ASPEN/SCCM Recommendations Flashcards
(111 cards)
1
Q
How should critically ill patients be assessed?
A
SGA has limited use for critically ill patients
ASPEN recommends that the Nutrition Risk Score (NRS-2003) OR Nutrition Risk in Critically Ill (NUTRIC) tool be used to assess nutrition risk & plan interventions
2
Q
SGA
A
“Subjective Global Assessment”
- Validated, reliable assessment tool for diagnosing nutrition status, which relies on the patients medical hx and physical assessment
- patients are classified to: “well-nourished,” “moderately malnourished,” “severely malnourished”
- has 5 components that consider medical hx (wt. changes, dietary intake, GI symptoms, functional capacity, metabolic stress)
- has 3 components for physical exam (muscle wasting, fat depletion, nutrition-related edema)
3
Q
**ASPEN // AND Classification for Malnutrition
A
-Similar to SGA but includes how pro-inflammatory states affect malnutrition and seeks to identify the etiology on an individual basis
- 3 etiologies:
- Acute illness
- Chronic Illness
- Social/environment/behavioral circumstances
- 2 characteristics, out of 6, required to dx malnutrition:
- Weight Loss
- Fat Loss
- Decreased energy intake
- Muscle mass loss
- Decreased hand strength
- Fluid accumulation
- *Enter Image w/ specific wt. loss requirements
- most similar to PHSW guidelines
4
Q
IBW
A
Males: 50 kg + 2.3 kg for each inch over 5 feet.
Females: 45.5 kg + 2.3 kg for each inch over 5 feet.
5
Q
ABW
A
Estimated Adjusted Body Weight (kg)
If the actual body weight is greater than 30% of the calculated IBW, then use this:
ABW = IBW + 0.4 (actual weight - IBW)
6
Q
NFPE
A
Nutrition-Focused Physical Exam; focuses on changes to muscle, fat stores, fluid retention and/or other sign that can result from micronutrient deficiencies or excesses
-should evaluate parts of the body with high cell turnover (hair, skin, mouth, tongue)
FOR ASPEN/AND MALNUTRITION CRITERIA:
- mild fat/muscle/fluid loss is required for Acute/Chronic/Social malnutrition
- moderate fat/muscle loss/fluid losses (can be moderate or severe) is required for Acute
- severe fat/muscle/fluid loss is required for Chronic/Social
7
Q
Name 6 benefits in EN feeding.
A
Nutrients provided via the enteral route undergo first-pass metabolism, 1. promoting efficient nutrient utilization. The presence of nutrients in the SI maintains normal gallbladder function by stimulating the release of cholecystokinin, 2. reducing the risk of cholecystitis that may occur if patients are kept NPO.
- Luminal nutrients provide GI structural support and
- help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
((this is via: IgA, which is secreted within the GI tract when there are nutrients, can prevent bacterial adherence and translocation)) - EN reduces infectious complications
- less expensive than PN
8
Q
Name 8 contraindications for EN.
A
- Severe Short Bowel Syndrome (<100-150 cm remaining small bowel in the absence of the colon, OR 50-70 cm remaining small bowel in the presence of the colon).
- Other severe malabsorptive conditions
- Severe GI bleed
- Distal high-output GI fistula
- Paralytic ileus
- Intractable vomiting and/or diarrhea that does not improve with medical mgmt
- Inoperative mechanical obstruction
- When the GI tract cannot be accessed – ie: when upper GI obstruction prevent feeding tube placement
9
Q
**What is the ASPEN recommendation for when EN needs to be initiated in a well-nourished patient?
A
**NPO/Inadequate oral intake x 7-14 days
10
Q
**What is the ASPEN recommendation for when EN needs to be initiated in a high-risk critically ill patient?
A
**Within 24 - 48 hours of initial insult (mechanical ventilation, surgery, neurologic injury) (“Early EN initiation”
11
Q
What is the recommended EN initiation for critically-ill patients?
A
Start at 10 - 40 mL/hr, increasing by 10 - 20 mL/hr Q 8 - 12 hours to goal rate.
Many critically-ill patients can tolerate rapid advancement of EN to goal rate within 24 - 48 hours, minimizing energy and protein deficits.
12
Q
What are the energy recommendations for critically-ill patients w/ sepsis, starting EN?
A
Provide 60 - 70% of energy needs (with 100% estimated protein needs), during the first week of EN. Then advance to more than 80% of estimated energy needs after the first week.
13
Q
**What is the ASPEN recommendation for flushing feeding tubes?
A
**At least 30 mL water Q 4 hours during continuous feeding
OR, before and after intermittent or bolus feedings in adult patients
AND, 30 ml of water, before and after GRV checks
14
Q
**What is ASPEN/SCCM recommendations for checking GRVs in critically-ill patients?
A
- **It is not recommended, because a number of factors can compromise the accuracy of GRV checks:
- feeding tube type, diameter and position
- viscosity of GRVs
- technique, including size of syringe and time and effot spent
- position of the patient
*GRVs have not been found to correlate with incidence of PNA or aspiration, and checking them increases episodes of feeding tube occlusion, reduce the total volume of EN delivered, and take up RN time
15
Q
**If GRVs are checked, what are the ASPEN/SCCM recommendations?
A
**In the absence of other signs of intolerance (vomiting or abdominal distention), EN should not be held for GRVs of less than 500 mL.
16
Q
What methods should be used routinely for checking GI function?
A
- Passage of flatus and stool
- Stool frequency and consistency
- Physical exam to assess bowel sounds, abdominal girth, and abdominal radiographs
17
Q
**What are SCCM/ASPEN guidelines for acceptable blood glucose control in hospitalized patients?
A
**140 - 180 mg/dL
BG levels should be checked every 4 - 6 hours for patients with diabetes OR in patients with BG over 180 mg/dL
18
Q
If an MD notes serum albumin and prealbumin as indicators of nutrition status, what would you say?
A
They are now known as indicative of inflammatory status and not nutrition intake. No serum lab values indication nutrition status or adequacy of nutrition provision.
19
Q
**What are EN practice recommendations from ASPEN, include what statements regarding enteral formulation selection? (3)
A
- *1. The accuracy of adult enteral formula labeling and product claims is dependent on formula vendors
- Nutrition support clinicians and consumers are responsible for determining the accuracy of information about adult enteral formulas.
- Interpret enteral formulations content/labeling and health claims with caution until such time as more specific regulations are in place.
EN formulas are not FDA-approved, so their claims are not regulated.
20
Q
**What are the ASPEN/SCCM recommendations related to use of fiber in EN formulations?
A
**They suggest that clinicians consider fiber-containing formulas if patients have persistent diarrhea.
Also, both insoluble and insoluble fiber be avoided if the patients are at a high risk for bowel ischemia and have severe dysmotility.
21
Q
What is EN formula tolerance or diarrhea, most often related to? (4)
A
- Severity of illness
- Co-morbid conditions
- Enteric pathogens
- Concomitant use of meds administered through the enteral access device
22
Q
**What do North American nutrition support guidelines say for diabetic patients in the ICU?
A
**Does not recommend the use of diabetes-specific formulas based on the evidence available.
23
Q
**What does ESPEN/ASPEN recommend for elemental EN formula use with patients with GI issues?
A
*ESPEN does not recommend the routine use of elemental formulas with Crohn’s disease, ulcerative colitis, or short-bowel syndrome.
**ASPEN also recommends that routine elemental and disease-specific EN formulas be avoided in critically ill patients because no clear benefit to patient outcomes has been shown in the literature.
24
Q
**What are SCCM/ASPEN guidelines for IMFs in critically ill patients?
A
- *1. Do not recommend the routine use of IMFs with severe sepsis.
2. Recommend IMF use be reserved for the postoperative patients in the surgical ICU.
25
Define respiratory quotient (RQ).
"a value that describes CO2 production in relation to oxygen consumption, varies for carbs (1.0), protein (0.8), and lipid (0.7)"
Research has showed that total energy provision or overfeeding was more important than composition of formula in respiratory status of vented patients.
26
**What does SCCM/ASPEN recommend for specialized formulas for ARDS/ALI?
**Does not recommend for ARDS/ALI
Also, does not recommend the use of high-fat, low-carb formulas containing high levels of omega-6 FAs
27
**What does SCCM/ASPEN recommend for EN formulas for patients (in ICU) with AKI?
**They recommend the use of standard, high-protein EN formulas for AKI.
Patients with hyperkalemia or hyperphosphatemia may require a renal-specific formula.
28
**What does SCCM/ASPEN recommend for EN formulas for patients with acute respiratory failure?
**They recommend the use of concentrated formulas, because of the presence of concomitant fluid overload, pulmonary edema, and renal failure. These formulas may also be used in other disease states and conditions, such as liver and heart failure, that result in fluid overload, hypervolemic hyponatremia, decreased urine output, early satiety, and elevated nutrition needs.
29
**What are the SCCM/ASPEN recommendations for critically ill obese patients?
**They recommend these patients should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores
The energy goal should not exceed 65 - 70% of energy requirements as calculated.
30
*What are the equations for estimating energy needs in obese ICU patients, when IC is not available?
** For BMI 30 - 50: Use 11-14 kcal/kg ACTUAL weight
| For BMI greater than 50: Use 22 - 25 kcal/kg IBW
31
**What is the protein recommendation for critically ill obese patients?
More than 2.0 g/kg/day protein is adequate to maintain nitrogen balance with hypocaloric feedings, preserve LBM, and allow for adequate wound healing
32
**Where does ASPEN recommend feeding first?
**Stomach as a first choice.
Note, that recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration PNA.
33
(T/F) The American Society of Gastrointestinal Endoscopy guidelines consider placement of a percutaneous feeding tube to be a high-bleeding-risk procedure.
TRUE
Routine pre-procedural testing of coagulation parameters and platelets is no longer recommended for patients undergoing enterostomy tube placement. But these should be considered if there is a concern.
34
**What does SCCM/ASPEN recommend for GRVs in critically ill patients?
**SCCM/ASPEN does not recommend routine checks of GRVs in critically ill patients.
35
What are some diseases that cause maldigestion/malabsorption?
- Gluten-sensitive enteropathy
- Crohn's disease
- Diverticular disease
- Radiation enteritis
- Enteric fistulas
- HIV
- Pancreatic insufficiency
- Short-gut syndrome
- SIBO (small intestinal bacterial overgrowth)
- ETC
36
**How should medications that contain sorbitol be administered?
Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome.
**Most drugs and electrolytes (ie: potassium), should be mixed with a minimum of 30 to 60 mL water per 10 mEq dose to avoid direct irritation of the gut.
37
**What are the SCCM/ASPEN guidelines for GRVs in ICU patients?
**GRVs should not be used as part of the routine care to monitor ICU patients receiving EN.
**If ICUs still use GRVs, it is recommended that clinicians avoid holding EN for GRVs less than 500 mL, in the absence of other signs of feeding intolerance (quality of evidence: low).
38
*What are the guidelines for tube-fed patients for preventing TF intolerance?
* Assessed for signs of tube-feed intolerance (distention, fullness feeling, discomfort, N/V) Q 4 hours
- HOB elevation 30 - 45 degrees, or position in chair or reverse Trendelenburg position
- Good oral care BID (with chlorhexidine in critically ill patients)
- Continuous tube feeding schedules
- Use of minimal sedation techniques
- Appropriate and timely oropharyngeal suctioning (ie: prior to lowering the bed, deflating the cuff of endotracheal tubes or extubation)
- Tube placement should be checked by noting any change in the visible tube length or marking at stoma Q 4 hours
- Unless the patient is vomiting, GRVs up to 250 mL should be re-instilled to replace fluid, electrolytes and feeding formula.
- Prokinetic agents and small bowel feedings should be considered for patients determined to be at high aspiration risk
39
**What are the SCCM/ASPEN guidelines for EN in patients at risk for refeeding syndrome?
**Should provide only 25% of the energy goal on Day 1, with attention to the energy contribution from IV fluids, and then cautiously advanced toward the energy goal over the next 3 to 5 days, as dictated by clinical status and/or stable electrolyte levels.
40
**What are the indications for PN use:
**ASPEN Recommendation:**
-PN may be appropriate for patients who are unable to meet nutrition requirements with EN. These patients are already or have the potential to become malnourished.
PPN may be used in selected patients to provide partial or total nutrition support for up to 2 weeks when those patients cannot ingest or absorb oral or enteral tube-delivered nutrients, OR when CPN is not feasible.
CPN support is necessary when PN is indicated for longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or FR is required, and the benefits of PN outweigh the risks.
41
**What are the indications for CPN use:
**ASPEN Recommendation:**
The patient has failed the EN trial with appropriate tube placement (post-pyloric)
EN is contraindicated or the GI tract has a severely diminished function because of the underlying disease or treatment. Specific applicable conditions are as follows:
Paralytic ileus
Mesenteric ischemia
SBO
GI fistula, except when enteral access may be placed posterior to the fistula or volume of output (less than 200 ml/day), support a trial of EN.
The exact duration of starvation that can be tolerated without increased morbidity is unknown, as can occur in postoperative nutrition support. Expert opinion suggests that wound healing will be impaired if PN is not started within 5 to 10 days postoperatively for patients who cannot eat/tolerate EN.
The patient's clinical condition is considered in the decision to withhold or withdraw therapy. Conditions where nutrition support is poorly tolerated and should be withheld until the condition improves are:
Severe hyperglycemia
Azotemia (elevation in BUN > 100 mg/dL and [Cr] levels)
Encephalopathy and Hyperosmolarity
Severe fluid and electrolyte disturbances
42
**What is the recommendation for initiating PN in critically ill patients with normal nutrition risk or no malnutrition?
**Initiate PN when patient has been NPO/Inadequate intake x 7 days, with normal nutrition risk.
43
**What is the recommendation for initiating PN when patients are malnourished or have high nutrition risk?
**PN is indicated when EN is not feasible.
44
**What is the recommendation for initiating PN in other conditions that preclude the use of the GI tract?
**More than 7 to 10 days.
45
**ASPEN/SCCM Recommendation**
| What are the recommendations for nutrition support in the ICU?
**ASPEN/SCCM Recommendation**
Recommend the enteral route as the preferred means of nutrition support in the critically ill. The greatest benefit derived in patients started on enteral feedings within 24 to 48 hours of ICU admission.
46
**ASPEN Recommendation**
| What are the recommendations for the provision of nutrition support in adult patients receiving anticancer therapy?
**ASPEN Recommendation**
Recommends a thorough assessment of the patient's nutrition status and the use of PN ONLY in those who are malnourished and likely to be unable to ingest and absorb adequate nutrients for a period of 7 to 14 days.
EN always preferred with functional GI tract. Also, preferred in patients undergoing hematopoietic cell transplant because glycemic control is better during EN than PN.
Consider immune-enhancing EN formulas.
47
What are the indications for home PN?
Duration of PN is prolonged (more than 2 weeks)
Medicare requires documentation that:
The patient's GI tract is nonfunctional ("artificial gut"), AND
The condition is permanent (at least 90 days of therapy is needed), AND
Must have documented evidence of inability to tolerate EN (malabsorption, obstruction)
48
**ASPEN/SCCM Recommendation**
| What is the recommendation regarding w-6 FAs in critically ill patients receiving PN?
**ASPEN/SCCM Recommendation**
Suggests that clinicians either withhold soybean oil-based ILE or limit it to a maximum of 100 grams (often divided into 2 doses) during the first week following initiation of PN, if the patient is at risk for EFAD.
49
**ASPEN Recommendation**
| What types of trace elements products be used for PN formulations?
**ASPEN Recommendation**
When multiple-element products are inappropriate, single-element products should be used to meet individual patient needs.
50
**To provide hyperglycemia with the initiation of PN, what does ASPEN/SCCM recommend?
**PN should be initiated at half of the estimated energy needs, or approximately 150 to 200 g dextrose, for the first 24 hours. Delivery of less dextrose (~100 g) would be appropriate if the patient has a low BMI or poor glucose control.
51
(TRUE/FALSE)**
Withholding or limiting soy-based ILE in critically ill patients for the first week of PN has been suggested as a strategy to reduce immunosuppression complications.
TRUE.
| However, ASPEN/SCCM gave the quality of the evidence a very low rating.
52
**What are the ASPEN recommendations related to hypertriglyceridemia?
** ASPEN recommends that serum triglyceride concentrations greater than 400 mg/dL be avoided when infusing ILE, and clinicians should reduce the ILE dose or discontinue ILE if this level of hypertriglyceremidemia occurs.
The dose of ILE should also be reduced or discontinued in mechnically ventilated patients receiving propofol for sedation because it is supplied as a 10% ILE.
53
**What is the advice from ASPEN to help clinicians cope with parenteral MVI product shortages?
**ASPEN recommends:
Reserve a supply of IV MVIs for those patient solely receiving PN
Use oral or enterally administered MVI whenever possible
To ensure fair allocation of products nationwide, do not stockpile parenteral MVI
Do not use pediatric IV MVIs for adult patients
When all options to obtain IV MVIs have been exhausted, ration use by reducing the dose by 50% or giving 1 dose 3 times a week.
If IV MVIs are no longer available, administer individual thiamine, ascorbic acid, pyridoxine, and folic acid daily.
54
(TRUE/FALSE)
| Iron is a component of PN formulation.
FALSE.
| It is not a component because of compatibility limitations.
55
**What is the ASPEN recommendation for phosphorus added to PN formulations?
** 20 to 40 mmol/day.
56
**What is the recommended target BG levels for pregnant women with diabetes (type 1 or gestational)?
Fasting BG
1-hour post-prandial BG
2-hour post-prandial BG
**
Fasting BG: 95 mg/dL or lower
1-hour post-prandial BG: 140 mg/dL or less
2-hour post-prandial BG: 120 mg/dL or less
**THESE TARGETS ARE ALSO IMPORTANT TO FOLLOW FOR PREGNANT WOMEN REQUIRING NUTRITION SUPPORT.
57
**What is the current recommendation for DHA supplementation for pregnant and lactating women?
** At least 200 mg DHA in the diet
58
What are the AND recommendations for calculating energy requirements in pregnancy? (Hint: Based on BMI)
BMI <18.5: 42 to 50 kcal/kg pregravid weight
BMI 18.5 - 24.9: 40 to 45 kcal/kg pregravid weight
BMI > 25: 30 to 35 kcal/kg pregravid weight
59
What are the IOM recommended weight gain goals? BMI <18.5 BMI 18.5 to 24.9 BMI 25 to 29.9 BMI >30
```
Based on pregravid:
BMI: BMI <18.5: 28 - 40 lbs
BMI 18.5 to 24.9: 25 - 35 lbs
BMI 25 to 29.9: 15 - 25 lbs
BMI >30: 11 - 20 lbs
```
60
What are the treatment steps for hyperemesis gravidarum?
Initial: SFM compromised of low-fat, high-CHO foods and the avoidance of trigger foods and foods with strong odors.
If unsuccessful: Supplemental vitamin B12, ginger and acupressure
Next: Combined vitamin B6/doxylamine, antihistamines, dopamine antagonists, serotonin antagonists, and IV fluid with or w/o diazepam.
Lastly: Corticosteroids, EN, PN (in severe cases), gabapentin, or transdermal clonidine.
61
**When IC is not available, how would you recommend energy needs for a critically-ill, pregnant woman?
*
Traditional equations that estimate the needs of critically ill patients can be used with 200 to 300 kcal/day added for pregnancy
NOTE: This pregnancy energy deposition is slightly below the recommendations to support weight gain in a healthy pregnancy because the energy expenditure from activity while recovering from trauma would most likely be LOW and it is important to AVOID OVERFEEDING the critically ill patient.
62
**How would you calculate protein needs for a critically-ill, pregnant women?
**By the same method for nonpregnant patients, beginning with 1.5 to 2.0 g/kg/day pregravid weight.
63
What are the other important nutrition recommendations for pregnant women?
MVI with minerals should be provided daily, as well as additional folic acid
Consider additional iron (may be necessary)
Glucose control should be managed!!!
64
**What is the recommended energy guideline for adults with pressure injuries who are assessed as being at risk for malnutrition?
**30 to 35 kcal/kg/day
| NOTE: It is also recommended that energy intake is adjusted based on weight change or level of obesity.
65
**What is the energy recommendation for patients with pressure injuries but not at risk for malnutrition?
** 30 kcal/kg/day
| NOTE: Harris-Benedict equation underestimates by ~10%.
66
**What is the protein recommendation for adults with pressure injuries?
**1.25 to 1.5 g/kg/day.
67
**What are the recommendations regarding arginine, glutamine, etc. for wound healing?
* *NPUAP, EPUAP, PPPIA recommend supplements associated with protein, arginine and micronutrients for adults with stage 3 or 4 or multiple pressure injuries/ulcers when traditional high-calorie, high-protein supplements do not meet nutritional requirements and facilitate wound healing.
* *No research examining the use of arginine ALONE as a supplement to promote wound healing demonstrated efficacy.
68
**What are the recommendations in regards to MVIs?
**Recommend a MVI with minerals be considered when an individual with a pressure injury is NOT consuming a balanced diet OR a deficiency is suspected or confirmed.
69
**What are the overall energy and protein needs for patients with wounds?
** 30 to 35 kcal/kg/d energy
1.2 to 1.5 g/kg/d protein
Plus DRIs for micronutrients
70
(TRUE/FALSE)
| **SCCM and ASPEN recommend the use of immune-modulating formulations for surgical and trauma patients.
TRUE
71
**According to SCCM/ASPEN guidelines, when should nutrition support be initiated?
**In patients who are unable to achieve 60% of their energy and protein requirements with EN alone AFTER 7 to 10 days, the SCCM/ASPEN guidelines recommend using supplemental PN.
PN should also be considered when patients who are high nutrition rik or malnourished and nutrition support is indicated but EN is not feasible.
72
**What are the nutrition recommendations for energy and protein for patients with SCI (spinal cord injury?)
** ENERGY: IC first, or 15% less than Harris-Benedict equation (no validated predictive equation best determines the SCI energy expenditure)
PROTEIN: 1.5 to 2.0 g/kg/d (immediately following a SCI)
73
**What are the general energy recommendations for weight maintenance for quadriplegic patients?
** 20 to 22 kcal/kg/d OR 55 to 90% of the Harris-Benedict equation.
74
**What are the general energy recommendations for weight maintenance for paraplegic patients?
** Energy recommendations are increased slightly to 22 to 24 kcal/kg/d OR 80 to 90% of the Harris-Benedict equation)
75
**What is the protein intake for patients in long-term care after a SCI?
**Healthy patients; 0.8 to 1.0 g/kg/d
If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.
76
**Healthy patients; 0.8 to 1.0 g/kg/d
If pressure injuries: 1.25 to 1.5 g/kg/d with energy (30 to 35 kcal/kg/d), sufficient daily fluid, and vitamin/mineral supplementation if intake is poor or deficiencies are suspected.
**
| EN start within 24 to 48 hours of admission.
77
**What are the energy requirements for patients with acute stroke?
**IC is the gold standard; no equation has been validated to precisely determine the energy expenditure for the stroke population.
Based on available data, the energy requirements following an ischemic stroke are likely close to estimated BMR via Harris-Benedict equation or Penn-State equation.
Patients with hemorrhagic stroke, especially SAH, have elevated energy needs as compared with estimates of BMR.
78
**What are the protein requirements for patients following an acute stroke?
** Recommended protein goals range from 1.0 to 1.5 g/kg/d
79
**What are the energy requirements for patients with ALS?
**Mifflin St. Jeor and Harris-Benedict equations have been shown to be the most accurate methods, with HB being the most practical
Some research supports increasing the calculated resting energy expenditure by 10%
Others: recommend energy needs to be 120% greater than BMR by IC and 130% x HB equation.
As the ratio of organ mass to muscle mass increases, patients may require 34 to 35 kcal/kg/d
80
**What are the protein requirements for patients with ALS?
** Ranges from 0.8 to 1.2 g/kg/day
81
(TRUE/FALSE)
**SCCM/ASPEN recommend that clinicians evaluate weight loss and nutrition history prior to admission, level of disease severity and GI function.
TRUE
82
**What are SCCM/ASPEN recommendations related to nutrition support in a critically ill septic patient?
**ASPEN/SCCM guidelines recommend trophic feeding (10 to 20 kcal/hr or 500 kcal/d) for the initial phase of sepsis, advancing as tolerated after 24 to 48 hours to greater than 80% of target energy goal over the first week.
83
**What are the SCCM/ASPEN recommendations related to PN in a critically ill septic patient?
**When a patient is in the acute phase of severe sepsis, the ASPEN/SCCM guidelines suggest NOT using exclusive PN or supplemental PN in conjunction with EN regardless of patient's degree of nutrition risk.
Obviously, if the gut is deemed unreliable, PN may be selected.
84
**When does SCCM/ASPEN recommend initiation of enteral support in critically ill septic patients?
**SCCM/ASPEN guidelines recommend that critically ill patients receive EN therapy within 24 to 48 hours of making the diagnosis of severe sepsis/septic shock, as soon as resuscitation is complete and the patient is hemodynamically stable.
Feeding immediately after the initial dx of sepsis yields a distinct set of problems.
85
**What are the energy requirements for patients with sepsis/septic shock?
**Increases of 20 to 60% over basal expenditure
| Range of 20 to 30 kcal/kg/d is considered safe for critically ill patients (excluding the morbidly obese)
86
**What are the CHO recommendations related to energy expenditure in critically ill septic patients?
**CHO administeration should supply 50 to 60% of the total energy prescription to avoid exceeding the maximum contribution of glucose oxidation and contributing to excess lipogenesis.
Glucose admin. rates greater than 4 to 6 mg/kg/min result in excess lipogensis and lead to hyperglycemia.
87
**In critical care and sepsis patients, the amount of ILES should not exceed XXXXX, if XXXX.
**1.0 g/kg/d
if soybean oil is the source of lipid.
Guidelines for enteral lipid delivery are similar to those for parenteral lipid provision. The usual lipid goal of 1.0 g/kg/d can be liberalized when enteral lipids include lipid substrates containing omega-3 FAs, MCTs, and SCFA. And a mixture of lipid fuels should be delivered whenever possible.
88
(TRUE/FALSE)
**Conflicting data prevented the ASPEN/SCCM guidelines from making a recommendation for use of anti-inflammatory lipid formulas at this time.
TRUE.
89
**What are the SCCM/ASPEN guidelines for protein in sepsis?
** 1.5 to 2.0 g/kg/d (possibly even up to 2.5 g/kg/d in selected cases).
90
(TRUE/FALSE)
**ASPEN/SCCM guidelines recommend use of an arginine/fish oil formula only in surgical ICU patients and do NOT recommend their routine use in patients with sepsis alone.
**TRUE.
91
(TRUE/FALSE)
**SCCM/ASPEN guidelines recommend that clinicians supplement severely ill ICU patients with enteral or parenteral glutamine.
FALSE.
| It is NOT recommended.
92
**Does SCCM/ASPEN have specific guidelines for supplementing zinc, selenium, or antioxidants in sepsis?
**NO
There is not a definitive recommendation.
The literature suggests clinicians provide at least the RDA of antioxidants vitamins and trace elements to critically ill patients throughout hospitalization.
93
**ASPEN/SCCM guidelines recommend assessment using XXXXX or XXXXX to identify patients who would benefit from nutrition therapy.
NRS-2002 (Nutrition Risk Screening)
Attempts to account for both preexisting malnutrition (ie: weight loss, decreased food intake) AND severity of illness (ie: type of injury, APACHE II score)
NUTRIC (Nutrition Risk in Critically Ill)
Focus on severity of illness.
94
**How should energy needs be calculated in trauma patients?
**ASPEN/SCCM guidelines recommend using IC to measure resting energy expenditure in the critically ill, surgical, injured and burn patients, when it is available.
95
**What is the current recommendation for stressed patients (including those with burns), for protein?
**20 to 25% of total nutrient intake by provided by protein
Equates to ~ 1.5 to 2.0 g/kg/d, with the higher range to promote N equilibrium
2.0 g/kg/d IBW has been suggested for obese patients (BMI equal or greater than 30)
In patients with large surface area burns, 3 to 4 g/kg/d may be required.
96
**In previously well-nourished patients, when should PN be initiated, according to ASPEN/SCCM guidelines?
**Only after efforts to provide nutrition via the enteral route have failed to advance EN to meet 60% of target goal energy for 7 to 10 days.
EXCEPTIONS:
Preexisting malnutrition
Cannot receive EN
Are expected to undergo major upper GI surgery
97
**For patients that are in the 'PN exception group,' when should PN be initiated, according to ASPEN/SCCM guidelines?
**Patients include:
Preexisting malnutrition
Cannot receive EN
Are expected to undergo elective major upper GI surgery
ASPEN/SCCM recommend that 5 to 7 days of preoperative PN be provided with continued PN postoperatively.
If EN was contraindicated and the malnourished GI surgery patient did not receive preoperative PN, ASPEN/SCCM recommend (based on limited data), that initiation of PN be delayed postoperatively for 5 to 7 days if EN continues to be contraindicated. PN provided for fewer than 5 days has not shown benefit.
98
What is the ERAS protocol?
Avoid preoperative fasting:
Solid meals are provided up until 6 hours before surgery.
800 mL (~ 100 g and 400 kcal) of a CHO-rich, CL is given at midnight and 400 mL of the same formula is given again 2 hours before the surgical intervention
Patients receive a smaller volume of IV fluids
99
**What are the ASPEN/SCCM guidelines for PN.
**PN should be reserved and initiated only after the first 7 days of hospitalization in patients WITHOUT malnutrition.
100
(TRUE/FALSE)**
ASPEN/SCCM guidelines recommend that use of continuously administered enteral immunonutrition formulations with supplemental omega-3 FAs and arginine in postoperative and trauma ICU patients.
**TRUE.
101
(TRUE/FALSE)**
| ASPEN/SCCM guidelines recommend adding glutamine to EN for any critically ill.
FALSE**
| NOT recommended adding until additional evidence is available.
102
**(TRUE/FALSE)
Based on high quality evidence, the SCCM/ASPEN 2016 nutrition therapy guidelines did make a recommendation regarding the routine use of an enteral formulation characterized by the anti-inflammatory lipid profile in patients with ARDS.
FALSE***
| There is only low quality evidence, therefore SCCM/ASPEN did NOT make this recommendation.
103
If IC is not available, what equation should be used to estimate energy requirements for obese critically ill patients?
OR
For hypocaloric, high-protein regimen, what should you recommend?****
Penn State University 2010 equation
| Less than 14 kcal/kg ABW with 1.2 to 1.5 g/kg ABW***
104
ASPEN states there IS/IS NOT evidence to support the use of BCAAs in the comatose ICU patient who is already receiving standard tx for HE.
NO EVIDENCE
105
**ASPEN/SCCUM recommend using which 2 nutrition assessment tools for critically ill patients?
1. NUTRIC (Nutrition Risk in Critically Ill)
| 2. NRS 2002 (Nutrition Risk Screening)
106
**(TRUE/FALSE)
According to ASPEN clinical guidelines, patients undergoing major cancer-related surgeries do benefit from routine use of EN.
FALSE
Perioperative nutrition support may be beneficial in moderately or severely malnourished patients if administered for 7 to 14 days preoperatively, but the potential benefits must be weighed against potential risks, including the risks associated with delaying surgery
107
**(TRUE/FALSE)
ASPEN recommends immune-modulating enteral formulas containing a mixture of arginine, nucleic acids, and essential FAs may be beneficial in malnourished cancer patients undergoing major operations.
TRUE
108
**ASPEN guidelines suggest which supplementation may help stabilize weight in cancer patients on oral diets experiencing progressive, unintentional weight loss?
OMEGA-3 supplementation
109
**The AACE and ADA define hyperglycemia in hospitalized individuals as BG concentrations greater than what?
140 mg/dL
110
What is the recommended A1C for non-pregnant individuals?
A1c less than 7%
111
**What does ASPEN/SCCM suggest (critically ill w/ nutrition support) for patients with a concern for EFAD?
**ASPEN/SCCM suggest withholding soybean oil-based ILE OR limiting it to 100 g/wk
