Review Notes

Question 1

Routes of feeding

Answer 1

Question 2

Types of Enteral Formulas

Answer 2

When to use: What are nutritional needs of patient?
* Polymeric (intact Protein)
* Semi-elemental and Elemental (predigested and broken down to facilitate nutrient absorption)
* Specialized formula

Question 3

Semi- elemental & Elemental EN formulas

Answer 3

protein and lipid predigested and broken down to facilitate nutrient absorption
* Protein; either as smaller peptides or amino acids
* Fat; may contain MCT
* Indication for use: short bowel, severe GI inflammation, liver disease

Question 4

general guidelines for starting continuous feeds for over 14 years of age

Answer 4

Continuous Feeds:
* Initiate: 0.4-0.5 ml/kg/hr (typically 10-30 mls/hr based
on ASPEN guidelines)
Daily Increases: 0.5-1.0 ml/kg/hr every 24hours (or 0.2-0.3 ml/kg/hr q 8 hrs, or 20-25 ml/hr q 8 hrs).

These are general guidelines to administration; rates of initiation and progression of feeds must be individualized based on the nutritional and medical needs of the patient !!! Note recommended rates may be lower in some patient populations

Question 5

Energy needs based on kcal/kg

Answer 5

25-35 kcal/kg
* when weight gain not desired (i.e. >75yrs of age), use 25-30kcal/kg

Question 6

What are the components of energy requirements?

Answer 6

• BMR (basal metabolic requirements)
• Activity (requirements for physical activity)
• Metabolic Stress (requirements related to metabolic stress); note many factors may influence this.

Question 7

Activity and Metabolic Stress: Impact on Energy Requirements

Answer 7

Need to consider activity levels: in-patient vs. out-patient. Consider Activity Factor (variable)
* 1.0 Bed-rest
* 1.2 Out of bed; very light activity
* 1.3-1.5 Sedentary
* 1.7 Normal Activity

Stress Factors: can have wide range: for cancers often 1.1-1.3; but may be higher.

Question 8

PN dextrose for adults

Answer 8

Supplies the majority of non-protein calories and osmolality
* Provides 3.4 kcal/g

Typically reported in g/L concentrations on PN bag
* 10% solution = 100 g/L
* 20% solution = 200 g/L
* 30% solution = 300 g/L
* stock solutions of IV dextrose may be as high as 70% as on TPN forms; but can’t deliver this even in central line (it is diluted down to much lower concentrations ie as above)

Delivery
* usually given to patient as a 10% or 20% (but can be a special, for example 17.5%)
* CVL=10-30%
* PIV = anything less than 12.5% w/v (risk of phlebitis and decreased life span of line)

Question 9

• What is the concentration of D7.5W.
• If you wish to make 1.5 litres of a D7.5W how many kcal would you get??

Answer 9

1. 7.5%=75 gm in 1 L.
2. 1.5 L=1500 ml =75 g dextrose x 1.5 L=112.5 g dextrose
3. In 112.5 g dextrose x 3.4 kcal/g=382.5 kcal dextrose.

Question 10

GIR calculation

Answer 10

Question 11

Stress factors

Answer 11

Patients may have ranges of SF based upon the extent of injuries or metabolic changes.
* Skeletal trauma: 1.35
* Major sepsis: 1.6
* Major Head Trauma 1.5
* Minor Operation: 1.2
* Fever/Sepsis: 1.2-1.3 (occ higher) * Severe Burn 2.0

Question 12

Writing Out TPN order example

Answer 12

Question 13

Nutrient absorption in jejunum

Answer 13

Intestinal Failure = Malabsorption + Losses

Question 14

Nutrient absorption in ileum

Answer 14

Intestinal Failure = Malabsorption + Losses

Question 15

Nutrient balance: Role of the colon

Answer 15

Intestinal Failure = Malabsorption + Losses

Question 16

Acid Base Balance

Answer 16

Arterial blood gases are critical in the determination: pH, PC02 and HCO3 are important in the definitions.
* Note: pCO2 represents the acid part of the equation. Usually when this increases then pH in blood decreases.
* Bicarbonate represents the base part of the equation (as reflected in the CO2 levels in arterial blood).
* Need PCO2 +pH to calculate bicarbonate (or total carbon dioxide);
* Note pCO2 is not the same as the CO2 concentration; one represents partial pressures; the other actual concentration in blood

Question 17

Respiratory Acidosis

Answer 17

Primary problem is lung → Low pH and elevated pCO2
* Typically caused by retention of CO2 (retention of CO2 can be caused by problems with ventilation ie decreased respiratory rate due to damage in the lungs, or in CNS). More typical in acute lung failure or acute CNS damage. Note: its typically partial pressures of CO2 that increases
* As pCO2 increase in the blood, H+ are retained within the blood. This results in decreased pH in the blood.

Question 18

Respiratory Alkalosis

Answer 18

Increased respiration leading to excessive C02 elimination (low pC02 and elevated pH); this results in decreased pC02, and hence decreased H+ ions— leads to an increase in blood pH.
* This may occur when patient experiences lung damage and increasing respiratory rates or possibly when surrounding O2 in environment is decreased.
* In a ventilated patient this may occur when the patient is being weaned off ventilatory support and the O2 is decreased. The patients starts to breath more, but is unable to oxygenate sufficiently.

Question 19

Waterlow’s Criteria for Classification of Malnutrition

Answer 19

Question 20

Wasting

Answer 20

• Weight % is much lower than height %ile
• Can be that weight is more than two percentile curves away from height (weight for height)
• Can be that weight is less than 3% ile (weight for age) or is on the 3%ile. But typically weight is at least two centiles below the height centile (and typically weight centile is less than 3- 10%iles)
• Does not have to be both

Question 21

Stunting

Answer 21

• Height % is much lower than 3 %ile
• Weight for age and weight for height may be fine or they can be low!!
• However, typically height is outside the normal ranges of age appropriate growth (ie less than 3%ile)

Question 22

Energy & Protein Requirements in Childhood (Enteral) in Healthy Children

Answer 22

Total energy needs
* 100-110 kcal/kg for 0-3 yrs
* 80-90 kcal/kg for 4-6 yrs
* 60-70 kcal/kg for 7-10 yrs

Protein:
* 1.2-1.5 g/kg for 1-3 yrs
* 1.2-1.5 g/kg for 4-6 yrs
* 1.0 g/kg for 7-10 yrs

Question 23

Peds AF

Answer 23

Question 24

protein requirements for EN calculations

Answer 24

Question 25

Fluid in Infants & Children

Answer 25

• An essential component of parenteral nutrition
• Need to consider TFI of pt (total fluid intake)
• Assess other sources of IV fluid, ex maintenance line, meds – does TPN meet req’ts or are other IV’s req’d?

Question 26

Administration of EN support in infants and children: continuous feeds (over 24 hrs)

Answer 26

Question 27

energy requirements for PN in children

Answer 27

Growth requirements: Influenced by age, disease type & severity, gender, body composition
* 80-100 kcal/kg; infants < 1 year
* 60-90 kcal/kg for 1-12 years
* 30-60 kcal/kg (adolescents > 12 years)

Question 28

Guidelines for Administration of Parenteral Dextrose in peds

Answer 28

Question 29

Guidelines for Administration of Parenteral Amino Acids in peds

Answer 29

Question 30

Guidelines for Adminisration of Parenteral Lipids

Answer 30