Critical Care Guidelines Flashcards
(46 cards)
Which of the following characterizes the current understanding of the inflammatory response?
A) Overstimulated immune system
B) Mixture of immune stimulation and suppression
C) Initial immune suppression followed by stimulations
D) Immune suppression
B
-There is a compensatory action which will cause immune metabolic suppression, and decreased immunity sometimes pre-dominates depending on source of inflammation, timing, and clinical status of the patient.
Why is hemodynamic stability an important consideration before initiating enteral nutrition?
As gastrointestinal perfusion may be compromised
When is GI perfusion compromised?
- In septic states, particularly in the context of hemodynamic instability
- Feeding into the GI tract may elicit an ischemia event
What is the best reason to conservatively prescribe energy in nutrition support regimens?
For glycemic control
- Hyperglycemia is associated with adverse outcomes, such as increased incidence of infections.
- Conservative prescriptions and a gradual increase of infusion rates to goal energy req. can assist in controlling BG levels
What are the most common sources of sepsis for adult hospital admission?
- Lung
- Urinary tract
- GI system
- Skin
What is sepsis?
No longer considered a disease, but a group of diseases based on the patient, severity of insult, response of host and number of organs involved.
Define sepsis
Life-threatening organ dysfunction caused by a dysregulated host response to the infection
Define septic shock
Subset of sepsis in which profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than sepsis itself. Associated with hemodynamic unstability
(T/F) Sepsis requires an infectious agent
F
-Severe trauma, pancreatitis, burn injury etc can produce the same clinical findings without an infectious source
What are the two phases of sepsis?
Inflammatory and anti-inflammatory in the later phase
When is nutritional support optimized in the septic patient?
During the later immuno-suppressed phase
How does nutrition therapy play a key role in sepsis and in severe infections?
- Modulate the inflammatory response
- Maintain immune function
- Abrogating skeletal muscle catabolism
- Improving wound healing
- Maintaining GI and pulmonary mucosal barrier function
Discuss the dysregulation of CHO metabolism during sepsis
Pro-inflammatory cytokines will potentiate the release of catabolic hormones (glucagon, catecholamines, cortisolP) to mobilize glucose, inducing hyperglycemia and insulin resistance.
–> Onset of sepsis will use up glycogen stores within hours, and lipid and protein will predominate as energy sources.
_____ increases with progressive organ failure, and _____ will impair blood flow to liver, leading to hepatic dysfunction, hypoglycemia and end of live.
- Gluconeogenesis
- Reduced splanchnic blood flow
Discuss the dysregulation of protein metabolism during sepsis
- Protein breakdown and synthesis increases, however remain in a net-negative nitrogen balance.
- Decreased AA uptake and accelerated peripheral muscle protein breakdown, which results in a flux of AA to the liver, increasing production of creatinine, uric acid and ammonia which are excreted in high amounts.
Discuss hepatic re-prioritization in septic patients
- Hepatic uptake of AA increases and hepatic protein synthesis increases, which will allow for the production of glucose via gluconeogenesis and APP
- Liver will prioritize synthesizing positive acute phase proteins, such as CRP at the expense of negative acute phase proteins, such as albumin and pre-albumin
In an unfed, stressed up to ____ of lean body mass will be broken down each day
250 g
Consequences of prolonged catabolism of skeletal muscle protein?
- Compromises respiratory function
- Impairs wound healing
- Exacerbates immunosuppression
- Accelerates the loss of strength and endurance needed for recovery
- Increases ventilator time and ICU stay
Discuss the dysregulation of lipid metabolism during sepsis
- Catabolic hormones epinephrine, norepinephrine and glucagon are the predominant stimulators if the hydrolysis of TG by stimulating HSL
- Impaired acyl-carnitine carrier which will decrease FFA uptake
- Accumulation of FFA in the cell, and can result in intracellular acidosis and accumulation of lactate and pyruvate –> Results in impaired ketogenesis but high-levels of B-hydroxybutyrate
- Inactivation of LPL, which causes hyperlipidemia
Energy expenditure changes in sepsis?
Significant increase of 20-60% above the basal energy expenditure.
What may attenuate the anti-inflammation in sepsis?
-EN and use of anti-inflammatory lipids (EPA and DHA) can attenuate the catabolic response to stress.
(T/F) PN is preferable in the septic patient
F
EN is associated with better outcomes
Susceptibility to ischemia in EN and sepsis?
GI tract and liver associated with ischemia risk secondary due to shunting of blood flow away from the splanchnic bed.
-EN may enhance perfusion during septic states
What must be considered amongst EN delivery and vasopressors during the critically ill?
-Vasopressors may prevent a normal increase in splanchnic blood flow associated with EN, therefore aggravating necrosis
