Chatgbt Flashcards
1
Q
What defines peripheral venous access?
A
Tip terminates outside of central vasculature
2
Q
What is the max osmolarity for peripheral parenteral nutrition (PPN)?
A
<900 mOsm/L
3
Q
What are disadvantages of PPN?
A
Short-term use, risk of phlebitis, limited calorie delivery
4
Q
What is a single-lumen catheter?
A
One channel for infusion
5
Q
What is a double-lumen catheter?
A
Two channels—can infuse different solutions simultaneously
6
Q
What is a triple-lumen catheter?
A
Three channels—used in critical care or multiple infusions
7
Q
Why are multiple lumens helpful?
A
Separate administration of incompatible medications/nutrition
8
Q
What is a nasogastric (NG) tube?
A
Inserted through the nose into the stomach—short-term use
9
Q
A
10
Q
What is a nasojejunal (NJ) tube?
A
Inserted through the nose into the jejunum—post-pyloric feeding
11
Q
A
12
Q
What is a gastrostomy (G-tube)?
A
Tube placed directly into the stomach—long-term EN
13
Q
A
14
Q
What is a jejunostomy (J-tube)?
A
Tube placed directly into the jejunum—used if stomach not functional
15
Q
A
16
Q
What is a PEG tube?
A
Percutaneous endoscopic gastrostomy—G-tube placed via endoscopy
17
Q
A
18
Q
What is a PEJ tube?
A
Percutaneous endoscopic jejunostomy—J-tube placed via endoscopy
19
Q
A
20
Q
What is the difference between balloon vs. non-balloon G-tube?
A
Balloon: easier at-home replacement; Non-balloon: more secure
21
Q
A
22
Q
What is a low-profile G-tube?
A
Flush with skin, used for active patients
23
Q
A
24
Q
How is enteral tube patency maintained?
A
Flush with water before/after feeding or medication
25
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What is a common cause of tube occlusion?
Medication residue, inadequate flushing
27
28
How can clogged tubes be cleared?
Warm water flushes, enzyme-based unclogging kits (no soda or juice)
29
30
What is a drug-nutrient interaction?
A reaction between a drug and a nutrient that affects absorption, metabolism, or excretion of either
31
32
What is the interaction between phenytoin and EN?
EN decreases phenytoin absorption
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How to manage phenytoin interaction with EN?
Hold tube feeds 1–2 hours before and after dosing
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36
How does warfarin interact with nutrition?
Vitamin K intake can reduce warfarin effectiveness
37
38
How to manage warfarin interaction?
Maintain consistent vitamin K intake
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40
What nutrient deficiencies can PPIs cause?
Vitamin B12, magnesium, calcium
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42
What are nutrition concerns with corticosteroids?
Hyperglycemia, increased protein breakdown, bone loss
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44
What are nutrient losses associated with loop diuretics?
Potassium, magnesium, calcium, thiamine
45
46
What is a key nutritional concern with thiazide diuretics?
Hypercalcemia and potassium loss
47
48
What nutrient interactions occur with cholestyramine?
Decreases absorption of fat-soluble vitamins (A, D, E, K)
49
50
What is a common nutrient concern with prolonged antibiotic use?
Vitamin K deficiency and altered gut microbiota
51
52
What decreases iron absorption?
Calcium (think cows milk/dairy and iron deficient kids), PPIs, antacids (better absorption with acid present), tannins (tea/coffee)
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54
What enhances iron absorption?
Vitamin C and acidic environment
55
56
What nutrient should be supplemented with methotrexate?
Folic acid
57
58
What nutrient competes with levodopa for absorption?
Protein—high protein meals can reduce drug effectiveness
59
60
What drug is lipid-based and contributes calories?
Propofol (1.1 kcal/mL)
61
62
What vitamins are light-sensitive and degrade in TPN?
Vitamins A, C, and B1 (thiamine)
63
64
What trace element should be monitored in patients on long-term PPI or H2RA therapy?
Magnesium
-reduced absorption
Calcium and B12 (not trace but same mechanism)
- decreased solubility in low acid
Iron
-impairs nonheme absorption
Zinc
Possible reduced absorption
65
66
What are the indications for enteral nutrition (EN)?
Functioning GI tract, unable to meet needs orally for >2–3 days
67
68
When should EN be initiated in critically ill patients?
Within 24–48 hours of ICU admission
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What are contraindications to EN?
Non-functioning GI tract, bowel obstruction, hemodynamic instability
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What are common routes for EN?
Nasogastric, nasojejunal, gastrostomy, jejunostomy
73
74
What is the difference between gastric and post-pyloric feeding?
Gastric: easier placement, higher aspiration risk; Post-pyloric: lower aspiration risk, for high reflux/vomiting
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What are polymeric formulas?
Standard EN formulas with intact protein, fat, and carbohydrates
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What are elemental/semi-elemental formulas?
Formulas with hydrolyzed proteins, for malabsorption or GI dysfunction
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What is a modular formula?
Customizable formula components (e.g., protein powder, glucose polymers)
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What is the recommended protein intake in EN for critically ill adults?
1.2–2.0 g/kg/day
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84
What is the typical goal for EN advancement?
Reach goal rate within 48–72 hours if tolerated
85
86
What are signs of EN intolerance?
High gastric residuals, abdominal distension, vomiting, diarrhea
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88
What is refeeding syndrome?
Fluid and electrolyte shifts (↓phos, K, Mg) when feeding is initiated after starvation
89
90
How can refeeding syndrome be prevented?
Start low and go slow, supplement electrolytes, monitor labs closely
91
92
How should medications be given via feeding tube?
Use liquid forms or crushable tablets, flush before/after administration
93
94
Which drugs interact with tube feeds?
Phenytoin, warfarin, fluoroquinolones—require holding feeds before/after
95
96
What is the difference between open vs. closed EN systems?
Open: decanted, increased contamination risk; Closed: prefilled, safer, longer hang time
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What is the typical hang time for open EN systems?
4–8 hours
99
100
What is the typical hang time for closed EN systems?
Up to 24–48 hours
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102
How much free water is in most standard EN formulas?
About 80%
103
104
What is the typical calorie density of standard EN formulas?
1.0–1.2 kcal/mL
105
106
What calorie density is considered energy-dense?
≥1.5 kcal/mL, used for fluid restriction
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108
What is the typical fluid requirement for adults?
30–35 mL/kg/day
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What is the Holliday-Segar method for pediatric fluid needs?
100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for weight >20 kg
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What are signs of fluid overload?
Edema, hypertension, pulmonary congestion
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What are signs of dehydration?
Hypotension, tachycardia, decreased urine output, elevated BUN/Cr
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116
Normal serum sodium range?
135–145 mEq/L
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118
What does hyponatremia indicate?
Fluid overload, SIADH, renal failure
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120
What does hypernatremia indicate?
Dehydration, diabetes insipidus
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122
Normal serum potassium range?
3.5–5.0 mEq/L
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124
Causes of hypokalemia?
Diuretics, GI losses, refeeding syndrome
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Causes of hyperkalemia?
Renal failure, acidosis, tissue breakdown
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Normal serum calcium range?
8.5–10.5 mg/dL
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What should you check in hypoalbuminemia?
Corrected calcium
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132
Corrected calcium formula?
Measured Ca + 0.8 × (4 - serum albumin)
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Causes of hypocalcemia?
Vitamin D deficiency, pancreatitis, low magnesium
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136
Causes of hypercalcemia?
Hyperparathyroidism, malignancy
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138
Normal serum phosphorus range?
2.5–4.5 mg/dL
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140
Causes of hypophosphatemia?
Refeeding syndrome, TPN without phosphorus, DKA
141
142
Causes of hyperphosphatemia?
Renal failure, tumor lysis syndrome
143
144
Normal serum magnesium range?
1.5–2.5 mg/dL
145
146
Causes of hypomagnesemia?
Diarrhea, alcoholism, diuretics
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148
Causes of hypermagnesemia?
Renal failure, excessive supplementation
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150
What is metabolic acidosis?
Low pH, low HCO3; causes: diarrhea, renal failure, ketoacidosis
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What is metabolic alkalosis?
High pH, high HCO3; causes: vomiting, diuretics
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What is respiratory acidosis?
Low pH, high CO2; causes: hypoventilation, COPD
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What is respiratory alkalosis?
High pH, low CO2; causes: hyperventilation, anxiety
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Where does most nutrient absorption occur?
Small intestine (primarily jejunum)
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What is the function of the ileum?
Absorbs bile salts, vitamin B12, and some water/electrolytes
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162
What is the role of the colon in digestion?
Absorbs water, electrolytes, short-chain fatty acids
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164
What is the function of the pancreas in digestion?
Secretes enzymes for digestion of protein, fat, and carbohydrates
165
166
Where is intrinsic factor produced and what is its role?
Stomach; binds to vitamin B12 for absorption in the ileum
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168
What is short bowel syndrome (SBS)?
Malabsorption from significant loss of small bowel surface area
169
170
What are nutrition concerns in SBS?
Fluid/electrolyte imbalance, fat malabsorption, nutrient deficiencies
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172
Which part of the bowel can adapt best after resection?
Jejunum
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174
Which part is most difficult to compensate for if resected?
Ileum
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176
What is the role of the colon in patients with SBS?
Colon helps absorb fluids, SCFAs—important if ileum resected
177
178
What is small intestinal bacterial overgrowth (SIBO)?
Excessive bacteria in small bowel causing bloating, diarrhea, malabsorption
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Risk factors for SIBO?
Stasis, strictures, blind loops, motility disorders
181
182
What is the role of bile salts?
Emulsify fats for digestion and absorption
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184
What happens when bile salts are malabsorbed?
Fat malabsorption, steatorrhea, loss of fat-soluble vitamins
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What is the concern with pancreatic insufficiency?
Inadequate digestion of fat/protein, leading to steatorrhea and malnutrition
187
188
How is pancreatic insufficiency managed?
Pancreatic enzyme replacement therapy (PERT) with meals/snacks
189
190
What is a chyle leak?
Loss of lymphatic fluid rich in fat/protein/electrolytes
191
192
How is a chyle leak managed nutritionally?
Low-fat or MCT-based diet; may require EN or PN
193
194
What is bile acid diarrhea?
Occurs after ileal resection; bile salts enter colon causing fluid secretion
195
196
Treatment for bile acid diarrhea?
Bile acid sequestrants (e.g., cholestyramine)
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What is an anastomosis?
Surgical connection between two parts of the bowel
199
200
What is a fistula?
Abnormal connection between bowel and another surface or organ
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202
What is high-output fistula defined as?
>500 mL/day output
203
204
Normal fasting glucose range?
70–99 mg/dL
205
206
What is hyperglycemia defined as?
>180 mg/dL
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208
What is hypoglycemia defined as?
<70 mg/dL
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210
Normal sodium range?
135–145 mEq/L
211
212
Normal potassium range?
3.5–5.0 mEq/L
213
214
Normal chloride range?
98–106 mEq/L
215
216
Normal CO2 (bicarb) range?
22–28 mEq/L
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218
Normal calcium range?
8.5–10.5 mg/dL
219
220
Normal magnesium range?
1.5–2.5 mg/dL
221
222
Normal phosphorus range?
2.5–4.5 mg/dL
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224
What does elevated AST/ALT suggest?
Hepatocellular injury
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What does elevated ALP and bilirubin suggest?
Cholestasis or bile duct obstruction
227
228
What does elevated direct bilirubin indicate?
Obstructive or hepatocellular jaundice
229
230
What is prealbumin used to assess?
Short-term changes in nutrition status
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232
Why is prealbumin not reliable in critically ill patients?
It is a negative acute-phase reactant
233
234
What is CRP used for?
Marker of inflammation
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What does a high CRP indicate?
Acute inflammation, infection, or trauma
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What does elevated BUN/creatinine indicate?
Dehydration or renal dysfunction
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What does a high BUN:Cr ratio suggest?
Pre-renal azotemia (often due to dehydration)
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What is a normal BUN:Cr ratio?
10:1 to 20:1
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What lab reflects iron storage?
Ferritin
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What lab reflects recent iron status?
Serum iron, transferrin saturation
247
248
What labs suggest iron deficiency anemia?
Low Hgb, low Hct, low ferritin, high TIBC
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250
What lab is used to assess vitamin D status?
25(OH)D
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252
What lab decreases in zinc deficiency?
Alkaline phosphatase and vitamin A
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254
What labs are monitored for refeeding syndrome?
Phosphorus, potassium, magnesium
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256
What does elevated ammonia indicate?
Liver failure, especially in hepatic encephalopathy
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258
What does an RQ >1.0 suggest?
Overfeeding, lipogenesis
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260
How many kcal/gram does dextrose provide in PN?
3.4 kcal/gram
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262
How many kcal/gram does protein provide in EN/PN?
4 kcal/gram
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264
How many kcal/gram does lipid provide in PN?
10 kcal/gram (from 20% lipid emulsion)
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266
How many kcal/gram does lipid provide in EN?
9 kcal/gram
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What is the typical non-protein calorie to nitrogen ratio (NPC:N) in PN?
100–150:1
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What is the purpose of the NPC:N ratio?
To ensure adequate calories to spare protein for tissue repair and growth
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How many grams of nitrogen are in 1 gram of protein?
1 gram of nitrogen = 6.25 grams of protein
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274
What macronutrient has the highest respiratory quotient (RQ)?
Carbohydrates (RQ ~1.0)
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276
What macronutrient has the lowest respiratory quotient (RQ)?
Fat (RQ ~0.7)
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What is the typical protein range in PN for a critically ill adult?
1.2–2.0 g/kg/day
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280
What is the minimum amount of carbohydrate needed to prevent ketosis?
100–150 g/day
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282
What is a concern with excessive carbohydrate intake in PN?
Hyperglycemia, increased CO2 production, hepatic steatosis
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284
What is a concern with excessive fat intake in PN?
Hypertriglyceridemia, impaired immune function
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What are the components of TPN macronutrients?
Dextrose, amino acids, lipids
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What are the phases of metabolic response to stress?
Ebb phase and Flow phase
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What occurs during the ebb phase?
Hypovolemia, decreased metabolic rate, reduced tissue perfusion
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What occurs during the flow phase?
Hypermetabolism, increased energy expenditure, catabolism, increased glucose production
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What hormones increase during stress?
Cortisol, catecholamines (epinephrine/norepinephrine), glucagon
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What are the consequences of prolonged stress response?
Muscle wasting, insulin resistance, negative nitrogen balance
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What is gluconeogenesis?
Formation of glucose from non-carbohydrate sources like amino acids
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What is lipolysis?
Breakdown of fat stores to free fatty acids and glycerol
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What is proteolysis?
Breakdown of muscle protein into amino acids
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What is the preferred fuel source in stress and sepsis?
Glucose
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What is insulin resistance?
Decreased cellular response to insulin, common in critical illness
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308
What metabolic changes occur during sepsis?
Increased glucose and lactate, altered protein metabolism
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How does starvation differ from stress metabolism?
Starvation leads to fat adaptation and protein sparing; stress causes protein catabolism
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312
What is the respiratory quotient (RQ) for carbohydrate metabolism?
1
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314
What is the RQ for fat metabolism?
0.7
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What RQ suggests overfeeding?
>1.0
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318
What is nitrogen balance and what does a negative balance indicate?
Difference between nitrogen intake and loss; negative balance indicates catabolism
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How do you calculate nitrogen balance?
Nitrogen in (g protein/6.25) – (UUN + 4)
Nitrogen Balance = Nitrogen Intake – Nitrogen Output
Where:
• Nitrogen intake (g) = Protein intake (g) ÷ 6.25
• Because protein is ~16% nitrogen (100 ÷ 16 = 6.25)
• Nitrogen output (g) = UUN (g/day) + 4 g
• UUN = Urinary Urea Nitrogen
• The extra 4 g accounts for insensible losses (feces, skin, etc.)
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What condition increases nitrogen losses?
Burns, trauma, sepsis, wounds
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324
What is the goal of nutrition in the critically ill?
Prevent further loss of lean body mass, support immune function, promote healing
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326
What is the function of iron?
Oxygen transport via hemoglobin and myoglobin
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328
What are symptoms of iron deficiency?
Microcytic anemia, fatigue, pallor
329
330
What are causes of iron toxicity?
Hemochromatosis, iron overload from transfusions or excess intake of iron via diet or supplements
331
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Which populations are at risk for iron deficiency?
Think at risk populations with poor blood - Infants with poor stores, menstruating women- losing blood, GI bleed patients-losing blood, children with poor diet/picky eating-excess cows milk
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334
Which nutrients/meds interfere with iron absorption?
Calcium, tannins, PPIs
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336
What is the function of zinc?
Wound healing, immune function, taste perception
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338
What are symptoms of zinc deficiency?
Poor wound healing, alopecia, dermatitis, taste changes
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340
Who is at risk for zinc deficiency?
Burn patients, diarrhea, TPN without zinc
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What inhibits zinc absorption?
High phytate intake, high calcium/non heme iron, oxalates, alcohol
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344
What is the function of copper?
Iron metabolism, antioxidant activity
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Symptoms of copper deficiency?
Microcytic anemia, neutropenia, myelopathy
Hematologic
• Microcytic anemia (often not responsive to iron)
• Neutropenia (low neutrophil count)
• Thrombocytopenia (less common)
Why? Copper is essential for iron metabolism and hematopoiesis.
⸻
2. Neurologic
• Peripheral neuropathy (numbness, tingling, weakness)
• Myelopathy (gait disturbances, spasticity, ataxia)
• Resembles B12 deficiency neurologically
Why? Copper is involved in myelin synthesis and nervous system function.
⸻
3. Skeletal/Connective Tissue
• Bone abnormalities (osteoporosis, fractures)
• Poor wound healing
Why? Copper is important for collagen cross-linking and bone matrix integrity.
347
At risk populations for copper deficiency
High-Risk Groups:
• Long-term TPN without copper
• Excessive zinc supplementation (zinc induces metallothionein, which binds and traps copper in enterocytes)
• Post-bariatric surgery
• Malabsorptive disorders (e.g. celiac, Crohn’s)
348
Who is at risk for copper deficiency?
Gastric bypass, high zinc intake, long-term PN without copper, GI losses and tx for Wilson disease like Penicillamine or other chelators used for Wilson disease
349
350
Function of selenium?
Antioxidant (glutathione peroxidase), thyroid function
Selenium is a key component of glutathione peroxidase (GPx) enzymes.
• These enzymes protect cells from oxidative damage
Cardiovascular Protection
Thyroid Hormone Metabolism
• Selenium-dependent enzymes (iodothyronine deiodinases) convert T4 (thyroxine) into T3 (triiodothyronine), the active form.
351
Copper toxicity
Excreted via bile and feces
Causes:
• Genetic: Wilson disease (autosomal recessive disorder → impaired copper excretion → accumulation in liver, brain, cornea)
• Iatrogenic: Excess copper in long-term TPN
• Environmental: Contaminated water, copper cookware (rare)
Clinical Relevance:
• In Wilson disease, copper accumulates because of impaired biliary excretion.
• Liver dysfunction may impair copper clearance, which is why copper content in TPN may need to be reduced in cholestasis or hepatic failure.
352
Symptoms of selenium deficiency?
Cardiomyopathy (Keshan disease p/w sx of CHF) muscle weakness, immune dysfunction
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Who is at risk for selenium deficiency?
TPN without selenium, GI surgery, malabsorption, short bowel, critically ill/septic patients, low selenium soil populations (underdeveloped)
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Function of manganese?
Cofactor for enzymes, bone formation
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358
Toxicity risk for manganese?
Cholestatic liver disease—can cause neurotoxicity
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360
Function of chromium?
Enhances insulin action
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Symptoms of chromium deficiency?
Glucose intolerance, neuropathy
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364
Who is at risk for chromium deficiency?
Long-term PN without chromium
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Function of iodine?
Thyroid hormone synthesis
Think iodized salt for thyroid health
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Symptoms of iodine deficiency?
Goiter, hypothyroidism
Goiter = enlargement of thyroid gland
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Toxicity of iodine?
Thyroid dysfunction
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Function of fluoride?
Dental and bone health
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Toxicity of fluoride?
Dental fluorosis, GI upset
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Function of molybdenum?
Cofactor in amino acid metabolism
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Deficiency symptoms?
Rare—tachycardia, headache, neurologic issues
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What are the six ASPEN malnutrition assessment characteristics?
Energy intake, weight loss, body fat loss, muscle loss, fluid accumulation, functional status
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How many criteria are needed to diagnose malnutrition per ASPEN?
At least 2 of the 6
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What defines severe malnutrition (chronic)?
>5% weight loss in 1 month or >10% in 6 months with minimal intake for >1 month
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What is functional status typically assessed with?
Handgrip strength
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What does SGA stand for?
Subjective Global Assessment
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What are the components of SGA?
Weight change, dietary intake, GI symptoms, functional capacity, physical exam (fat/muscle loss, edema)
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What are the SGA classifications?
A: well nourished, B: moderately malnourished, C: severely malnourished
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What is the NUTRIC score used for?
Assessing nutrition risk in critically ill patients
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What factors are included in NUTRIC?
Age, APACHE II (measures illness and mortality) SOFA score (measures organ dysfunction), number of comorbidities, days from hospital to ICU
NUTRIC score >/=5 is associated with adverse outcomes
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What does a high NUTRIC score indicate?
Greater risk of adverse outcomes, more likely to benefit from nutrition intervention
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What is MUST?
Malnutrition Universal Screening Tool—used in community and outpatient settings
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What is the MST?
Malnutrition Screening Tool—quick, uses weight loss and appetite
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What is the MNA?
Mini Nutritional Assessment—used for elderly patients
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What does %IBW =?
(Current weight / Ideal body weight) × 100
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What does %UBW =?
(Current weight / Usual body weight) × 100
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What does weight loss % =?
((Usual weight – current weight) / usual weight) × 100
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What is considered significant weight loss?
>5% in 1 month or >10% in 6 months
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What is BMI =?
Weight (kg) / height (m)^2
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What BMI is considered underweight?
<18.5 kg/m²
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What BMI range is normal?
18.5–24.9 kg/m²
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What are indications for parenteral nutrition (PN)?
Non-functioning GI tract, failed EN trial, bowel obstruction, severe malabsorption
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When should PN be initiated in critically ill adults?
If EN is not feasible after 7 days (or earlier in malnourished patients)
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What is the difference between central and peripheral PN?
Central PN allows higher osmolarity solutions; peripheral PN is limited to <900 mOsm/L
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426
What are typical macronutrient components of PN?
Dextrose, amino acids, IV lipids
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What is the max recommended glucose infusion rate (GIR)?
<4–5 mg/kg/min in adults
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430
What is a typical lipid dosing range for PN?
0.5–1.5 g/kg/day
431
432
What is the caloric value of 20% lipid emulsion?
2 kcal/mL (10 kcal/g)
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434
What is a concern with excessive lipid administration?
Hypertriglyceridemia, impaired immune function
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436
What are signs of essential fatty acid deficiency?
Dry, scaly skin; alopecia; impaired wound healing
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438
How often should lipids be given to prevent EFAD?
At least 100 g/week (2–3 times/week)
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What is SMOF lipid?
Soybean oil, MCT, olive oil, fish oil mix—less pro-inflammatory
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What is cyclic PN?
PN administered over <24 hours (typically 12–18 hrs/day)
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What are benefits of cyclic PN?
Improved liver function, mimics normal metabolism, mobility
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What are risks of starting PN too quickly?
Refeeding syndrome, hyperglycemia, electrolyte shifts
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448
What labs should be monitored closely during PN?
Glucose, electrolytes, triglycerides, liver function tests
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What are signs of PN-associated liver disease?
Elevated LFTs, cholestasis, steatosis, fibrosis
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452
What strategies help prevent PN-associated liver disease?
Cycle PN, avoid overfeeding, use trophic EN, lipid minimization
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What is the role of acetate in PN?
Converted to bicarbonate—used to manage metabolic acidosis
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What is the role of chloride in PN?
Used to manage metabolic alkalosis
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What are common PN complications?
Infection (catheter-related), liver dysfunction, metabolic disturbances
459
460
What is the recommended protein intake in PN for critically ill adults?
1.2–2.0 g/kg/day
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462
What is the max osmolarity for peripheral PN?
<900 mOsm/L
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464
How is PN osmolarity calculated?
Based on dextrose, amino acids, electrolytes—lipids don't contribute
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466
What organization develops nutrition support guidelines?
ASPEN (American Society for Parenteral and Enteral Nutrition)
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What are ASPEN's recommendations for initiating EN in the ICU?
Within 24–48 hours of admission if hemodynamically stable
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What is the ASPEN recommendation for protein in critically ill adults?
1.2–2.0 g/kg/day
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What is ASPEN's stance on glutamine in critical illness?
Not recommended for routine use in critically ill patients
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What is the FDA limit for aluminum in PN solutions?
<25 mcg/L
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476
What must manufacturers label on PN additives per FDA?
Maximum aluminum content at expiry
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What labeling standards apply to EN products?
Must list nutrient content per serving and per mL
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What is a DRG?
Diagnosis-Related Group—used for hospital reimbursement
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What is the role of ICD-10 codes?
Diagnosis classification used for billing and documentation
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What does CPT stand for?
Current Procedural Terminology—used for procedure coding
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What documentation supports nutrition reimbursement?
Nutrition diagnosis, care plan, progress notes, justification for EN/PN
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488
What is a root cause analysis (RCA)?
Structured method for identifying underlying causes of an event
489
490
What is a PDSA cycle?
Plan-Do-Study-Act—used in QI to test and implement changes
491
492
What do JCAHO and CMS require for nutrition?
Nutrition screening within 24 hours of hospital admission
493
What is the purpose of a nutrition care process (NCP)?
Standardized approach to nutrition assessment and care
494
495
What is the USP <797> guideline?
Standards for sterile compounding of parenteral nutrition
496
497
What is the Hang Time recommendation for open EN systems?
4–8 hours
498
499
What is the Hang Time recommendation for closed EN systems?
Up to 24–48 hours
500
501
What are key nutrition concerns in neonates?
Immature GI function, high energy/protein needs, fluid/electrolyte sensitivity
502
503
What trace elements are typically excluded in neonatal PN?
Manganese, chromium (risk of toxicity)
504
505
What is the typical GIR range for neonates?
4–12 mg/kg/min
506
507
How is fluid calculated for neonates?
Based on weight and age in mL/kg/day
508
509
What are key nutrition goals in AKI?
Avoid overfeeding, manage electrolytes, adequate protein (1.5–2.0 g/kg if on CRRT)
510
511
What electrolytes need close monitoring in CKD/AKI?
Potassium, phosphorus, magnesium
512
513
What type of formula may be needed in renal disease?
Low electrolyte, fluid-restricted, higher calorie density
514
515
What are nutrition concerns in liver disease?
Malnutrition, fat malabsorption, ascites, electrolyte imbalances
516
517
What is the preferred type of protein in hepatic encephalopathy?
Vegetable or BCAA-rich protein
518
519
What formula adjustments may be needed in liver failure?
Energy-dense, low sodium, moderate protein
520
521
What lab indicates impaired ammonia metabolism?
Elevated serum ammonia
522
523
What is cancer cachexia?
Metabolic syndrome with weight loss, muscle wasting, inflammation
524
525
What are nutrition goals in oncology?
Maintain weight, support immune function, prevent muscle loss
526
527
When is EN preferred in oncology?
When the GI tract is functional and oral intake is inadequate
528
529
What is the nutrition focus in Crohn's disease?
Manage flares with low-residue diet, maintain nutrient adequacy
530
531
What deficiencies are common in IBD?
Iron, B12, vitamin D, calcium
532
533
What EN formula is often used in pancreatitis?
Elemental or semi-elemental, low-fat, jejunal feeding
534
535
What are nutrition considerations in obesity during critical illness?
Use adjusted body weight for energy/protein needs
536
537
What protein range is used in critically ill obese patients?
2.0–2.5 g/kg IBW/day
538
539
What are increased needs in burn patients?
High protein (up to 2.5–3 g/kg), high calorie, fluid/electrolyte repletion
540
541
What vitamins and minerals are important in burn recovery?
Vitamin C, zinc, selenium, vitamin A
542
543
What are the phases of metabolic response to stress?
Ebb phase and Flow phase
544
545
What occurs during the ebb phase?
Hypovolemia, decreased metabolic rate, reduced tissue perfusion
546
547
What occurs during the flow phase?
Hypermetabolism, increased energy expenditure, catabolism, increased glucose production
548
549
What hormones increase during stress?
Cortisol, catecholamines (epinephrine/norepinephrine), glucagon
550
551
What are the consequences of prolonged stress response?
Muscle wasting, insulin resistance, negative nitrogen balance
552
553
What is gluconeogenesis?
Formation of glucose from non-carbohydrate sources like amino acids
554
555
What is lipolysis?
Breakdown of fat stores to free fatty acids and glycerol
556
557
What is proteolysis?
Breakdown of muscle protein into amino acids
558
559
What is the preferred fuel source in stress and sepsis?
Glucose
560
561
What is insulin resistance?
Decreased cellular response to insulin, common in critical illness
562
563
What metabolic changes occur during sepsis?
Increased glucose and lactate, altered protein metabolism
564
565
How does starvation differ from stress metabolism?
Starvation leads to fat adaptation and protein sparing; stress causes protein catabolism
566
567
What is the respiratory quotient (RQ) for carbohydrate metabolism?
1
568
569
What is the RQ for fat metabolism?
0.7
570
571
What RQ suggests overfeeding?
>1.0
572
573
What is nitrogen balance and what does a negative balance indicate?
Difference between nitrogen intake and loss; negative balance indicates catabolism
574
575
How do you calculate nitrogen balance?
Nitrogen in (g protein/6.25) – (UUN + 4)
576
577
What condition increases nitrogen losses?
Burns, trauma, sepsis, wounds
578
579
What is the goal of nutrition in the critically ill?
Prevent further loss of lean body mass, support immune function, promote healing
580
581
What is the function of iron?
Oxygen transport via hemoglobin and myoglobin
582
583
What are symptoms of iron deficiency?
Microcytic anemia, fatigue, pallor
584
585
What are causes of iron toxicity?
Hemochromatosis, iron overload from transfusions
586
587
Which populations are at risk for iron deficiency?
Infants, menstruating women, GI bleed patients
588
589
Which nutrients/meds interfere with iron absorption?
Calcium, tannins, PPIs
590
591
What is the function of zinc?
Wound healing, immune function, taste perception
592
593
What are symptoms of zinc deficiency?
Poor wound healing, alopecia, dermatitis, taste changes
594
595
Who is at risk for zinc deficiency?
Burn patients, diarrhea, TPN without zinc
596
597
What inhibits zinc absorption?
High phytate intake, high calcium/iron
598
599
What is the function of copper?
Iron metabolism, antioxidant activity
600
601
Symptoms of copper deficiency?
Microcytic anemia, neutropenia, myelopathy
602
603
Who is at risk for copper deficiency?
Gastric bypass, high zinc intake, long-term PN
604
605
Function of selenium?
Antioxidant (glutathione peroxidase), thyroid function
606
607
Symptoms of selenium deficiency?
Cardiomyopathy, muscle weakness, immune dysfunction
608
609
Who is at risk for selenium deficiency?
TPN without selenium, GI surgery
610
611
Function of manganese?
Cofactor for enzymes, bone formation
612
613
Toxicity risk for manganese?
Cholestatic liver disease—can cause neurotoxicity
614
615
Function of chromium?
Enhances insulin action
616
617
Symptoms of chromium deficiency?
Glucose intolerance, neuropathy
618
619
Who is at risk for chromium deficiency?
Long-term PN without chromium
620
621
Function of iodine?
Thyroid hormone synthesis
622
623
Symptoms of iodine deficiency?
Goiter, hypothyroidism
624
625
Toxicity of iodine?
Thyroid dysfunction
626
627
Function of fluoride?
Dental and bone health
628
629
Toxicity of fluoride?
Dental fluorosis, GI upset
630
631
Function of molybdenum?
Cofactor in amino acid metabolism
632
633
Deficiency symptoms?
Rare—tachycardia, headache, neurologic issues
634
635
What are the six ASPEN malnutrition assessment characteristics?
Energy intake, weight loss, body fat loss, muscle loss, fluid accumulation, functional status
636
637
How many criteria are needed to diagnose malnutrition per ASPEN?
At least 2 of the 6
638
639
What defines severe malnutrition (chronic)?
>5% weight loss in 1 month or >10% in 6 months with minimal intake for >1 month
640
641
What is functional status typically assessed with?
Handgrip strength
642
643
What does SGA stand for?
Subjective Global Assessment
644
645
What are the components of SGA?
Weight change, dietary intake, GI symptoms, functional capacity, physical exam (fat/muscle loss, edema)
646
647
What are the SGA classifications?
A: well nourished, B: moderately malnourished, C: severely malnourished
648
649
What is the NUTRIC score used for?
Assessing nutrition risk in critically ill patients
650
651
What factors are included in NUTRIC?
Age, APACHE II, SOFA score, number of comorbidities, days from hospital to ICU
652
653
What does a high NUTRIC score indicate?
Greater risk of adverse outcomes, more likely to benefit from nutrition intervention
654
655
What is MUST?
Malnutrition Universal Screening Tool—used in community and outpatient settings
656
657
What is the MST?
Malnutrition Screening Tool—quick, uses weight loss and appetite
658
659
What is the MNA?
Mini Nutritional Assessment—used for elderly patients
660
661
What does %IBW =?
(Current weight / Ideal body weight) × 100
662
663
What does %UBW =?
(Current weight / Usual body weight) × 100
664
665
What does weight loss % =?
((Usual weight – current weight) / usual weight) × 100
666
667
What is considered significant weight loss?
>5% in 1 month or >10% in 6 months
668
669
What is BMI =?
Weight (kg) / height (m)^2
670
671
What BMI is considered underweight?
<18.5 kg/m²
672
673
What BMI range is normal?
18.5–24.9 kg/m²
674
675
What are indications for parenteral nutrition (PN)?
Non-functioning GI tract, failed EN trial, bowel obstruction, severe malabsorption
676
677
When should PN be initiated in critically ill adults?
If EN is not feasible after 7 days (or earlier in malnourished patients)
678
679
What is the difference between central and peripheral PN?
Central PN allows higher osmolarity solutions; peripheral PN is limited to <900 mOsm/L
680
681
What are typical macronutrient components of PN?
Dextrose, amino acids, IV lipids
682
683
What is the max recommended glucose infusion rate (GIR)?
<4–5 mg/kg/min in adults
684
685
What is a typical lipid dosing range for PN?
0.5–1.5 g/kg/day
686
687
What is the caloric value of 20% lipid emulsion?
2 kcal/mL (10 kcal/g)
688
689
What is a concern with excessive lipid administration?
Hypertriglyceridemia, impaired immune function
690
691
What are signs of essential fatty acid deficiency?
Dry, scaly skin; alopecia; impaired wound healing
692
693
How often should lipids be given to prevent EFAD?
At least 100 g/week (2–3 times/week)
694
695
What is SMOF lipid?
Soybean oil, MCT, olive oil, fish oil mix—less pro-inflammatory
696
697
What is cyclic PN?
PN administered over <24 hours (typically 12–18 hrs/day)
698
699
What are benefits of cyclic PN?
Improved liver function, mimics normal metabolism, mobility
700
701
What are risks of starting PN too quickly?
Refeeding syndrome, hyperglycemia, electrolyte shifts
702
703
What labs should be monitored closely during PN?
Glucose, electrolytes, triglycerides, liver function tests
704
705
What are signs of PN-associated liver disease?
Elevated LFTs, cholestasis, steatosis, fibrosis
706
707
What strategies help prevent PN-associated liver disease?
Cycle PN, avoid overfeeding, use trophic EN, lipid minimization
708
709
What is the role of acetate in PN?
Converted to bicarbonate—used to manage metabolic acidosis
710
711
What is the role of chloride in PN?
Used to manage metabolic alkalosis
712
713
What are common PN complications?
Infection (catheter-related), liver dysfunction, metabolic disturbances
714
715
What is the recommended protein intake in PN for critically ill adults?
1.2–2.0 g/kg/day
716
717
What is the max osmolarity for peripheral PN?
<900 mOsm/L
718
719
How is PN osmolarity calculated?
Based on dextrose, amino acids, electrolytes—lipids don't contribute
720
721
What organization develops nutrition support guidelines?
ASPEN (American Society for Parenteral and Enteral Nutrition)
722
723
What are ASPEN's recommendations for initiating EN in the ICU?
Within 24–48 hours of admission if hemodynamically stable
724
725
What is the ASPEN recommendation for protein in critically ill adults?
1.2–2.0 g/kg/day
726
727
What is ASPEN's stance on glutamine in critical illness?
Not recommended for routine use in critically ill patients
728
729
What is the FDA limit for aluminum in PN solutions?
<25 mcg/L
730
731
What must manufacturers label on PN additives per FDA?
Maximum aluminum content at expiry
732
733
What labeling standards apply to EN products?
Must list nutrient content per serving and per mL
734
735
What is a DRG?
Diagnosis-Related Group—used for hospital reimbursement
736
737
What is the role of ICD-10 codes?
Diagnosis classification used for billing and documentation
738
739
What does CPT stand for?
Current Procedural Terminology—used for procedure coding
740
741
What documentation supports nutrition reimbursement?
Nutrition diagnosis, care plan, progress notes, justification for EN/PN
742
743
What is a root cause analysis (RCA)?
Structured method for identifying underlying causes of an event
744
745
What is a PDSA cycle?
Plan-Do-Study-Act—used in QI to test and implement changes
746
747
What do JCAHO and CMS require for nutrition?
Nutrition screening within 24 hours of hospital admission
748
749
What is the purpose of a nutrition care process (NCP)?
Standardized approach to nutrition assessment and care
750
751
What is the USP <797> guideline?
Standards for sterile compounding of parenteral nutrition
752
753
What is the Hang Time recommendation for open EN systems?
4–8 hours
754
755
What is the Hang Time recommendation for closed EN systems?
Up to 24–48 hours
756
757
What are key nutrition concerns in neonates?
Immature GI function, high energy/protein needs, fluid/electrolyte sensitivity
758
759
What trace elements are typically excluded in neonatal PN?
Manganese, chromium (risk of toxicity)
760
761
What is the typical GIR range for neonates?
4–12 mg/kg/min
762
763
How is fluid calculated for neonates?
Based on weight and age in mL/kg/day
764
765
What are key nutrition goals in AKI?
Avoid overfeeding, manage electrolytes, adequate protein (1.5–2.0 g/kg if on CRRT)
766
767
What electrolytes need close monitoring in CKD/AKI?
Potassium, phosphorus, magnesium
768
769
What type of formula may be needed in renal disease?
Low electrolyte, fluid-restricted, higher calorie density
770
771
What are nutrition concerns in liver disease?
Malnutrition, fat malabsorption, ascites, electrolyte imbalances
772
773
What is the preferred type of protein in hepatic encephalopathy?
Vegetable or BCAA-rich protein
774
775
What formula adjustments may be needed in liver failure?
Energy-dense, low sodium, moderate protein
776
777
What lab indicates impaired ammonia metabolism?
Elevated serum ammonia
778
779
What is cancer cachexia?
Metabolic syndrome with weight loss, muscle wasting, inflammation
780
781
What are nutrition goals in oncology?
Maintain weight, support immune function, prevent muscle loss
782
783
When is EN preferred in oncology?
When the GI tract is functional and oral intake is inadequate
784
785
What is the nutrition focus in Crohn's disease?
Manage flares with low-residue diet, maintain nutrient adequacy
786
787
What deficiencies are common in IBD?
Iron, B12, vitamin D, calcium
788
789
What EN formula is often used in pancreatitis?
Elemental or semi-elemental, low-fat, jejunal feeding
790
791
What are nutrition considerations in obesity during critical illness?
Use adjusted body weight for energy/protein needs
792
793
What protein range is used in critically ill obese patients?
2.0–2.5 g/kg IBW/day
794
795
What are increased needs in burn patients?
High protein (up to 2.5–3 g/kg), high calorie, fluid/electrolyte repletion
796
797
What vitamins and minerals are important in burn recovery?
Vitamin C, zinc, selenium, vitamin A
798
How many kcal/gram does dextrose provide in PN?
3.4 kcal/g
799
800
How many kcal/gram does protein provide?
4 kcal/g
801
802
How many kcal/gram does fat provide in EN?
9 kcal/g
803
804
How many kcal/mL does 20% IV lipid provide?
2 kcal/mL
805
806
How many kcal/mL does propofol provide?
1.1 kcal/mL
807
808
How many grams of nitrogen are in 1 gram of protein?
1 gram of nitrogen = 6.25 grams of protein
809
810
How is nitrogen balance calculated?
Nitrogen in (g protein/6.25) – (UUN + 4)
811
812
What is the goal NPC:N ratio for moderate stress?
100–150:1
813
814
What is the general adult fluid requirement?
30–35 mL/kg/day
815
816
What is the Holliday-Segar method for pediatric fluids?
100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for each kg >20
817
818
How is glucose infusion rate (GIR) calculated?
(mg dextrose/day ÷ weight in kg ÷ 1440)
819
820
What is the max GIR for adults?
<4–5 mg/kg/min
821
822
What is the max GIR for neonates?
≤12 mg/kg/min
823
824
How is PN osmolarity calculated?
Dextrose × 5 + AA × 10 + electrolytes
825
826
What is the max osmolarity for peripheral PN?
<900 mOsm/L
827
828
What is the formula for BMI?
Weight (kg) / height (m)^2
829
830
What is the formula for IBW (female)?
45.5 kg + 2.3 kg per inch over 5 feet
831
832
What is the formula for IBW (male)?
50 kg + 2.3 kg per inch over 5 feet
833
834
How is adjusted body weight (AdjBW) calculated?
IBW + 0.25 × (ABW - IBW)
835
836
What are common energy equations?
Mifflin-St. Jeor, Harris-Benedict, Ireton-Jones, Penn State
837
838
What is the kcal/protein range for critically ill patients?
25–30 kcal/kg and 1.2–2.0 g/kg protein
839
840
When should adjusted body weight be used?
For obese patients (>120% IBW) to estimate energy/protein needs
841
842
What is refeeding syndrome?
Electrolyte shifts (↓phosphorus, potassium, magnesium) after initiating nutrition in malnourished patients
843
844
Who is at risk for refeeding syndrome?
Severely malnourished, NPO >7 days, chronic alcoholism, significant weight loss
845
846
How is refeeding syndrome prevented?
Start low and advance slowly, supplement electrolytes, monitor labs closely
847
848
What are consequences of overfeeding?
Hyperglycemia, increased CO2 production, hepatic steatosis, fluid overload
849
850
What RQ indicates overfeeding?
>1.0
851
852
What are consequences of underfeeding?
Impaired wound healing, muscle wasting, immune dysfunction
853
854
What causes hyperglycemia in nutrition support?
Excess dextrose, stress response, insulin resistance
855
856
How is hyperglycemia managed?
Adjust dextrose load, use insulin, monitor glucose
857
858
When can hypoglycemia occur in nutrition support?
Abrupt discontinuation of PN, insulin overdose
859
860
What is PN-associated liver disease (PNALD)?
Liver dysfunction due to long-term PN use
861
862
What are signs of PNALD?
Elevated LFTs, cholestasis, steatosis
863
864
How is PNALD prevented/managed?
Avoid overfeeding, cycle PN, use enteral feeding if possible
865
866
What are signs of EN intolerance?
High gastric residuals, abdominal distention, vomiting, diarrhea
867
868
How is diarrhea from EN managed?
Adjust formula, reduce rate, add fiber or antidiarrheals
869
870
How is constipation from EN managed?
Increase fluid/fiber, stool softeners
871
872
Who is at high risk for aspiration?
Sedated, neurologically impaired, post-stroke, gastric feedings
873
874
How is aspiration risk reduced?
Elevate HOB ≥30°, post-pyloric feeding, continuous infusion
875
876
What are common enteral tube complications?
Occlusion, dislodgment, infection at site
877
878
How are occluded feeding tubes cleared?
Warm water flushes, enzymatic declogging agents
879
880
What is a CLABSI?
Central line-associated bloodstream infection
881
882
How are line infections prevented?
Aseptic technique, catheter care, ethanol locks if indicated
883
884
What causes metabolic bone disease in PN patients?
Aluminum exposure, vitamin D deficiency, low calcium/phosphorus
885
886
What are symptoms of EFAD?
Dry, scaly skin, alopecia, impaired wound healing
887
888
How is EFAD prevented?
Provide at least 100 g IV lipid per week
889
890
What defines a central venous catheter (CVC)?
Tip terminates in the superior vena cava (SVC) or right atrium
891
892
What are examples of central venous access devices?
PICC, tunneled catheter (e.g., Hickman), implanted port, non-tunneled CVC
893
894
What are advantages of central access?
Can deliver hyperosmolar solutions, long-term use
895
896
What are common insertion sites for central lines?
Subclavian, jugular, femoral
897
898
What are risks of central lines?
Infection, thrombosis, pneumothorax, catheter occlusion
899
900
What defines peripheral venous access?
Tip terminates outside of central vasculature
901
902
What is the max osmolarity for peripheral parenteral nutrition (PPN)?
<900 mOsm/L
903
904
What are disadvantages of PPN?
Short-term use, risk of phlebitis, limited calorie delivery
905
906
What is a single-lumen catheter?
One channel for infusion
907
908
What is a double-lumen catheter?
Two channels—can infuse different solutions simultaneously
909
910
What is a triple-lumen catheter?
Three channels—used in critical care or multiple infusions
911
912
Why are multiple lumens helpful?
Separate administration of incompatible medications/nutrition
913
914
What is a nasogastric (NG) tube?
Inserted through the nose into the stomach—short-term use
915
916
What is a nasojejunal (NJ) tube?
Inserted through the nose into the jejunum—post-pyloric feeding
917
918
What is a gastrostomy (G-tube)?
Tube placed directly into the stomach—long-term EN
919
920
What is a jejunostomy (J-tube)?
Tube placed directly into the jejunum—used if stomach not functional
921
922
What is a PEG tube?
Percutaneous endoscopic gastrostomy—G-tube placed via endoscopy
923
924
What is a PEJ tube?
Percutaneous endoscopic jejunostomy—J-tube placed via endoscopy
925
926
What is the difference between balloon vs. non-balloon G-tube?
Balloon: easier at-home replacement; Non-balloon: more secure
927
928
What is a low-profile G-tube?
Flush with skin, used for active patients
929
930
How is enteral tube patency maintained?
Flush with water before/after feeding or medication
931
932
What is a common cause of tube occlusion?
Medication residue, inadequate flushing
933
934
How can clogged tubes be cleared?
Warm water flushes, enzyme-based unclogging kits (no soda or juice)
935
936
What is a drug-nutrient interaction?
A reaction between a drug and a nutrient that affects absorption, metabolism, or excretion of either
937
938
What is the interaction between phenytoin and EN?
EN decreases phenytoin absorption
939
940
How to manage phenytoin interaction with EN?
Hold tube feeds 1–2 hours before and after dosing
941
942
How does warfarin interact with nutrition?
Vitamin K intake can reduce warfarin effectiveness
943
944
How to manage warfarin interaction?
Maintain consistent vitamin K intake
945
946
What nutrient deficiencies can PPIs cause?
Vitamin B12, magnesium, calcium
947
948
What are nutrition concerns with corticosteroids?
Hyperglycemia, increased protein breakdown, bone loss
949
950
What are nutrient losses associated with loop diuretics?
Potassium, magnesium, calcium, thiamine
951
952
What is a key nutritional concern with thiazide diuretics?
Hypercalcemia and potassium loss
953
954
What nutrient interactions occur with cholestyramine?
Decreases absorption of fat-soluble vitamins (A, D, E, K)
955
956
What is a common nutrient concern with prolonged antibiotic use?
Vitamin K deficiency and altered gut microbiota
957
958
What decreases iron absorption?
Calcium, PPIs, antacids, tannins (tea/coffee)
959
960
What enhances iron absorption?
Vitamin C and acidic environment
961
962
What nutrient should be supplemented with methotrexate?
Folic acid
963
964
What nutrient competes with levodopa for absorption?
Protein—high protein meals can reduce drug effectiveness
965
966
What drug is lipid-based and contributes calories?
Propofol (1.1 kcal/mL)
967
968
What vitamins are light-sensitive and degrade in TPN?
Vitamins A, C, and B1 (thiamine)
969
970
What trace element should be monitored in patients on long-term PPI or H2RA therapy?
Magnesium
971
972
What are the indications for enteral nutrition (EN)?
Functioning GI tract, unable to meet needs orally for >2–3 days
973
974
When should EN be initiated in critically ill patients?
Within 24–48 hours of ICU admission
975
976
What are contraindications to EN?
Non-functioning GI tract, bowel obstruction, hemodynamic instability
977
978
What are common routes for EN?
Nasogastric, nasojejunal, gastrostomy, jejunostomy
979
980
What is the difference between gastric and post-pyloric feeding?
Gastric: easier placement, higher aspiration risk; Post-pyloric: lower aspiration risk, for high reflux/vomiting
981
982
What are polymeric formulas?
Standard EN formulas with intact protein, fat, and carbohydrates
983
984
What are elemental/semi-elemental formulas?
Formulas with hydrolyzed proteins, for malabsorption or GI dysfunction
985
986
What is a modular formula?
Customizable formula components (e.g., protein powder, glucose polymers)
987
988
What is the recommended protein intake in EN for critically ill adults?
1.2–2.0 g/kg/day
989
990
What is the typical goal for EN advancement?
Reach goal rate within 48–72 hours if tolerated
991
992
What are signs of EN intolerance?
High gastric residuals, abdominal distension, vomiting, diarrhea
993
994
What is refeeding syndrome?
Fluid and electrolyte shifts (↓phos, K, Mg) when feeding is initiated after starvation
995
996
How can refeeding syndrome be prevented?
Start low and go slow, supplement electrolytes, monitor labs closely
997
998
How should medications be given via feeding tube?
Use liquid forms or crushable tablets, flush before/after administration
999
1000
Which drugs interact with tube feeds?
Phenytoin, warfarin, fluoroquinolones—require holding feeds before/after
1001
1002
What is the difference between open vs. closed EN systems?
Open: decanted, increased contamination risk; Closed: prefilled, safer, longer hang time
1003
1004
What is the typical hang time for open EN systems?
4–8 hours
1005
1006
What is the typical hang time for closed EN systems?
Up to 24–48 hours
1007
1008
How much free water is in most standard EN formulas?
About 80%
1009
1010
What is the typical calorie density of standard EN formulas?
1.0–1.2 kcal/mL
1011
1012
What calorie density is considered energy-dense?
≥1.5 kcal/mL, used for fluid restriction
1013
1014
What is the typical fluid requirement for adults?
30–35 mL/kg/day
1015
1016
What is the Holliday-Segar method for pediatric fluid needs?
100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for weight >20 kg
1017
1018
What are signs of fluid overload?
Edema, hypertension, pulmonary congestion
1019
1020
What are signs of dehydration?
Hypotension, tachycardia, decreased urine output, elevated BUN/Cr
1021
1022
Normal serum sodium range?
135–145 mEq/L
1023
1024
What does hyponatremia indicate?
Fluid overload, SIADH, renal failure
1025
1026
What does hypernatremia indicate?
Dehydration, diabetes insipidus
1027
1028
Normal serum potassium range?
3.5–5.0 mEq/L
1029
1030
Causes of hypokalemia?
Diuretics, GI losses, refeeding syndrome
1031
1032
Causes of hyperkalemia?
Renal failure, acidosis, tissue breakdown
1033
1034
Normal serum calcium range?
8.5–10.5 mg/dL
1035
1036
What should you check in hypoalbuminemia?
Corrected calcium
1037
1038
Corrected calcium formula?
Measured Ca + 0.8 × (4 - serum albumin)
1039
1040
Causes of hypocalcemia?
Vitamin D deficiency, pancreatitis, low magnesium
1041
1042
Causes of hypercalcemia?
Hyperparathyroidism, malignancy
1043
1044
Normal serum phosphorus range?
2.5–4.5 mg/dL
1045
1046
Causes of hypophosphatemia?
Refeeding syndrome, TPN without phosphorus, DKA
1047
1048
Causes of hyperphosphatemia?
Renal failure, tumor lysis syndrome
1049
1050
Normal serum magnesium range?
1.5–2.5 mg/dL
1051
1052
Causes of hypomagnesemia?
Diarrhea, alcoholism, diuretics
1053
1054
Causes of hypermagnesemia?
Renal failure, excessive supplementation
1055
1056
What is metabolic acidosis?
Low pH, low HCO3; causes: diarrhea, renal failure, ketoacidosis
1057
1058
What is metabolic alkalosis?
High pH, high HCO3; causes: vomiting, diuretics
1059
1060
What is respiratory acidosis?
Low pH, high CO2; causes: hypoventilation, COPD
1061
1062
What is respiratory alkalosis?
High pH, low CO2; causes: hyperventilation, anxiety
1063
1064
Where does most nutrient absorption occur?
Small intestine (primarily jejunum)
1065
1066
What is the function of the ileum?
Absorbs bile salts, vitamin B12, and some water/electrolytes
1067
1068
What is the role of the colon in digestion?
Absorbs water, electrolytes, short-chain fatty acids
1069
1070
What is the function of the pancreas in digestion?
Secretes enzymes for digestion of protein, fat, and carbohydrates
1071
1072
Where is intrinsic factor produced and what is its role?
Stomach; binds to vitamin B12 for absorption in the ileum
1073
1074
What is short bowel syndrome (SBS)?
Malabsorption from significant loss of small bowel surface area
1075
1076
What are nutrition concerns in SBS?
Fluid/electrolyte imbalance, fat malabsorption, nutrient deficiencies
1077
1078
Which part of the bowel can adapt best after resection?
Jejunum
1079
1080
Which part is most difficult to compensate for if resected?
Ileum
1081
1082
What is the role of the colon in patients with SBS?
Colon helps absorb fluids, SCFAs—important if ileum resected
1083
1084
What is small intestinal bacterial overgrowth (SIBO)?
Excessive bacteria in small bowel causing bloating, diarrhea, malabsorption
1085
1086
Risk factors for SIBO?
Stasis, strictures, blind loops, motility disorders
1087
1088
What is the role of bile salts?
Emulsify fats for digestion and absorption
1089
1090
What happens when bile salts are malabsorbed?
Fat malabsorption, steatorrhea, loss of fat-soluble vitamins
1091
1092
What is the concern with pancreatic insufficiency?
Inadequate digestion of fat/protein, leading to steatorrhea and malnutrition
1093
1094
How is pancreatic insufficiency managed?
Pancreatic enzyme replacement therapy (PERT) with meals/snacks
1095
1096
What is a chyle leak?
Loss of lymphatic fluid rich in fat/protein/electrolytes
1097
1098
How is a chyle leak managed nutritionally?
Low-fat or MCT-based diet; may require EN or PN
1099
1100
What is bile acid diarrhea?
Occurs after ileal resection; bile salts enter colon causing fluid secretion
1101
1102
Treatment for bile acid diarrhea?
Bile acid sequestrants (e.g., cholestyramine)
1103
1104
What is an anastomosis?
Surgical connection between two parts of the bowel
1105
1106
What is a fistula?
Abnormal connection between bowel and another surface or organ
1107
1108
What is high-output fistula defined as?
>500 mL/day output
1109
1110
Normal fasting glucose range?
70–99 mg/dL
1111
1112
What is hyperglycemia defined as?
>180 mg/dL
1113
1114
What is hypoglycemia defined as?
<70 mg/dL
1115
1116
Normal sodium range?
135–145 mEq/L
1117
1118
Normal potassium range?
3.5–5.0 mEq/L
1119
1120
Normal chloride range?
98–106 mEq/L
1121
1122
Normal CO2 (bicarb) range?
22–28 mEq/L
1123
1124
Normal calcium range?
8.5–10.5 mg/dL
1125
1126
Normal magnesium range?
1.5–2.5 mg/dL
1127
1128
Normal phosphorus range?
2.5–4.5 mg/dL
1129
1130
What does elevated AST/ALT suggest?
Hepatocellular injury
1131
1132
What does elevated ALP and bilirubin suggest?
Cholestasis or bile duct obstruction
1133
1134
What does elevated direct bilirubin indicate?
Obstructive or hepatocellular jaundice
1135
1136
What is prealbumin used to assess?
Short-term changes in nutrition status
1137
1138
Why is prealbumin not reliable in critically ill patients?
It is a negative acute-phase reactant
1139
1140
What is CRP used for?
Marker of inflammation
1141
1142
What does a high CRP indicate?
Acute inflammation, infection, or trauma
1143
1144
What does elevated BUN/creatinine indicate?
Dehydration or renal dysfunction
1145
1146
What does a high BUN:Cr ratio suggest?
Pre-renal azotemia (often due to dehydration)
1147
1148
What is a normal BUN:Cr ratio?
10:1 to 20:1
1149
1150
What lab reflects iron storage?
Ferritin
1151
1152
What lab reflects recent iron status?
Serum iron, transferrin saturation
1153
1154
What labs suggest iron deficiency anemia?
Low Hgb, low Hct, low ferritin, high TIBC
1155
1156
What lab is used to assess vitamin D status?
25(OH)D
1157
1158
What lab decreases in zinc deficiency?
Alkaline phosphatase
1159
1160
What labs are monitored for refeeding syndrome?
Phosphorus, potassium, magnesium
1161
1162
What does elevated ammonia indicate?
Liver failure, especially in hepatic encephalopathy
1163
1164
What does an RQ >1.0 suggest?
Overfeeding, lipogenesis
1165
1166
How many kcal/gram does dextrose provide in PN?
3.4 kcal/gram
1167
1168
How many kcal/gram does protein provide in EN/PN?
4 kcal/gram
1169
1170
How many kcal/gram does lipid provide in PN?
10 kcal/gram (from 20% lipid emulsion)
1171
1172
How many kcal/gram does lipid provide in EN?
9 kcal/gram
1173
1174
What is the typical non-protein calorie to nitrogen ratio (NPC:N) in PN?
100–150:1
1175
1176
What is the purpose of the NPC:N ratio?
To ensure adequate calories to spare protein for tissue repair and growth
1177
1178
How many grams of nitrogen are in 1 gram of protein?
1 gram of nitrogen = 6.25 grams of protein
1179
1180
What macronutrient has the highest respiratory quotient (RQ)?
Carbohydrates (RQ ~1.0)
1181
1182
What macronutrient has the lowest respiratory quotient (RQ)?
Fat (RQ ~0.7)
1183
1184
What is the typical protein range in PN for a critically ill adult?
1.2–2.0 g/kg/day
1185
1186
What is the minimum amount of carbohydrate needed to prevent ketosis?
100–150 g/day
1187
1188
What is a concern with excessive carbohydrate intake in PN?
Hyperglycemia, increased CO2 production, hepatic steatosis
1189
1190
What is a concern with excessive fat intake in PN?
Hypertriglyceridemia, impaired immune function
1191
1192
What are the components of TPN macronutrients?
Dextrose, amino acids, lipids
1193
1194
How many kcal/gram does dextrose provide in PN?
3.4 kcal/g
1195
1196
How many kcal/gram does protein provide?
4 kcal/g
1197
1198
How many kcal/gram does fat provide in EN?
9 kcal/g
1199
1200
How many kcal/mL does 20% IV lipid provide?
2 kcal/mL
1201
1202
How many kcal/mL does propofol provide?
1.1 kcal/mL
1203
1204
How many grams of nitrogen are in 1 gram of protein?
1 gram of nitrogen = 6.25 grams of protein
1205
1206
How is nitrogen balance calculated?
Nitrogen in (g protein/6.25) – (UUN + 4)
1207
1208
What is the goal NPC:N ratio for moderate stress?
100–150:1
1209
1210
What is the general adult fluid requirement?
30–35 mL/kg/day
1211
1212
What is the Holliday-Segar method for pediatric fluids?
100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for each kg >20
1213
1214
How is glucose infusion rate (GIR) calculated?
(mg dextrose/day ÷ weight in kg ÷ 1440)
1215
1216
What is the max GIR for adults?
<4–5 mg/kg/min
1217
1218
What is the max GIR for neonates?
≤12 mg/kg/min
1219
1220
How is PN osmolarity calculated?
Dextrose × 5 + AA × 10 + electrolytes
1221
1222
What is the max osmolarity for peripheral PN?
<900 mOsm/L
1223
1224
What is the formula for BMI?
Weight (kg) / height (m)^2
1225
1226
What is the formula for IBW (female)?
45.5 kg + 2.3 kg per inch over 5 feet
1227
1228
What is the formula for IBW (male)?
50 kg + 2.3 kg per inch over 5 feet
1229
1230
How is adjusted body weight (AdjBW) calculated?
IBW + 0.25 × (ABW - IBW)
1231
1232
What are common energy equations?
Mifflin-St. Jeor, Harris-Benedict, Ireton-Jones, Penn State
1233
1234
What is the kcal/protein range for critically ill patients?
25–30 kcal/kg and 1.2–2.0 g/kg protein
1235
1236
When should adjusted body weight be used?
For obese patients (>120% IBW) to estimate energy/protein needs
1237
1238
What is refeeding syndrome?
Electrolyte shifts (↓phosphorus, potassium, magnesium) after initiating nutrition in malnourished patients
1239
1240
Who is at risk for refeeding syndrome?
Severely malnourished, NPO >7 days, chronic alcoholism, significant weight loss
1241
1242
How is refeeding syndrome prevented?
Start low and advance slowly, supplement electrolytes, monitor labs closely
1243
1244
What are consequences of overfeeding?
Hyperglycemia, increased CO2 production, hepatic steatosis, fluid overload
1245
1246
What RQ indicates overfeeding?
>1.0
1247
1248
What are consequences of underfeeding?
Impaired wound healing, muscle wasting, immune dysfunction
1249
1250
What causes hyperglycemia in nutrition support?
Excess dextrose, stress response, insulin resistance
1251
1252
How is hyperglycemia managed?
Adjust dextrose load, use insulin, monitor glucose
1253
1254
When can hypoglycemia occur in nutrition support?
Abrupt discontinuation of PN, insulin overdose
1255
1256
What is PN-associated liver disease (PNALD)?
Liver dysfunction due to long-term PN use
1257
1258
What are signs of PNALD?
Elevated LFTs, cholestasis, steatosis
1259
1260
How is PNALD prevented/managed?
Avoid overfeeding, cycle PN, use enteral feeding if possible
1261
1262
What are signs of EN intolerance?
High gastric residuals, abdominal distention, vomiting, diarrhea
1263
1264
How is diarrhea from EN managed?
Adjust formula, reduce rate, add fiber or antidiarrheals
1265
1266
How is constipation from EN managed?
Increase fluid/fiber, stool softeners
1267
1268
Who is at high risk for aspiration?
Sedated, neurologically impaired, post-stroke, gastric feedings
1269
1270
How is aspiration risk reduced?
Elevate HOB ≥30°, post-pyloric feeding, continuous infusion
1271
1272
What are common enteral tube complications?
Occlusion, dislodgment, infection at site
1273
1274
How are occluded feeding tubes cleared?
Warm water flushes, enzymatic declogging agents
1275
1276
What is a CLABSI?
Central line-associated bloodstream infection
1277
1278
How are line infections prevented?
Aseptic technique, catheter care, ethanol locks if indicated
1279
1280
What causes metabolic bone disease in PN patients?
Aluminum exposure, vitamin D deficiency, low calcium/phosphorus
1281
1282
What are symptoms of EFAD?
Dry, scaly skin, alopecia, impaired wound healing
1283
1284
How is EFAD prevented?
Provide at least 100 g IV lipid per week
1285
1286
What defines a central venous catheter (CVC)?
Tip terminates in the superior vena cava (SVC) or right atrium
1287
1288
What are examples of central venous access devices?
PICC, tunneled catheter (e.g., Hickman), implanted port, non-tunneled CVC
1289
1290
What are advantages of central access?
Can deliver hyperosmolar solutions, long-term use
1291
1292
What are common insertion sites for central lines?
Subclavian, jugular, femoral
1293
1294
What are risks of central lines?
Infection, thrombosis, pneumothorax, catheter occlusion
