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1

What are the 4 factors malnutrition can be caused by?

• Insufficient intake
• Impaired absorption
• Increased nutrient requirements
• Altered nutrient transport and utilization

2

Name indications for nutrition support

- Inadequate oral intake for 7-14 days
- Altered GI function
- Impaired nutrient utilization
- Swallowing/chewing difficulties
- PEM
- Increased nutrient needs that cannot be met orally (major infections, burns, trauma)
- Significant involuntary weight loss

3

Name indications for EN

Patients with a functional GI tract AND
o Unable to meet their nutritional needs orally (< 50% of needs) for 7-14 days (unsafe, insufficient or impossible)
o Expected not to meet their nutritional needs orally for at least 7- to 14- day period
o Hemodynamically stable

4

Name contraindications for EN

- Mechanical GI obstruction (tube cannot enter)
- Intractable N/V (untreatable with medication; common in whole body radiation from bone marrow transplant)
- Short bowel syndrome (malabsorption); < 100-150 cm in the absence of colon and < 50-70 cm in presence of colon
- Paralytic ileus (flexible)
- High-output GIT fistula (> 500 ml/d)
- Severe GI bleeds or malabsorption
- Short supply period (< 5-7 days in malnourished; < 7-9 days in nourished)
- Aggressive intervention not warranted/desired (end of life, palliative care)

5

Name contraindications to PEG

Severe ascites, severe gastroparesis, coagulopathy (high risk for placement), gastric varices (upper GI hemorrhage), neoplastic or inflammatory disease of the gastric or abdominal wall
Active head and neck cancer, morbid obesity.

6

What is the only case in which IMFs can be used?

Post-op in SICU and TBI

7

What are the nutrient needs for obese critically ill patients?

Energy:
PENN state x 0.65-0.7
BMI 30-50: 11-14 kcal/kg ABW
BMI > 50: 22-25 kcal/kg IBW

Protein:
2g/kg ABW/d

8

When should fiber NOT be used?

- Possible cases of bowel ischemia
- On vasopressors (levophed, epinephrine, phenylephrine)
- Strictures or acute exacerbations/obstructions of CD

9

How should EN be initiated in stable non-critically ill patients?

Stable non-critically ill patients usually tolerate EN initiated at the goal rate (or advance to goal within 24-48 hours)
Standard EN protocols usually indicate to start EN at a rate of 50 mL/hr and advance by 15mL/hr q4h until goal rate
Bolus feedings may be advanced by volumes of 60-120 mLq8-12 hours

10

How should EN be initiated in critically ill patients?

Critically ill patients: Start EN at 10-40 mL/hour and advance at the goal rate by 10-20mL/hour q 8-12 hours – But starting too low and slow may result in energy and protein deficits.

11

How should EN be initiated in sepsis?

Sepsis: Start EN at 60-70% of goal in first week, then advance to > 80% after first week. --> but ADEQUATE PROTEIN!

12

What is the stress factor for fever?

1.2 per 1°C over 37°C

13

In what circumstances do we use Adjusted BW?

If close to IBW, use ABW

If underweight, (i.e. < 90% IBW), use ABW and add energy when ready to gain weight (+ 500 kcal/d) or use IBW in equation to accommodate recovery

If overweight (i.e. > 125% IBW), use adjusted BW for fluids. Use ABW with MSJ and Ireton-Jones but adjusted with HB

14

What can increase chances that the tube will clog?

High fiber, small diameter tubes, use of silicone tubes, checking of GRVs, and improper medication administration via the tube

15

When do we initiate EN in well-nourished non-critically ill patients?

> 7 days for NRS < 3

16

When do we initiate EN in high-risk critically ill patients?

24-48h for NRS2002 ≥ 3

NRS ≥ 5: Advance to goal as quickly as tolerated over 24-48h while monitoring for RS – efforts to provide > 80% of estimated or calculated goal energy and protein within 48-72 hours should be made.

17

When should GRVs be checked?

GRVs should be checked every 4 hours during the first 48 hours of gastric feeding, after that, every 6-8 hours for patients who are not critically ill. d/c after 24h if no signs of intolerance.
In critically ill: Check q 4h

18

What to do in patients at risk of RS?

Initiate E intake at 25-50% of needs in the first 24h
Dextrose < 1.5g/kg/d
Thiamin 100-300 mg/d IV x 3-7 days
MVI x 7 days
Folate 1-5 mg/d (watch meds though)

19

What are the risk factors for RS?

Patients who have 1 or + of the following:
 BMI < 16
 Unintentional weight loss > 15% within last 3-6 months
 Little or no nutritional intake for more than 10 days
 Low levels of K, PO3 or Mg prior to feeding

OR patients who have 2 or + of the following
 BMI < 18.5
 Unintentional weight loss > 10% within the last 3-6 months
 Little or no nutritional intake for more than 5 days
 History of alcohol abuse

20

What are questions to ask for the management of diarrhea?

1. Distended, tympanic, painful abdomen?
2. Is medical/surgical history consistent with diarrhea? (E.g. IBD, terminal ileal resection, chemotherapy, short bowel, pancreatic insufficiency…)
3. Is there risk of stool impaction? (e.g. chronic constipation, absent BM x 5d, regular narcotic use, limited fluid intake)
4. Receiving cathartic agents? (substances that accelerate defecation) (e.g. citromag, docusate, milk of magnesia, cascara, enema, PEG, hypertonic or sorbitol-containing liquid medications, oral electrolyte solutions, lactulose, kayexalate, etc.)
5. C. Diff? Ischemia? --> if NO --> EN with fiber or semi-elemental

21

What is the minimum urine output required to remove wastes?

30mL/h or 700 mL/d

22

What is the max dextrose concentration for PPN? AA? K? Ca?

Dextrose: 150-300 g/d or 5-10% final concentration
AA: 50-100 g/d or 3% final concentration
K: < 40 mEq/L
Ca: < 5 mEq/L

23

At what point do high TG cause pancreatitis?

11.30 mmol/L

24

When can IC not be used?

Cannot be used in the presence of air leaks, chest tubes, supplemental oxygen, ventilator setting, CRRT, anaesthesia, physical therapy, excessive movement (e.g. seizures)

25

What is the predictive equation for energy in critically ill patients?

25-30 kcal/kg/d

26

What are the protein needs of critically ill obese patients?

2g/kg/d IBW

27

What are the protein needs of critically ill patients?

1.2-2.0 g/kg/d

28

When is PN started in ICU?

Low risk NRS2002 =< 3 or NUTRIC =< 5: withhold exclusive PN for 7 days if volitional intake inadequate and early EN not feasible

High risk NRS2002 >= 5 or severely malnourished and EN not feasible: Initiate exclusive PN as soon as possible

29

How much energy is fed to high risk or severely malnourished patients on their first week in the ICU?

First ICU week: Hypocaloric PN (<20 kcal/kg/d) or 80% EEE) with adequate protein (>= 1.2 g/kg/d) in high risk or severely malnourished patients
Withhold soybean oil lipids during first week. If concerned for EFAD, use 100g/week maximum divided into 2 doses/week

30

When is PN discontinued in ICU?

When EN/PO intake > 60%