify in breastfed infants by 4-6 months
*formula contains iron
108
no cows milk before 1 year because
low in iron, low in vitamins c and e, low in essential fatty acids, high renal solute load
109
sodium needs in preterm neonates
2-5 meq/kg
110
sodium needs in infants/children
2-5 meq/kg
111
sodium needs in adolescents and children >50 kg
1-2 meq/kg
112
potassium needs preterm neonates
2-4 meq/kg
113
potassium needs infants/children
2-4 meq/kg
114
potassium needs adolescents + children >50 kg
1-2 meq/kg
115
calcium needs preterm neonates
2-4 meq/kg
116
calcium needs infants/children
0.5-4 meq/kg
117
calcium needs adolescents + children >50 kg
10-20 meq
118
phosphorus needs preterm neonates
1-2 mmol/kg
119
phosphorus needs infants/children
0.5-2 mmol/kg
120
adolescents + children >50 kg
10-40 mmol
121
magnesium needs preterm neonates
0.3-0.5 meq/kg
122
magnesium needs infants/children
0.3-0.5 meq/kg
123
magnesium needs adolescents + children >50 kg
10-30 meq
124
trace element deficiency associated with microcytic anemia and neutropenia
copper
125
trace element deficiency associated with growth failure and hair loss
zinc
126
neonate
first 28 days of life
127
neonate parenteral calorie goals
preterm: 85-111 kcals/kg, 3-4 grams pro/kg
late preterm: 100-110 kcals/kg, 3-3.5 grams pro/kg
term: 90-108 kcals/kg, 2.5-3 grams pro/kg
128
neonate enteral calorie goals
preterm: 110-130 kcals/kg, 3.5-4.5 g pro/kg
late preterm: 120-135 kcals/kg, 3-3.2 g pro/kg
term: 105-120 kcals/kg, 2-2.5 g pro/kg
129
cyclosporine commonly used after solid organ transplantation for immune suppression may cause
hyperkalemia, hypomagnesemia, hyperglycemia, hypercholesterolemia
cnsc exam aspen modules
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