Clinical Findings of Refeeding Syndrome - Hypo ___ , hypo ___ , hypo ___ - ___ distress - Paresthesias - Tetany - Cardiac ___ - Hemolytic ___

- hypophosphatemia, hypomagnesemia, hypokalemia - respiratory - arrhythmias - anemia

Risk Factors for Refeeding - Rapid feeding, excessive ___ infusion - Low BMI (less than __ - __ kg/m2) - Excessive weight loss - Insufficient caloric intake - Low levels of ___ , ___ , or ___ prior to feeding - Loss of subcutaneous fat or muscle mass - High-risk comorbidities: ___ , anorexia nervosa, ___

- dextrose - 16-18.5 - K, Phos, Mag - alcoholism, Marasmus

Nutrition II Flashcards by Reagan Smith

Complications – PN

Mechanical (catheter-related)
– Clotting of line
– Displacement

Infectious
– Catheter-related ___
– Solution contamination
– Bacterial translocation

sepsis

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Bacterial Translocation

___ -dependent passage of bacteria or endotoxins from the ___ to extra-intestinal sites

___ organisms cause systemic infections
- Pneumonia
- Central line infections
- Abscesses
- Multi-organ dysfunction syndrome (MODS)

time
GI tract
Enteric

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Complications – PN (cont.)

Metabolic
- Electrolyte imbalances
- Fluid imbalance
- Hyper- and hypo ___
– Liver function abnormalities:
* Steatosis (fatty liver)
* Intrahepatic cholestasis
* Cholelithiasis

glycemia

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Baseline Monitoring – PN

Baseline
- CMP, Mg, Phos, Ca
- Hepatic function panel
- ___ / ___
- PT/INR

Q4-6H
- Finger sticks for ___
* Correct elevated glucose concentrations with insulin via
infusions and/or sliding scale
- Residuals, distention, vomiting, ___

Prealbumin/CRP
glucose
aspiration

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Ongoing Monitoring – PN

Daily
- Vital signs
- Intake/Output (stools)
- ___ (electrolytes, glucose, BUN/SCr)
- Feeding tube placement and patency
- May decrease frequency when stable

CMP

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Ongoing Monitoring – PN

Twice Weekly
- Weight
- CBC
- Mg, Phos, Ca, ___ / ___
- ICU setting -> increase to ___

prealbumin/CRP
daily

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Ongoing Monitoring – PN

Weekly
- Albumin, transferrin, nitrogen balance
- Liver function tests (alk phos, AST, ALT, LDH, bilirubin)
- ___
- PT/INR
- ___ ___ /Indirect Calorimetry

TG
Respiratory Quotient (RQ)

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Refeeding Syndrome

Constellation of fluid, micronutrient,
electrolyte, and vitamin ___
Occurs within first few days of feeding a ___ patient
Potentially life threatening

imbalances
starved

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Clinical Findings of Refeeding Syndrome

Hypo ___ , hypo ___ , hypo ___
___ distress
Paresthesias
Tetany
Cardiac ___
Hemolytic ___

hypophosphatemia, hypomagnesemia, hypokalemia
respiratory
arrhythmias
anemia

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Risk Factors for Refeeding

Rapid feeding, excessive ___ infusion
Low BMI (less than __ - __ kg/m2)
Excessive weight loss
Insufficient caloric intake
Low levels of ___ , ___ , or ___ prior to feeding
Loss of subcutaneous fat or muscle mass
High-risk comorbidities: ___ , anorexia nervosa, ___

dextrose
16-18.5
K, Phos, Mag
alcoholism, Marasmus

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Prevention of Refeeding Syndrome

Replete ___ before initiating feeds

Initiation recommendations (Day #1):
- Limit carbohydrates (dextrose) to ___ - ___ gm
- Limit fluids to ___ mL/day
- Provide adequate amounts of ___
- Provide approximately ___% of total caloric needs
- Advance calories/dextrose by 20-33% of goal every 1-2 days as tolerated
- Give ___ 100 mg daily x5-7 days

electrolytes
- 100-150
- 800
- electrolytes
- 50%
- thiamine

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Essential Fatty Acid (EFA)

Requirements

Estimated to be __ - __% of daily calories
EFAs include __ and __ acids

4-10%
linoleic, linolenic

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Essential Fatty Acid Deficiency (EFAD)

Mechanism:
- Continuous infusion of hypertonic dextrose will increase circulating insulin levels
- Inhibits ___ and fatty acid mobilization

Clinical onset:
- Several weeks on a fat-free PN regimen ( __ - __ days)

Symptoms:
- Dry scaly skin, brittle hair, lack of luster

lipolysis
10-14

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Prevention of EFAD

Recommended minimum requirement is to provide approximately __ % of caloric intake as lipids

Prevention:
- Provide at least 500 mL of 10% fat emulsion over at least 3-5 hours __ weekly
– OR –
- Provide at least 250 mL of 20% fat emulsion over at least 5-9 hours __ weekly

4%
twice
twice

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EN indications

“If the gut works, use it.”
* Oral consumption inadequate
* Oral consumption ___ :
– ___ obstruction
– Head and ___ surgery
– Dysphagia
– Trauma
– Cerebrovascular accident
– Dementia

contraindicated
esophageal
neck

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Advantages - EN

Provides GI ___
- Decreased chance for bacterial ___
- Stimulates biliary flow through biliary tract

Avoids risks associated with IVs
- Non-invasive tube placement at the bedside
- Line ___ , pneumothorax, etc.

More ___ than PN

Bolus feeds are more physiologic than continuous

Less stringent protocol for administration

Less expensive (depending on the formula)

stimulation
translocation
infections
physiologic

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EN - decreased bacterial translocation

Time-dependent passage of bacteria or
endotoxins from GI tract to extra-intestinal
sites

Enteric organisms cause systemic infections
– Pneumonia
– Central line infections
– Abscesses
– Multi-organ dysfunction syndrome (MODS)

___ infectious morbidity and mortality w/ EN

decreased

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Contraindications to EN

Mechanical obstruction
- Hernia, tumors, adhesions, scar tissue, etc.

Non-mechanical obstruction – ___
- No peristalsis, decreased perfusion, post-op, etc.

Intractable vomiting
Severe malabsorption
Severe GI hemorrhage
Certain types of __
- High output, proximal small bowel

ileus
fistulas

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Routes of Administration – EN

___ (NG) / Orogastric (OG)
Nasojejunal (NJ) / Orojejunal (OJ)
- Dobhoff®
- Cortrak® / Corpak®

___ ; Percutaneous endoscopic gastrostomy (PEG)
- Surgical placement

___ ; PEG/PEJ

Nasogastric
gastronomy
jejunostomy

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Determining Route of Access

Risk of aspiration
- If low risk – may utilize ___
- If high risk – ___ (post-pyloric) is preferred

Tolerance
- Vomiting – use ___
- Gastric residuals – use ___

Duration of therapy
- Long term – consider ___ or ___

gastric
jejunal
jejunal
jejunal
PEG or PEJ

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Bolus

Mimics ___

Administer > 200 mL formula over 5-10 min
- Maximum volume 300 – 400 mL

Used primarily for patients with ___
- Nursing facilities
- Ambulatory settings

Advantages
- More convenient for patients
- Requires minimal equipment (syringe)
- Less medication interactions

Disadvantages
- Cannot feed into ___
- Higher risk of ___ and intestinal side effects?

meal
gastrostomy
small bowel
aspiration

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Intermittent

Administer > 200 mL formula over 20-30 minutes (gravity drip)
- __ - __ feedings per day

Advantage
- Helps __

Disadvantage
- More equipment required (requires use of reservoir bottle or bag)

4-8
tolerance

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Continuous Infusion

Administer continuously over 12-24 hours/day
Requires use of infusion pump
Preferred method when feeding into the ___

Advantages
- Lower risk of gastric distention and ___
- Better tolerated by the patient

Disadvantages
- Problematic for ___ administration
- Requires infusion ___

jejunum
medication
pump

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Trickle or Trophic

___ continuous infusion at 10 – 30 mL/hr

Advantages
- Prevent mucosal ___ and bacterial __
- May shorten time on ___ and decrease mortality

Disadvantage
– Difficult to achieve sufficient ___ delivery

Study These Flashcards

slow
atrophy, translocation
venetilator
calorie

# Initiation & Advancement of Tube Feeding - Initiate full strength at __ mL/h - Advance 25 mL/h q 4-6 hrs as tolerated up to goal rate - Check ___ q 4-6 hrs - May hold for > 500 mL - Dilution of formula has limited benefit (not recommended)

- 25 - residuals

# Cyclic - Administer over __ - __ hours/day - Often infused ___ Advantage - increased ___ for the patient

- 8-20 - overnight - independence

# EN – ICU Initiation Points Achieve > __ - __ % goal calories within first week (if not, consider PN) - Do not initiate if ___ unstable (concern for intestinal ___ ) - Bowel sounds or flatus not needed for initiation - EN promotes gut ___

- 50-60 - hemodynamically - ischemia - motility

# NPO Times Minimize holding times - Inadequate nutrient delivery - May stimulate ___ development Patients undergoing frequent surgical procedures have ___ infections when EN is not stopped for each procedure

- ileus - fewer

# Immune-modulating Contents (Impact 1.5) - ___ : T lymphocyte function - ___ : Antioxidant, immune support, and nitrogen retention - ___ : Reduced inflammation, arrhythmia incidence, ARDS, and sepsis - ___: Selenium, ascorbic acid, and vitamin E

- arginine - glutamine - omega-3 fatty acids - antioxidants

# Immune-modulating Formulation (Impact 1.5) - Target Patient Populations: Major elective surgery, ___ , ___ , head or neck cancer, mechanically ___ - Use w/ Caution: Severe ___ - Benefits: Reduced time on ventilator, infectious morbidity, length of hospital stay

- trauma, burn, ventilated - sepsis

# EN Nutrient Composition Protein - Intact protein * Requires complete digestion into smaller peptides - Partially digested (peptide-based) * ___ ; may be beneficial for pts with malabsorption, diarrhea Fat - Long-chain fatty acids - ___ -chain fatty acids * More water soluble; rapid hydrolysis, little or no pancreatic lipase for absorption Carbohydrates – ___ polymers primarily used for tube feeding formulas – Simple glucose used for oral supplements (higher in osmolality)

- Elemental - medium-chain - Glucose

# Adjunctive Therapies- modular supplements Pro-Stat - 2 Tbsp (30 mL) - __ g protein - 72 kcal - 3 g CHO

15 g

# Adjunctive Therapies - glutamine - May reduce hospital and ICU length of stay - Reduces mortality in ___ patients - No systemic effect when given by ___ route - Will help maintain gut integrity - 0.3 – 0.5 g/kg/day divided in 2 – 3 doses * Do not supplement if already receiving glutamine via an immune-modulating formula (i.e., ___ )

- burn - enteral - Impact 1.5

# Adjunctive Therapies - Probiotics Microorganisms conferring potential health benefits to host: - Inhibit pathogenic bacterial growth - Block pathogen attachment - Eliminate toxins - Enhance host inflammatory response Clinical efficacy data are mixed/lacking May increase complications (e.g., ___ )

diarrhea

# Vitamins and Trace Elements - Used for antioxidant effects and/or repletion - Vitamin E and vitamin C - Trace elements (Selenium, zinc, copper, chromium, manganese) - Beneficial in most ICU patients - Emphasis on ___ , ___ , and ___ ___ - Consider organ dysfunction as previously discussed

- burn, trauma, and mechanically ventilated

# Complications - GI - High gastric ___ - ___ - Nausea/vomiting or ___ motility - Consider prokinetic medications - Metoclopramide, erythromycin may be given Abdominal distention - Diarrhea - Check meds, formula Constipation – Check meds

- residuals - aspiration - decreasd

# High Gastric Residuals Lower cut offs do not protect patient from complications Residuals - < ___ mL: do not hold unless intolerance signs - 200 to 500 mL: implement risk reduction measures to avoid ___ - Cutoffs may vary by site

- 500 - aspiration

# Aspiration Risk Reduction - Elevate ___ 30-45 degrees - Administer as ___ infusion - Change to post-pyloric delivery - Consider ___ drugs or narcotic antagonists

- HOB - continuous - prokinetic

# Decreased Motility: Consider Prokinetic Agents - ___ 10 mg IV/PO/feeding tube QID - ___ base 250 – 500 mg PO/feeding tube TID or 3 mg/kg IV Q8hr - ___ 8 mg via feeding tube QID - ___ weight-based dosing IV x1

- metoclopramide - erythromycin - naloxone - methylnaltrexone

# Diarrhea Formula - Change to soluble ___ -containing or small ___ formulations - Suspect Clostridium difficile colitis - Consider other infectious etiologies **Evaluate medications:** - ____ medications – Liquid formulations with sorbitol – ___ regimen – ___ ___ antibiotics

- fiber, peptide - hyperosmolar - bowel - broad sprectrum

# Hyperosmolar Medications ≥ ___ mOsm/kg

3000

Medications with Sorbitol

# Complications - Metabolic Hyper- or hypoglycemia - Check meds, ___ regimen - Stress - Infection Overhydration; dehydration - Monitor fluid status Electrolyte imbalance - ___ is most common

- insulin - hyponatremia

# Glycemic Control in ICU Goal blood glucose (BG) - ≤ ___ mg/dL NICE-SUGAR Study - ____ mortality with tight glycemic control - Higher rate of hypoglycemia with tight control

- 180 - increased

# Complications - Mechanical - ___ of feeding tube - Tube ___ (abdominal X-ray “KUB”) Rhinitis - Reposition daily - Use smaller bore tube - Change from NG to ___ Sinusitis

- clogging - malposition - OG

# Complications - Medication Related - ___ feeding tubes - Drug-tube feed ___

- clogged - interactions

# General Guidelines for Medication Delivery via Enteral Feeding Tubes - ___ medications are preferred whenever possible. - If using oral dosage forms, crush the tablet to a fine powder (or empty capsule contents) and mix in water. - **Do not crush ___ -released or ___ coated formulations!!** - Administer each medication separately. - Ensure adequate flushing with water between each medication. - Dilute ___ medications or those irritating to the gastric mucosa in at least 30 mL of water before administering

- liquid - sustained, enteric - hypertonic

# Liquid Medications Preferred Avoid ___ formulations due to risk of clogging tube: – Syrups – Mineral oil – Granules Can sometimes crush tablets or open capsules - Dilute in __ - __ mL of sterile water

viscous 15-30

# Unclogging the Tube - 1 ___ tab + 1 ___ cap + 10 mL warm sterile water - place slurry into feeding tube - clamp tube for 15-30 min - flush when complete

- sodium bicarb - pancreatic enzyme

# Drug/Tube Feed Interactions antibiotics (4) anti-retrovirals (3) other (4) hold tube feed - wait ___ hour Give med - wait ___ hours Resume feed

- 1 - 2

# Monitoring – Gastrointestinal - Gastric ___ - Emesis - Check q __ - __ hrs - ___ daily (frequency, volume) - Bloating/distention - Bronchial/tracheal aspirate

- residuals - 4-6 - stools

# Monitoring – Metabolic - I/Os; bowel movements - ___ : 2-3 times per week - Serum electrolytes, glucose, BUN/SCr [CMP]: ___ until stable -> twice weekly -> weekly - Mg, Phos, Ca, triglycerides, LFTs: ___ - Albumin, prealbumin/CRP, nitrogen balance: ___

- weight - daily - weekly - weekly

# Monitoring – Mechanical - Feeding tube ___ - Feeding tube __

- placement - patency

# Special Considerations and Disease States Acute Renal Failure - Use a normal EN formula unless electrolyte profile dictates otherwise Hemodialysis/Continuous Renal Replacement Therapy - CRRT: ___ protein requirement to prevent nitrogen deficit (max 2.5 g/kg/day) - HD: 0.8-1.2 g/kg/day protein - Loss of ___ micronutrients ( ___ , ___ , ___ ) – ___ accumulates due to it being cleared renally (falsely high)

- increased - water-soluble, selenium, zinc, thiamine - prealbumin - falsely

# Special Considerations and Disease States Hepatic Failure - Traditional nutritional assessment tools are ___ due to presence of ascites, intravascular volume depletion, edema, portal hypertension, and hypo-albuminemia - Standard enteral formulations for most liver disease patients - ___ ___ ___ ___ formulations (BCAA) for encephalopathic patients refractory to other treatments

- inaccurate - Branched chain amino acid

# Special Considerations and Disease States Pulmonary Failure Fluid- ___ , calorically dense formulations - ___ - ___ kcal/mL - Monitor ___ closely - Component of adenosine triphosphate (ATP) and 2,3-disphosphoglycerate (2,3-DPG): essential for normal ___ function

- restriction - 1.5-2.0 - phosphate - diaphragmatic

# Special Considerations and Disease States Acute Pancreatitis Metabolic changes – ↑ protein ___ - inability of exogenous glucose to inhibit ___ – ↑ energy expenditure – ↑ ___ resistance – ↑ dependence on ___ oxidation for energy EN vs. PN – Recovery and resumption of oral intake often occurs within 3-7 days, not requiring __

- catabolism - gluconeogenesis - insuline - fatty acid - PN

# Special Considerations and Disease States Acute Pancreatitis (cont.) Protein requirements - ___ - ___ g/kg/day - Consider adding ___ Glucose - Safe, same maximum as other patients Lipid infusions - Safe if ___ levels are within normal limits -> monitor closely **Parenteral nutrition does NOT affect ___ secretion and function**

- 1.2-1.5 - glutamine - TG - pancreatic

# Special Considerations and Disease States Burn Metabolic changes – ↑ basal metabolic rate and ___ loss - Glycolysis, proteolysis, lipolysis Nutritional requirements - High in protein ( __ - __ g/kg/day) and calories - ___ feeding with EN Supplements - Adult multivitamin - If TBSA >10%: Ascorbic acid, Zinc, Vitamin E, Selenium - If TBSA >20%: oxandrolone/growth hormones - Vitamin D (if deficient); Vitamin A (if on corticosteroids)

- nitrogen - 2-2.5 - early

Nutrition II Flashcards

(59 cards)