ICM - Nutrition

Question 1

What was the EPaNIC Trial and what did it show

Answer 1

Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients

RCT n-4640 with insufficient enteral

Either, additional parenteral in 48 hours or after 7 days

No difference in anything

BUT excluded malnourished patients and was low mortality risk patients

Question 2

What was the TICACOS study and what did it show

Answer 2

High risk ICU patients - showed the additional parenteral nutrition supplemented to enteral reduced mortality in hospital and at 60 days

Question 3

What was the CALORIES trial and what did it show

Answer 3

ICNARC RCT
Route of early nutritional support in critically ill patients

No difference in 30 day mortality or infections between enteral and parenteral

60% never met their calorie target

EN - higher risk of vomiting and hypo’s

PN is neither mroe beneficial nor more harmful

Question 4

In general, is early feeding supported?

Answer 4

Yes

Question 5

Factors that may make enteral feeding fail

Answer 5

MOF
Vasoactive drugs
Sedation and opioids

Question 6

Ways of measuring calorie needs

Answer 6

Indirect calorimetry (gold standard)

Harris-Benedict

Schofield eqns

Question 7

Specific calorie adjustments

Answer 7

Fever: 10% more for every 1C above 37 (limit 40)

Sepsis: 9% more

Surgery/trauam: 6%

Burns: Increase by 100% for any burn over 30%

Question 8

How would you start enteral nutrition

Answer 8

Commence at 50% of estimated target energy/protein needs

Increase over 24-48 hours

Continue full electrolye, fluid and vitamin needs from the start

Question 9

Suggested calorie intake

Answer 9

25-35 KCal/kg

Some books say under 65 - 20kcal
over 65 25

Question 10

Macronutrient requirements

Answer 10

Protein 0.8-1.5g/Kg
Lipid: 40% of total calories
Carbs 3-4g/kg

Carbs should be 60% of the non protein calories

Question 11

Examples of micronutrients

Answer 11

Zinc
Copper
Selenium

Thiamine B1
Riboflavin B2
Vit D

Question 12

Fluid/Electrolyte needs

Answer 12

Water 30ml/kg
Sodium 1mmol/kg
K 0.7 to 1mmol/Kg
Calcium 0.1
Mg 0.1
Choride 1-2
Phosphate 0.4

Question 13

Feeding points:

Haemodynamically stable patients unlikely to eat for 3 days and functioning GI tract

Answer 13

Enteral within 24 hours

Question 14

If not at target enteral feed

Answer 14

Add parenteral

Question 15

Should we “rest” patients for feeding overnight

Answer 15

No

Question 16

Why should patients on enteral feed be sat up at 30 degrees

Answer 16

Reduced aspiration risk

Reduced VAP risk

Question 17

Can peripheral access be used for feeding

Answer 17

Yes as a PICC

Short peripherals/midlines can be used for a short time and if the osmolarity is <850

Question 18

Order of infection by CVC line site

Answer 18

Subclavian (lowest)
IJ
Fem

Question 19

With the jugular vein, does a high or low approach increase risk of contamination and infection

Answer 19

High

Question 20

Features of refeeding syndrome

Answer 20

Low PO3 –> muscle weakness
Low Mg - Myocardial dusfunction, neuro issues
Low K - Arrhythmias, arrest
High glucose - osmotic diuresis dehydration, metabolic ketoacidosis
Low thiamine -> Wernickes’s, Korsakoffs

Question 21

Risk for Refeeding

Answer 21

One of:

BMI less than 16
Weight loss more than 15% in 3-6 months
Little no intake for 10 days
Low K, PO, Mg prior to feeding

Two of:
BMI less than 18.5
Weight loss more than 15% in 3-6 months
No/little intake for 5 days
History of alcohol/drugs (insulin/chemo/antacids/diuretics)

Question 22

Feeding strategy for refeeding

Answer 22

Dietitican
Slow feed (max 10kcal/kg/day)
Slowly increase over 4-7 days
Monitor fluid and electrolytes

Supplement Thiamine and Vit B
K, Mg and PO

Question 23

Is there an increased risk of PE in upper limb DVT

Answer 23

No

Question 24

ICU risk factors for VTE

Answer 24

Sepsis
Vasopressors
Resp/Cardiac failure
Sedation
MV
CVC
ESRF

Question 25

CXR positioning for CVC

Answer 25

2cm from carina on CXR

Tip not pointing at wall of SVC

Question 26

Formula methods for CVC

Answer 26

Pere’s formula

Right IJ - Height/10
Left IJ (Height/10)+4

Question 27

Features of short bowel syndrome

Answer 27

Abdo pain
Diarroheoa, steatoorrhoea
Fluid/micronutrient depletion
Weight loss
Fatigue

Question 28

What is a high output stoma

Answer 28

More than 1500ml/day

Question 29

How to manage a high output stoma

Answer 29

Exclude organic causes (infection/steroid withdrawel/obstruction/sepsis)

Restrict oral intake to 500ml/day

Loperamide 4mg qds and increase to 8mg

Codeine 15-60 qds

Omeprazole

Trial Abx for bacterial overgrowth

Add St Marks solution - glucose electrolyte.
NBM 24-48 hours

Octreotide 200mcg tds for 3-4 days