Disease Specific Nutrition Overview Flashcards
(140 cards)
1
Q
what is the inpatient glycemic target for critically ill patients
A
140-180 mg/dL
2
Q
Under conditions of sepsis and stress, glucose production will ____ and glucose uptake will ____
A
increased blood glucose production & decreased glucose uptake
3
Q
during sepsis and stress hormones induce ____ resistance and ____
A
insulin resistance
hyperglycemia
4
Q
what immunomodulating nutrients may be harmful in patients with sepsis/septic shock
A
arginine
5
Q
Arginine is considered beneficial for immune function because
A
it increases tissue oxygenation
6
Q
what is a benefit of enteral glutamine supplementation in the critically ill patient with multi organ failure
A
decreases nosocomial infections
7
Q
what are the counter regulatory hormones responsible for hypercatabolism in critically ill trauma patients?
A
Glucagon
Epinephrine
Cortisol
8
Q
Glucagon, epinephrine and cortisol are hormones released during _____ and lead to these four metabolic processes
A
traumatic injury glycogenolysis gluconeogenesis proteolysis free fatty acid release
9
Q
What is the goal of releasing hormones such as epinephrine, cortisol, and glucagon during trauma
A
maintain survival and homeostasis and promote recovery
10
Q
In a trauma patient, after timely resuscitation, restoration of perfusion, oxygenation and hemodynamic stability, what is the next important component of supportive therapy
A
early initiation of nutrition
11
Q
In patients with burns, providing caloric support above energy expenditure has been found to have ____ effect on preservation of lean body mass
A
have no effect
12
Q
although patients with burns have increased caloric needs, feeding in excess is still not recommended because it may cause
A
hyperglycemia, hepatic steatosis, or prolonged ventilatory dependence
13
Q
In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in
A
respiratory acidosis
14
Q
respiratory acidosis results from disorders producing alterations in ventilatory control due to the increased production of
A
CO2 and respiratory muscle weakness
15
Q
Essential fatty acid deficiency in patients with cystic fibrosis is rare after _____ because EFA profiles have been shown to improve after it
A
lung transplantation
16
Q
In cystic fibrosis, disruption of the exocrine function of the pancreas contributes to malabsorption of
A
fat, protein and fat soluble vitamins
17
Q
EFAD status is usually evaluated by measuring
A
triene: tetraene ratio
18
Q
clinical trials have ____ results in using omega 3 fatty acids in routine supplementation in the management of CF
A
mixed
19
Q
what is the best choice for feeding a pancreatic insufficient infant with CF and why
A
Human Milk with enzymes because it has good immunologic properties, growth factors, pre and probiotics
20
Q
Protein hydrolysate or free amino acid formulas with MCT are not indicated in infants with CF unless
A
there is another medical reason such as bowel resection leading to malabsorption or liver abnormalities
21
Q
What is the glomerular filtration rate (GFR) for a patient with ESRD?
A
<15mL/min/1.73m2
22
Q
a GFR indicating stage 1 kidney damage equates to
A
> 90mL/min/1.73m2
23
Q
what is a GFR of Stage 2 Kidney damange
A
60-89mL/min/1.73m2
24
Q
what is a GFR of Stage 3 Kidney Damage
A
30-59 mL/min/1.73m2
25
what is a GFR of Stage 4 kidney disease
15-29mL/min/1.73m2
26
Increased mortality in maintenance of HD patients has been associated with
low baseline body fat percentage and low muscle mass
27
low muscle mass reflects poor ____ status and ______
nutrition status
| inflammation
28
low fat mass reflects low body stores of _____
energy
29
Elevated CRP levels in HD can cause
weight loss
decreased albumin
decreased appetite
30
which BMI is considered protective in HD patients
30-34.9
31
A BMI less than ____ and hypoalbuminemia are strong indicators of mortality in HD patients
< 23
32
What has been shown to delay weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease who are receiving enteral nutrition
refeeding syndrome
underfeeding
overfeeding
33
Hypophosphatemia can delay weaning from mechanical ventilation because
hypophosphatemia exacerbates respiratory dysfunction, diaphragmatic weakness and decreased cellular energy production
34
_____ feeds are defined as feeding in an amount of substrate enough to provide gut stimulation and are typically at a rate of 10-20mL/hr of EN
trophic feeds
35
What is the maximum dietary protein intake in critically ill adult patients getting continuous renal replacement therapy (CRRT)
2.5 g/kg/day
36
high protein needs of 2.5g/kg/day in the critically ill adult on CRRT is due to
hyper-catabolism, obligatory use of protein as preferred fuel source during the stress response and the likelihood of significant protein losses in CRRT effluent
37
Typical protein losses in CRRT equate to
10-17%
38
what are some disadvantages of going over 2.5g/kg/day of protein in CRRT
uremia
increased hepatic and renal demand
increased costs
39
what are the protein requirements for a stable patient getting peritoneal dialysis
1.2-1.3 g/kg/day (when clinically stable)
40
what are some causes of protein energy malnutrition in liver disease
```
malabsorption
decreased kcal intake
abnormal fuel metabolism
early satiety
fat malabsorption from altered bile acid circulation
increased protein and fat oxidation
```
41
Energy expenditure is ___ in patients with infections and ascites with liver disease
increased
42
Protein energy malnutrition is most common in which of the following types of liver disease
Cirrhosis
43
patients with viral disease such as hepatitis B and C are not susually
severely malnourished
44
Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for
azotemia
45
Loop diuretics cause electrolyte imbalances as a result of decreased urine output, so azotemia is caused by
volume depletion
46
hypoglycemia requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease
Fulminant Hepatic Failure from impaired glycogenolysis, gluconeogenesis, and hyperinsulinemia requiring aggressive glucose administration
47
which metabolic derangements are common in fulminant hepatic failure
impaired glycogenolysis
hypoglycemia
impaired gluconeogenesis
hyperinsulinemia
48
patients with fulminant hepatic failure are in a ____ state with increased energy ____ and can rapidly become ____
hypercatabolic
expenditure
malnourished
49
In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting association starvation during the night
late evening snack
50
Cirrhotic patients have ____ glycogen stores and utilize more ____ as fuel during periods of prolonged starvation (usually seen in an overnight fast of 12-18 hours)
depleted glycogen stores
| fat as fuel
51
what is an important indicator of protein energy malnutrition in chronic liver disease
muscle wasting & subcutaneous fat
52
in patients with chronic liver disease, using triceps skin fold and mid arm circumference can possibly be skewed by
fluid retention
53
Treatment for patients with overt hepatic encephalopathy who have impairments in cognitive and neuromuscular function include
supplementing zinc, thiamine, b6 and b12, use lactulose, provide a meal pattern of 3 meals and 3 snacks
54
______ is no longer restricted in patients with advanced liver disease
protein restriction
55
what micronutrients are common deficiencies in chronic liver disease due to poor intake and decreased absorption
```
thiamine
vitamin B6
B12
Folate
zinc
```
56
which types of cancer have the highest prevalence & severity of weight loss
pancreatic and gastric cancer
57
what types of cancer have the lowest prevalence of weight loss
sarcomas, breast cancer, hematological cancers
58
that is the benefit of megesterol acetate in patients with cancer associated cachexia?
improves appetite and ameliorates weight loss
59
______ is a synthetic progestational agent that promotes weight gain and helps to stimulate the appetite
megace
60
In the first 1-3 months after a bone marrow transplant the nutritional needs of a patient are best met with
30-35 kcal/kg body weight
| >/= 1.5 g protein/kg body wt
61
Which nutrient should NOT be supplemented routinely in the early stages following hematopoietic stem cell transplantation (HSCT)
Iron
62
in Hematopoietic Stem Cell Transplantation, blood products and transfusions are required before, after, and during HSCT and can cause an overabundance of which nutrient
iron
63
Iron overload in HSCT patients can increase the chance of
acute graft vs host disease
blood/fungal infection
sinusoidal obstruction of liver
64
What acute changes in serum chemistry profile would be expected in a patient who is experiencing tumor lysis syndrome?
hyperkalemia
| hyperphosphatemia
65
_____ is caused by massive tumor cell lysis with the release of large amounts of potassium, phosphate and nucleic acids into systemic circulation
Tumor Lysis Syndrome
66
Tumor Lysis Syndrome is common after
initiation of cytotoxic therapy
67
What is the best treatment of diarrhea in inflammatory bowel disease
Start anti-diarrheal agents once infectious etiology is ruled out
68
Anti-diarrheal medication should not be given to patients with IBD until what has been ruled out. Why?
infectious diarrhea such as CDiff. If to they can develop toxic megacolon
69
In patients with extensive bowel resection ______ can be given in conjunction with anti diarrhea medications
Cholestyramine to help with bile salt malabsorption
70
how much stool output is concerning for possible electrolyte deficiencies and volume depletion
> 500mL for 2 consecutive days
71
there are currently no evidenced based recommendations for using ___ or ____ as standard therapy with diarrhea
prebiotics & probiotics
72
A patient with Chron's Disease that involves the distal ileum should be closely monitored for malabsorption of which micronutrient
vitamin B12
73
what is a major contributing factor in the development of metabolic bone disease in patients with IBD?
corticosteroid use
74
complications of metabolic bone disease is associated with IBD are
osteopenia and osteoporosis
75
when patients are on long term steroids, what should be supplemented to reduce osteopenia
calcium & vitamin D
76
what is commonly found in patients with IBD?
```
malnutrition
vitamin D deficiency
corticosteroid therapy
magnesium deficiency
chronic inflammation
```
77
____, ____ and _____ may be associated with PN associated MBD
aluminum toxicity, hypercalciuria, magnesium deficiency
78
In patients with severe acute pancreatitis, the use of enteral nutrition via naso-jejunal feeding tube rather than PN is associated with
a lower risk of developing infectious complications, maintained equal nitrogen balance and reduced incidence of hyperglycemia than those with PN
79
when is PN recommended in severe acute pancreatitis
when EN is not available, tolerated or patient is not meeting nutritional requirements via EN alone
80
A patient with chronic heart failure on high dose furosemide is started on EN for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms
Thiamine
81
which two medications are known for decreasing thiamine by uptake of cardiac cells in heart failure patients
furosemide and digoxin
82
Thiamine deficiency is a form of _____ which is characterized by an enlarged heart, electrolyte alterations, vasodilation and peripheral neuritis
Wet BeriBeri
83
gastric hypersecretions following significant small bowel resection can become problematic. Which of the following medications have shown to be the most successful in suppressing gastric hypersecretion
Proton Pump Inbitors
84
What metabolic complication may occur in patients with short bowel syndrome and small bowel intestinal bacterial overgrowth
metabolic acidosis
85
intestinal resection involving removal of the terminal ileum and or the ileocecal valve with the colon in continuity predisposes patients to
small intestinal bacterial overgrowth
86
in rare instances patients with short bowel syndrome can develop ____and encephalopathy. D lactate producing bacteria thrive in an acidic environment which is common in SBS as a result of metabolism of unabsorbed carbs leading to the production of lactate and decreases the pH
metabolic acidosis
87
patients with short bowel syndrome would benefit most from octreotide injections in the presence of
refractory diarrhea not controlled with diet and medication
88
what medication reduces the production of a variety of GI secretions and slows jejunal transit
octreotide
89
why should Octreotide by reserved only for patients with large volume stool loss whose fluid & electrolyte management is problematic
increases the risk for cholelithiasis
expensive
can inhibit bowel adaptation
has not been shown to improve absorption or eliminate the need for PN
90
what diet should be recommended to patients with short bowel syndrome (ileal resection) and colon in continuity
high complex carbohydrates 50-60% of total calories, low fat (20-30%) to increase energy absorption, optimize SCFA production & reduce instance of steatorrhea
91
a high complex carb diet low in fat helps reduce
magnesium & calcium losses, decreases oxalate absorption
92
oxalates bind to ____ and are excreted in the stool
calcium
93
patients with SBS who have a colon in continuity should restrict dietary oxalate intake & consume high calcium food or calcium citrate supplements to avoid
oxalate nephrolithiasis
94
A patient with SBS (regardless of bowel anatomy) complex carbs are important in the diet becuase
they reduce the osmotic load & may help with intestinal adaptation
95
Why are complex carbs recommended in SBS verses simple sugars
they take longer to break down than simple sugars which improves tolerance
96
why should concentrated sugars be avoided in short bowel syndrome
they can generate a high osmotic load and increase or promote stool output
97
calcium oxalate nephrolithiasis can occur in patients with short bowel syndrome with an intact colon who
don't maintain adequate hydration
98
patients with short bowel syndrome are at a high risk for oxalate stones because
there is increased availability of oxalate absorption in the colon as patients with SBS usually have steatorrhea
99
normally, oxalates bind to ____ and are excreted through the stool
calcium & magnesium
100
in patients with SBS and steatorrhea, why are oxalates absorbed at an increased rate?
calcium binds to fatty acids, allowing excess and unbound oxalate to be absorbed from the colon & be filtered through the kidneys leading to stone formation also exacerbated by dehydration
101
to avoid calcium oxalate nephrolithiasis, maintaining hydration with a goal urine output of _____ is important, with oral calcium supplements between ___ and ___ mg/day not exceeding ___ mg a a time is recommended
>1200mL a day
| 800-1200mg/calcium a day at does of no more than 500mg at one time
102
low dietary fat intake of 20-30% of total kcals is important in SBS in order to
minimize steatorrhea
minimize oxalate absorption
minimize loss of calcium & magnesium
103
SBS patients with less than ____ cm of terminal ileum resected are at lower risk of bile salt malabsorption & steatorrhea
100
104
what types of fistulas will result in the greatest degree of nutritional loss
proximal high output
105
the higher a fistula occurs in the GI tract, the ____ the output and risk of metabolic derangements
higher (more proximal)
106
patients with proximal high output fistulas in their GI tract will reuqire
increased protein/calorie needs
| close monitoring of fluids & electrolytes
107
patients with low output fistulas less than ____mL/day of stool loss will decrease the possibility of enteral nutrition
500mL/day
108
to minimize fistula output in distal ileal or colonic fistulas, what type of enteral nutrition formula should be used as high up as possible to increase surface area for absorption
fiber free or low fiber
109
A 24 year old, 10 week pregnant woman presents with persistent nausea & vomiting for the past 6 weeks associated with a 10% wt loss. Her symptoms were refractory to a 48 hour trials of anti-emetics & IVF. Given mother's nutritional status, decision was made to initiate nutrition support. What vitamin should be supplemented in this patient before providing nutrition support
thiamine
110
A 24 year old, 10 week pregnant woman presents with persistent nausea & vomiting for the past 6 weeks associated with a 10% wt loss. Her symptoms were refractory to a 48 hour trials of anti-emetics & IVF. Given mother's nutritional status, decision was made to initiate nutrition support to minimize further deterioration of the mother's nutritional status & possible negative side effects on the fetus. What is the most appropriate initial nutrition therapy to implement
EN with polymeric formula via NG tube
111
severe, intractable nausea and vomiting complicated by dehydration, electrolyte imbalance, nutrition deficiencies and weight loss in pregnant women is called
hyperemesis gravidarum
112
because constipation is often a problem in pregnancy, what type of formula should be considered in EN
fiber
113
A 14 year old with a 4 month history of intentional weight loss of 15% of her usual weight & a BMI < the 5th percentile is diagnosed with anorexia nervosa. She is admitted to the hospital for medical stabilization and is unwilling to consume enough food to meet her nutritional needs. A 24 hour calorie count reveals that the patient is consuming a very restricted diet averaging 850 calories a day. Which is the most appropriate nutrition intervention at this time
structured meal plan with supplemental enteral feedings
114
what is the preferred modality for nutrition rehabilitation
oral refeeding
115
a critically ill hyperglycemic patient receiving continuous enteral nutrition with a history of insulin dependent diabetes should ideally be placed on
continuous IV infusion
116
in the critical care setting, _______ has been shown to be the best method for achieving glycemic targets and allows for off cycles during the 24 hr period when EN is held or discontinued
continuous IV insulin infusion
117
Human Immunodeficiency Virus (HIV) associated lipodystrophy syndrome is most commonly associated with which class agent to treat HIV infection
nucleoside reverse transcriptase inhibitors (NRTI's)
118
_____ is manifested by subcutaneous adipose tissue loss with visceral adipose tissue sparing or accumulation
HIV associated lipodystrophy syndrome
119
where is subcutaneous tissue loss often seen in HIV
face, buttocks, lower extremities
120
Patients with lipodystrophy are at increased risk of being
insulin resistant
121
what is the most appropriate feeding strategy for a morbidly obese trauma patient
hypocaloric high protein
122
zinc supplementation should be considered for patients with
unexplained skin rashes & alopecia
123
Zinc is an essential trace element for ____ and ___
cell replication & growth
124
Zinc is a cofactor for ____ & ____ synthesis and proliferation of inflammatory cells/epithelial cells
collagen & protein synthesis
125
zinc deficiencies usually occur from
GI surgery
diseases that impair intestinal absorption
diseases that increase zinc loss es
Celiac, CF, IBD, Chron's
126
Chronic diarrhea &exudate from large wounds cause ___ deficiency
zinc
127
why are zinc levels not always reflective of zinc status?
the presence of inflammation and are dependent on albumin for transport, so interpret cautiously in presence of hypoalbuminemia & inflammation
128
what are the symptoms of zinc deficiency
rash, alopecia, impaired night vision, alterations in taste & smell, impaired immune function, anorexia, and diarrhea
129
Nutrition support for solid-organ transplant patients receiving cyclosporine may need to be modified due to the presence of
hyperkalemia
130
Cyclosporines, medications used after solid organ transplantation for immune suppression can cause electrolyte imbalances including
hyperkalemia, hypomagnesemia
hyperglycemia
hypercholesterolemia as it effects the renin angiotensin aldosterone system altering potassium homeostasis as well as decreased renal excretion of potassium
131
A patient with AKI who requires PN would most likely benefit from a solution containing
essential and non essential amino acids
132
A 51 year old F who is 10 years post gastric bypass surgery presents w/ numbness & tingling in her distal lower extremities that had progressively worsened. She had been on an oral MVI supplement. She was significantly anemic & neutropenic. Her vit B12 level was normal as were her serum iron, ferritin and transferrin levels. What nutritional deficiency is the most likely cause of all of these symptoms
Copper deficiency
133
Vitamin B12 deficiency in gastric bypass can cause
anemia & peripheral neuropathy (numbness & tingling in lower extremities)
134
Iron & Folate deficiencies cause ____ in gastric bypass patients
anemia
135
Thiamin deficiency can cause peripheral neuropathy but not _____ in gastric bypass patients
not anemia
136
what are the symptoms of copper deficiency
anemia
leukopenia
neutropenia
peripheral neuropathy
137
ERAS (Enhanced Recovery After Surgery) is a care program that has been shown to improve outcome after major surgery. The key mechanisms behind the ERAS effectiveness is
decrease the stress of surgery and support recovery
138
what are the objectives of ERAS
avoid starvation before surgery
limit post op IVF
optimize GI function & mobilization
139
What is done as part of ERAS protocol
avoid preop fasting by providing CHO nutrition/fluid and withholding routine bowel prep
140
ERAS was originally designed for which types of surgeries
colon resection
