PHRM 864: Therapeutics IV > Nutrition > Flashcards

Nutrition Flashcards

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1
Q

What is the way that we calculate IBW?

A
  • Male: 50kg + (2.3 x in over 60’’)
  • Female: 45.5kg + (2.3 x in over 60’’)
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2
Q

What is Nutrition Body Weight?

A
  • NBW = IBW + 0.25(wt - IBW)
  • USE when body weight is 130% more than IBW [<110% use actual body weight]
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3
Q

What are some of the ways that we are able to alleviate stress response?

A
  • Give MACRO and MIRCO nutrients [Protein, Carbs, Fat]
  • Gylcemic Control
  • START EARLY
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4
Q

What are some of the benefit of starting early?

A
  • DECREASE disease severity
  • DECREASE complication
  • DECREASE ICU stay
  • INCREASE patient outcomes
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5
Q

What are the 5 things we look at for Nutritional Assessments?

A
  • Risk factors for Malnutrition
  • History
  • Anthropometrics
  • Classifications of Malnutrition
  • Nitrogen Balence
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6
Q

What are some of the risk factors for Malnutrition?

A
  • Under Body Weight = 20% below IBW
  • Weight Loss [>10% within 6m]
  • NPO >10 days [clinical use 7days]
  • Gut problems
  • Mechanical Issues
  • Metabolic needs
  • Substance Abuse
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7
Q

When should we start using Nutrition within the ICU?

A
  • 48 HOURS
  • Can screen to see
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8
Q

What are the two important screening tools that are used for Nutrition?

A
  • NUTRIC & Nutritional Risk Score [NRS-2002]
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9
Q

What is important to remember about the NUTRIC scores?

A
  • HIGH RISK: 6-10 [5-9 w/o IL-6]
  • LOW RISK: 0-5 [0-4 w/o IL-6]
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10
Q

How is History used in Nutritional Assessments?

A
  • Dietary [intake, swallowing, ulcers, vomiting, diarrhea…]
  • Medical [GI trat connected?]
  • Medications [can decrease absorption]
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11
Q

What is Anthropometrics in Nutritional Assessment?

A
  • Looks at both Protein and Muscle [IBW]
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12
Q

What Viceral Protein is the most important within Nutrition?

A
  • Prealbumin; 2-3 half life; 15-40mg/dL conc.
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13
Q

What is C-Recactive Protein?

A
  • Positive reactant [increase by 25% during inflammation]
  • ALWAYS checked with Prealbumin
  • Prealbumin DECREASES; CRP INCREASES = inflammation
  • Prealbumin DECREASES; CRP NORMAL = Malnutrition
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14
Q

What are the Classifications of Malnutrition in the Nutrition Assessment?

A
  • Marasmus: PROTEIN/CALORIE - wasting of muscle
  • Kwashiorkor: PROTEIN - not about to get enough protein to keep up
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15
Q

What are some of the symptoms for Maramus and Kwashiorkor?

A
  • Marasmus: Hair loss, edema, skin folds
  • Kwashiorkor: Large Belly, decreased muscle mass, fatigue
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16
Q

What are some of the treatments for Maramus and Kwashiorkor?

A
  • Maramus: Macros + Vit B
  • Kwashiorkor: Carbs the High Protein
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17
Q

What is the Nitrogen Balence?

A
  • A measurement of urinary excertion of nitrogen as urea nitrogen [urinary urea nitrogen = UUN]
  • GOAL: +3 to +5g
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18
Q

What is the equation to find Nitrogen Balence?

A
  • Nitrogen Balence = Nin - Nout
  • Nin = 24h protein intake / 6.25
  • Nout = 24h UUN + Factor [4g]
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19
Q

What is the Harris-Benedict Equation?

A
  • Just shows how well we are doing at rest
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20
Q

What are some of the general guidelines about Caloric needs?

A
  • Non-stressed = 20-25 kcal/kg/day
  • STRESSED = 25-30 kcal/kg/day [IMPORTANT]
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21
Q

What is Indirect Calorimetry?

A
  • Shows energy expenditure [REE, RQ] at ONE point in time; within 24 hours
  • TEE = REE x 1.2 [REE is given]
  • RQ = Vco2 / Vo2 [RQ is given?]
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22
Q

For Respiratory Quotient Values, what is the most important one?

A
  • MIXED SUBSTRATE = 0.85 - 0.95 once weekly
  • Over 1 = OVERFEEDING - too much calories
  • Under 1 = UNDERFEEDING - using protein for calories
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23
Q

What are some of the general guidelines about Proteins?

A
  • Maintenance = 0.8 - 1 g/kg/day
  • Mild to Mod = 1 - 1.5 g/kg/day
  • ** Mod to Severe = 1.5 -2 g/kg/day**
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24
Q

What are some additional considerations about Proteins?

A
  • “Tolerance” may be decreased in some disease states; like renal and Hepatic failure
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25
What is the Non-Protein Caloire [NPC] Distribution?
- 70/30 - 70-90% = DEXTROSE - 15-30% = FATS - Gets adjusted based on tolerances; increase Blood sugar = decrease DEX & increase fats = decrease FAT
26
When might 100/0 NPC be used in a patient?
- During sepsis or bloodstream infections [FUNGAL]
27
What is the definition for Parenteral Nutrition?
- The process of supplying nutrients via IV - EXAMPLES: TPN, PN, TNA, 3-in-1
28
What are some of the indications for PN?
- NPO > 7days - Cannot absorb nutritents [ILEUS, SMALL BOWEL RESECTION] - Fistulas [nutrition goes somewhere else] - IBD - Hyperemesis Gravidum [Pregnant People] - Mucositis
29
What are the two route for administration for PN?
- Peripheral & Central
30
What are some advantages and disadvantages for Central PN?
- Advantages: Can use hypertonic, MORE calories - Disadvantages: Risk of infection, complications [Pneumothorax, Air Embolus, thormbus]
31
What is the main Central route in PN?
- Venous Access [Subclavian, Internal Jugular, Femoral] - Long Term: PICC
32
What type of catheter is best to use in a PN and why?
- Triple Lumen because it allows for other meds to be add; ONE lumen is ONLY for TPN
33
What is requirements for Proteins [how many kcal]?
- 4 kcal = 1g
34
What is the requirements for Carbohydrates [how many kcal]?
- 3.4kcal = 1g - Want D10W [10% dextrose]; Max D70W [70% dextrose] - For 100/0 [fungal] use 4-5 mg/kg/min
35
What is the requirements for Lipids [how many kcals]?
- ~10kcal = 1g
36
What are the two Lipid Emulsions that are used in PN?
- Intralipids - SMOFlipid
37
What is in Intralipid?
- Soybean oil 10% [omega-6] - Glycerin 2.25% [allergies?] - Egg Yolk 1.2% [allergies?] - Water
38
What is in SMOFlipid?
- Soybean Oil 30% - Medium-chain triglyceride 30% - Olive Oil 25% [omega-9] - Fish Oil 15% [omega-3]
39
What is the maximum intake of lipids within PN?
- MAX: 2.5g/kg/day if TOLERATING - 1-1.5g/kg/day in general - PROPOFOL has 1.1kcal/ml of fat
40
What is the recommended hangtime for fat emulsions?
- 12 hours for FAT - 24 hours for TPN - Helps reduce infectious complications
41
What are some of the filter sizes that are used and why are they used?
- Helps reduce infusion of particulates, precipitates, microorganisms... - SIZES: 1.2 micron for TNAs or 3-in-1 & 0.22 micron for 2-in-1 [NO lipids]
42
What is a Premix PN Solution?
- "Standard" TPN - Contains amino acids + dextrose [+/- Na, K, Mag, Ca, Acetate, Cl, Phos]
43
When should a patient be started on a Premix PN solution?
- CrCl > 50: PN with electrolytes - CrCl < 50: PN without electrolytes
44
What is the way that we Initiate or Discontinue a PN?
- Initiate: start ~25% --> final within 24hours [titrate up] & check Blood Glucose q 4-6 [Hyper?] - Discontinue: decrease by 1/2 q2hr until rate <50 [Hypo?]
45
What is cycling PN?
- Infusion over 12-18 hours OR going to EN or PO - The FIRST and LAST hour has to be lower to prevent dysglycemia
46
What are some of the additives that are used in PN?
- Electrolytes, Vitamins, Trace Elements, Medications?
47
What are the electrolytes and their daily ranges?
- Calcium: 10-20 mEq - Magnesium: 8-24 mEq - Phosphorus: 15-45 mMol - Sodium: 1-2 mEq/kg - Potassium: 0.5-1 mEq/kg up to 2 mEq/kg - Chloride: PRN [~2/3] - Acetate: PRN [~1/3]
48
What are some of the considerations for Eletrolytes?
- Renal disease: caution with Potassium, Phosphate, Magnesium - AVOID Calcium + Phosphate = Precipitation
49
What are some of the vitamins that are used in PN?
- Thiamin, Riboflavin, Niacin, Folic Acid, Panthotenic Acid, Pyridoxine, xyancobalamin, Biotin, Ascorbic Acid, A, D, E, K - ADULTS: 10 ml/day - PEDS: 2 ml/day
50
What are some of the trace elements that are used in PN?
- Zinc, Copper, Chromium, Selenium, Manganese, Iron
51
What is important to know about Iron within PN?
- NOT RECOMMENDED to add to PN [piggyback separately]
52
What are some of the complications for PN?
- Mechanical [clotting line, moved] - Infectious [Sepsis, Bacterial Translocation] - Metabolic [Electrolyte/Fluid imbalence, HYPER- or HYPOglycemia]
53
What is Bacterial Translocation?
- When the bacterial is traveling somewhere that it shouldn't be
54
What are some of the baseline monitoring parameters for PN?
- CMP, Mg, Phos, Ca [ionized] - Hepatic Function Panel - Prealbumin/CRP [ALWAYS together] - PT/INR [Clotting?]
55
What are some of the ongoing monitoring for PN?
- Daily: vitals, stools, CMP [eletrolytes, glucose, BUN] - Twice Weekly: CBC, PREALBUMIN/CRP [ICU --> daily] - Weekly: Triglucerides, RQ, Indirect Calorimetry [finds REE & RQ]
56
What is Refeeding Syndrome?
- Rapid feeding within a starved patient that can be life threatening [fluid, micronutrient, electrolyte, vitamin imbalence]
57
What are some of the important clinical findings for Refeeding Syndrome?
- HYPOPHOSPHATEMIA [VERY IMPORTANT] - HYPOMAGNESEMIA, HYPOKALEMIA
58
What are some of the risk factors that are associated for Refeeding Syndrome?
- Rapid Feeding [feed slowly] - Low BMI [16-18.5] - Already low K, Phos, Mag before feeding - Others: Alcoholism, Anorexia Nervosa, Maramus
59
What are some of the ways that we are able to prevent Refeeding Syndrome?
- Limit Carbs: 100-150g - Limit Fluids: 800ml/day - GIVE electrolytes - 50% of total calories - GIVE thiamine 100mg daily x5-7d
60
What is Essential Fatty Acid Deficiency?
- When you have low levels of EFAs [linoleic & lenolenic] that has an onset of 10-14 days - Shows as Dry Skin, Brittle Hair, Lack of luster
61
What is the way that we are able to prevent EFAD?
- 500ml of 10% twice weekly OR - 250ml of 20% twice weekly
62
What are the indications for Enteral Nutrition?
- "if the guts works, use it" - Contrainidications: anything where they cant swallow
63
What are some of the advantages of EN?
- GI stimulation: decrease bacterial translocation [DECREASED morbidity & mortality] - AVOIDS IV risks: decreased infections - can do bolus feeds
64
What are some of the contraindications [or indications to PN] for EN?
- Mechanical obstruction [blockage] - Non-Mechanical [ILEUS = leads to sepsis] - FISTULAS
65
What are some of the general routes of administration for EN?
- Nasogastric [NG = Nose --> Stomach] - Orogastric [OG = Mouth --> Stomach] - Nasojejunal [NJ = Nose --> Small Intestine] - Orojejunal [OJ = Mouth --> Small Intestine] - Surgery [Gastrostomy (PEG: cant do nose or mouth) or Jejunosotmy (PEG/PEJ: PEG that goes into small intestine)
66
What route of administration is better for feeds and/or Medications?
- NG/OG are better for medications - NJ/OJ are better for feeds
67
What are some of that way that we determine the route of access in EN?
- Aspiration: Low risk = gastric; High risk = jejunal - Tolerance: Vomiting = jejunal; Gastric Residuals = jejunal - Long Term: PEG or PEJ
68
What are some of the methods of administration in EN?
- Bolus, Intermittent, Continuous Infusion, Trickle or Trophic
69
What is important to know about Bolus administration in EN?
- mimic meals - > 200ml over 5-10mins
70
What are the advantages and disadvantages for Bolus administration in EN?
- Advantages: convenient, JUST syringe, less interactions - Disadvantages: can't feed small bowel, aspirations
71
What is important to know about Intermittent administration in EN?
- > 200ml over 20-30mins [gravity drip] - help with tolerance BUT needs a lot of equipment
72
What is important to know about Continuous Infusion administration for EN?
- over 12-24 hours - INFUSION PUMP - Preferred method for jejunum
73
What are some of the advantages and disadvantages for Continuous Infusion administration in EN?
- Advantages: low risk of aspiration - Disadvantages: INFUSION PUMP & 24 hour
74
What is important to know about Trickle or Trophic administration in EN?
- SLOW infusion at 10-30ml/hr - Can prevent mucosal atrophy & bacterial translocation BUT hard to get proper calories
75
What are some of the EN formulas that are used?
- Jevity: 1.06kcal/mL & 44.3 protein - Impact 1.5: 1.5kcal/mL & 94 protein [ICU!] - Glucerna: 1.2kcal/ml & 60 protein - Nepro: 1.8kcal/mL & 81 protein
76
What are some of the immune-modulating contents of Impact 1.5 in EN?
- Arginine, Glutamine, Omega-3, Antioxidants
77
What are some of the adjunctive therapies?
- Modular Supplements - Glutamine - Probiotics - Vitamins and trace elements
78
What is the most important modular supplements in EN?
- Pro-Stat: Protein; 30mL; 15 g protein
79
What in important to know about Glutamine [Glutasolve] in Modular Supplements?
- Reduce ICU stay - Reduce mortality in burn patients - DO NOT supplement if getting glutamine [Impact 1.5?]
80
What is important to know about Probiotics in EN?
- NOT COMMONLY USED - Inhibits bacterial growth - Blocks pathogen - Eliminates Toxins - Enhances inflammatory response
81
What is important to know about the Vitamins and Trace Elements in EN?
- Vitamin E & C - Trace: Slenium, Zinc, Copper, Chromium, Manganese - GOOD in burn patients
82
What are some of the complications for EN?
- Gastrointenstinal - Metabolic - Mechanical - Medication-Related
83
What are the Gastrointestinal Complications for EN?
- High Gastric Residual [Jejunal] - Aspirations [Jejunal] - N/V [Use Metoclopramide or Erythromycin] - Diarrhea or Constipation
84
What is important to know about High Gastric Residuals in EN? | Cutoffs?
- NOT GOOD CUTOFFS - < 500mL: DO NOT HOLD unless tolerance - 200-500mL: reduction to AVOID aspiration
85
What is important to know about Aspirations in EN?
- Elevate HOB [Head of Bed] to 30-45* [lets gravity work] - Continuous Infusion [Lower volume] - Post-pyloric delivery [Jejunal]
86
What are some of the medications that can be used to decrease motility [N/V]?
- Metoclopramide 10mg QID - Erythromycin 250-500mg TID or q8h - Naloxone 8mg QID [high dose] - Methylnaltrexone [NEVER 1st line]
87
What is important to know about diarrhea in EN?
- NEED TO LOOK AT MEDS - Hyperosmolar meds, meds with SORBITOL, bowel regimen, Antibiotics
88
What are some of the Hyperosmolar Medications that can cause Diarrhea in EN?
- Acetaminophen [exlixir or liquid] - Docusate - Lactulose - Metoclopramide
89
What should you do when you have 2 Hyperosmolar Medications in EN?
- DC, Decrease Dose, Make PRN
90
What are some of the medications that have Sorbitol?
- Acetaminophen - Guaifenesin/Dextromethorphan - Lithium Syrup - Metoclopramide - Kecellate???
91
What are some of the Metabolic Complications in EN?
- HYPER- or HYPOglycemia [check meds/insulin] - Electrolyte Imbalence [HYPOnatremia is common]
92
What are some of the mechanical Complications for EN?
- Clogging of Tube - Malposition [move, came out...] - Rhinitis - Sinusitis [move to mouth]
93
What is some of the general guidelines for medication delivery via EN?
- LIQUID!! - If using oral --> CRUSH IT - DO NOT CRUSH SUSTAINED RELEASE OR ENTERIC COATED
94
What is important to know about Liquid medications in EN?
- AVOID viscous --> Clogging [NO syrups, Mineral Oils, Granules]
95
What is on the "DO NOT CRUSH" list?
- Delayed or Extrended Release - Enteric Coated - Buccal or Sublingual - Carcinogenic, Teratogenic, Cytotoxic - +/- Capsules
96
What is the way that we can Unclog an EN tube?
- 1 sodium bicarb tab - 1 pancreatic enzyme cap - 10 ml of warm sterile warm
97
What are some of the Drug/Tube Feed Interactions?
- Antibiotics - Anti-Retrovirals - Others [Levothyroxine, Phenytoin, Theophylline, Warfarin]
98
What is important to know when giving a drug that interacts with tube feed, like step to take?
- Hold Feed - WAIT 1 hour - Give meds - WAIT 2 hours [Total 3 except keflex is 6] - Resume Feed
PHRM 864: Therapeutics IV
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