Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUTR 476 Advanced Clinical > Week 5 ICU Hypermetabolism II: ARDS/ Pulmonary Failure > Flashcards

Week 5 ICU Hypermetabolism II: ARDS/ Pulmonary Failure Flashcards

1
Q

What is ventilation?

A

Ventilation = respiratory rate (per min) X tidal volume/breath
* Can measure partial pressure of carbon dioxide (pCO2) to determine efficiency of ventilation
* Regulation of breathing : centrally mediated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Define resipiratory failure

A

This is a general term that describes ineffective gas exchange across the lungs by the respiratory system
* Infection/inflammation of lung tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Goals of treatment for respiratory failure

A
  • Preserve and restore LBM
  • Maintain fluid balance
  • Wean off of ventilator
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Respiratory failure effect on Cardiac Disease

A

Core Pulmonale
* right ventricular hypertrophy and failure due to increased pressure within pulmonary arteries from respiratory failure.
* Treat with oxygen therapy and diuretics to control edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Protein Requirements for respiratory failure

A

1-2 g/kg/d
* upper range if cachetic
* lower ranges if overweight or obese

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Fluid requirements for respiratory failure

A

2-3 l/d
* may have to restrict fluid if have CHF or cor pulmonale (usually 35 ml/kg or 25-30 mls/kg depending on age).
* If patients need to be fluid restricted then a TFI of 80-90% of basal fluid requirements may be needed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Indications for EN nutrition support in respiratory failure

A

when patient is unable to meet nutritional needs via oral route
* Polymeric feeds are usually fine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Considerations for EN with respiratory failure

A
  • consider if patient has a high risk of aspiration due to reflux or dysphagia or dyscoordination of ventilation (may occur with ++ SOB)
  • Consider specialized feeds (eg Pulmocare) with slightly lower CHO intake if acute illness where ++ SOB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

PN indications for respiratory failure

A

PN rarely indicated
* may occur in very acute situations where cannot meet nutritional needs via GI tract; eg serious infection with intractable diarrhea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

PN complication with respiratory failure

A

Central line placement challenging due to ↑ risk for coagulopathy and hyperinflation of line; use with caution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Define sepsis

A
  • Infection: characterized by an inflammatory response to the presence of micro-organisms or the invasion of normally sterile host tissue by these organisms
  • Bacteremia: presence of viable bacteria in the blood
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Consequences of sepsis

A
  • Can cause a state of hypermetabolism that is more variable than in trauma (clinical condition can change rapidly…within minutes)
  • Mortality and morbidity very high
  • Leads to impaired immunity (as does malnutrition)
  • Severe sepsis is associated with organ dysfunction, hypo-perfusion or hypotension.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

When can sepsis occur?

A

This can occur in either phase of Metabolic Stress
* ebb phase
* flow phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Systemic Inflammatory Response Syndrome?

A

Two or more of the following:
* Temperature > 38° C or < 36 °C
* Heart Rate > 90 beats/min
* Respiratory Rate > 20 breaths/min or PaC02 < 32 torr
* WBC > 12,000 cells/mm or < 4000 cells/mm3 or > 10% immature or band forms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is septic shock

A

sepsis with hypotension, despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that include lactic acidosis, oliguria or acute alteration in mental status
* acute, rapid on-set; sepsis…a little more chronic, may take more time.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Treatment for sepsis

A
  • Need to treat with IV anti-biotics or antifungals
  • Treat with blood products (including RBC, fresh frozen plasma), inotropic and vasoactive agents + have the potential for mechanical ventilation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Protein metabolic response during sepsis

A

Increased protein turnover
* need for gluconeogensis; biosynthesis of acute phase proteins
* Glutamine impt to reduce acidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Lipid metabolic response during sepsis

A
  • ↑lipolysis
  • ↓oxidation and synthesis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Carbohydrate metabolic response during sepsis

A
  • insulin resistance
  • hyperglycemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Vitamin/mineral response during sepsis

A

May have changes in nutrient balance of magnesium, zinc, phosphorus and potassium
* Zinc is sequestered in metallothionine system in liver (as is iron)
* Ferritin is an acute phase reactant; therefore get ↑ serum concentrations during sepsis; not reflective of total body iron status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

EN nutrition support for Sepsis

A

EN preferable;
* prevent bacterial translocation from gut but
* exercise caution due to ↓ perfusion to splanchic bed (particularly in septic shock)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

PN nutrition support for sepsis

A

PN is not typically a route of nutrition support.
* ↑ risk for infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

ARDS

A

Acute respiratory distress syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How is ARDS defined?

A

Onset of severe acute lung injury characterized by acute hypoxemic (low level of O2 in blood) respiratory failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are some characteristics of ARDS?

A
  • Get bilateral radiographic infiltrates with systemic or pulmonary inflammation
  • Functional surfactant is lost and get alveolar collapse: shifting of non-oxygenated blood past the collapsed lung
  • Finally get pulmonary hypertension due to the vasoconstrictive effects of acute hypoxia (very serious with high morbidity and mortality risk associated with this)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Phases of ARDS

A
  1. exudative phase (0-7 day)
  2. proliferative phase (7-21 days)
  3. fibrotic phase (>21 days)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

exudative phase of ARDS

A

initial insult - most dangerous (0-7 days)
* Interstitial edema
* capillary congestion
* exudate of airspaces (make need lung drainage)
* sloughing off of alveoloar cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Proliferative phase of ARDS

A

Beginnings of recovery (7-21 days)
* Myofibroblast proliferation in airspace and interstitum with mononuclear cell proliferation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Fibrotic phase of ARDS

A

Scarring/ permanent healing (>21 days)
* Increasing fibrosis
* honey combing and cyst formation
* scarring is trying to help with wound; see permanent places of damage

30
Q

What P/F ration is indicative of lungs working?

A

P/F ration <200

31
Q

Energy and protein nutrition requirements for ARDS

A
  • Energy: 25-30 kcal/kg; could be higher with sepsis (may be as high as 35)
  • Protein: 1.5-2 g/kg/d (consider renal function; if impaired may not want to go this high)

Increased if sepsis is present

32
Q

CHO nutrition requirements for ARDS

A

Avoid overfeeding with CHO; keep GIR < 5 mg/kg/min

33
Q

Electrolyte requirements for ARDS

A

Monitor serum electrolyte carefully
* particularly PO4 Mg and K+; re-refeeding syndrome

34
Q

micronutrient requirements for ARDS

A

Ensure micronutrient status
* all are micronutrients are important
* pay close attention to thiamin, antioxidants, pyridoxine and Zn re: infection risk
* Sometimes patients are prescribed antioxidant cocktails consisting of selenium, vitamin C and E and b-carotene (equivocal results)

35
Q

EN nutrition support for ARDS

A

preferred if nutrition support necessary
* May need ventilatory support for ARDS for 10-14 days
* Start with Ng
* typical energy dense, lower CHO (isoosmolar, polymeric, HP)

36
Q

PN nutrition support for ARDS

A

rarely indicated
* avoid overfeeding at all costs; better to give less so you don’t compromise respiratory function
* Keep GIR at 2-4 mg/kg/min
* Protein requirements: 1.5 g/kg/d (monitor renal function and may need to give less 1.2 g/kg/d)
* Energy: consider cachexia and ebb vs flow phase of stress response; if in acute distress; feed at lower energy intakes of 15-20 kcal/kg
* Keep PN within TFI set by MD; introduce PN cautiously and increase slowly as per Pt outcome
* Electrolyte and fluid management critical

37
Q

ASPEN guidelines for COVID

A
  • Early EN (24-36 hrs); hypocaloric and advanced slowly to 15-20 kcal/kg actual body weight
  • Protein 2-2.5 g/kg/d due to high risk for sarcopenia.
  • Recommend continuous feeding rather than bolus. NG or oro-gastric tube.
  • Early PN; top off if EN not meeting needs
38
Q

Define intestinal failure

A

Gastrointestinal function which is insufficient to satisfy body nutrient and fluid requirements.
* This means individuals have an inability to meet their nutritional and fluid needs
without external sources of fluid and nutrition (IV).

39
Q

When does intestinal failure require transplantation?

A

When a patient experiences complete intestinal failure with ongoing significant complications such as infection, liver failure

40
Q

length of SI

A
  • neonate: 250 cm
  • adult: avg. 600 cm (range 260-800 cm)
41
Q

Defining short gut syndrome by SI length

A

200 cm viable (adult)
* >50-80% has been lost

42
Q

SI length requiring lifelong TPN dependence

A
  • adult with intact colon: 60 cm
  • adult without colon: 100 cm
  • infant with ileocecal valve: 11 cm
  • adult without ileocecal valve: 12-25 cm

minimal gut length required for life

43
Q

What happens in terms of Nutrition when you have Intestinal Failure?

A
  • Malabsorption of macro-and- micronutrients, fluid and electrolytes
  • Can become dependent upon IV nutrition for fluid & nutritional needs
  • Failure to thrive
  • Increased risk for complications due to lack of enteral stimulation (Infection/ organ failure)
  • Decreased Quality of Life
44
Q

What can cause bowel obstruction

A
  • mechanical blockage
  • paralytic ileus (impaired motility)
45
Q

Symptoms of bowel obstruction

A

higher the obstruction the quicker the symptoms
* fecal matter gets stuck
* vomitting
* hypovolemia (obstruction absorbs fluid)
* may turn malodorous with fecal smell
* abdominal distension
* constipation with failure to pass flatus
* bowel sounds: high pitched at first then silent.

46
Q

Prognosis for intestinal autonomy (independance)

A
  • Residual small bowel length (More important for adults than children)
  • Presence of IC valve: prevent bacterial overgrowth from LI to SI
  • Presence of colon: affects intestinal transit and Fluid, electrolyte, energy absorption
  • Motility: prevent bacterial overgrowth
  • Enteral Stimulation to promote gut adaptation (critical)
47
Q

Why is residual bowel length more important in children than adults?

A

children have potential to increase gut length
* favorable long-term prognosis compared to adult for potential intestinal growth after resection

48
Q

Modes of Nutrition Therapy in Intestinal Failure

A
  • Total Parenteral Nutrition (TPN)
  • Enteral + PN + IV hydration
  • Enteral + IV fluid support (jejunostomy)
  • Enteral (continuous vs bolus feeds)
  • Oral diet (with small bowel adaptation)
49
Q

Medical Management of Diarrhea and Ostomy Output

A
  • Avoid factors that ↑ unabsorbed solute (eg CHO)
  • Monitor accurate input and output
  • Measure stomal fluid electrolytes (liquid losses include water, sodium, potassium, magnesium, zinc, selenium and bicarbonate)
50
Q

Types of ostomys

A
51
Q

Energy needs for intestinal failure

A

Increase energy density of diet
* Energy requirements tend to be 25% -200% higher due to severity of malabsorption
* higher if patient experiences liver failure

52
Q

EN energy management (calories) for intestinal failure

A

Consider use of nocturnal nasogastric feeding when necessary (po intake < 50% of total energy requirements)
* adults may range from 35-40 kcal/kg
* children and adolescents; 60-100 kcal/kg (dependent upon age)
* Infants: 120-150 kcal/kg

53
Q

PN energy management (calories) for intestinal failure

A

PN varies - onyl use when gut not functioning or in presence of severe esophageal varices
* have to be careful NOT to overfeed!

54
Q

Protein requirements for intestinal failure

A

1-1.5 g/kg/d
maybe higher depending on extent of intestinal or liver dysfunction

55
Q

Important considerations with intestinal failure

A
  • Be careful of re-feeding syndrome as most patients with intestinal failure ± liver failure have cachexia
  • pre: nutritional TX status affects morbidity and mortality in post-TX period
56
Q

What needs to be monitored in liver & intestinal failure for nutritional status?

A
  • fat soluble vitamins and others; ensure adequacy (give supplement)
  • Albumin; not good marker under these conditions
  • Serum and urine electrolytes; fluid and electrolyte status
  • Urea; recent protein intake, renalfunction and hydration
  • creatinine; lean body mass and renal function
  • Liver function tests: AST/ALT, ALP, GGT, Conjugated Bilirubin
  • CBC/ Hb, hct MCV; iron status
  • ferritin; reflective of iron stores but is also acute phase reactant so in presence of infection or sepsis does not reflect iron status well
57
Q

Goal of nutritional management with intestinal transplant

A

promote recovery and optimal nutrition in the Post-TX period and to minimize nutrition related complications of immunosuppressive therapy

58
Q

Phases of treatment with bowel/liver transplantation

A
  • Acute transplant period (post-operative course: 24-48 hours)
  • chronic phase
59
Q

Major Complications that exists for TX recipients

A
  • Rejection
  • Infection
  • Side Effects of the medications: increased poor bone health, increased protein turnover and increased risk for sarcopenia and frailty, increased cancer risk.
  • Increased CVD complication risk associated with insulin resistance, obesity and increased oral intake
60
Q

Potential electrolyte complications with Intestinal/Liver TX in the Acute Period

A

Electrolyte disturbances
* Increased stomal losses and immunosuppression; renal function may be compromised due to high levels of immunosuppressive drugs (these are often nephrotoxic).
* Commonly: serum potassium may be too low or too high; depending on meds
* Magnesium often low due to meds

61
Q

electrolyte needs in the acute period of intestinal/liver treatment

A

Meds often means you need to increase delivery; MD to order changes in acute period; RD to monitor.

62
Q

Energy needs in the acute period of intestinal/liver treatment

A

varies with individual, gender, coinciding medical events
* Ebb Phase consider 15-20 kcal; kg
* Flow Phase: 30-35 or possibly higher kcal/kg

63
Q

Potential protein complications with Intestinal/Liver TX in the Acute Period

A

Induces a stress response so protein turnover increases with
* ↑ biosynthesis of acute phase reactants;
* ↓protein synthesis and
* ↑protein oxidation
* Also corticosteroids (eg prednisone) increase protein turnover

64
Q

protein needs in the acute period of intestinal/liver treatment

A

1.5-2 g/kg/d in adults
* Protein needs increase due to losses in stomas, surgical drains

65
Q

What kind of EN feed would you choose in the acute post-operative phase for intestinal/liver Tx; assuming patient is hemodynamically stable?

A

All are possible; you need to consider patients TFI, blood work; review medical records for any indications for graft rejection
* Polymeric: lactose feed should be fine; what are they? Would you use a higher protein formula
* May need semi-elemental with MCT oil if still have some malabsorption due to acute rejection of new organ
* What about need for fluid restrictions?

66
Q

PN in acute period post TX?

A

Only if GI tract not working within 24-48 hours (in children); 4-5 days or longer (adults)
* Repeated endoscopy will show signs of rejection
* ↑ stomal output form intestinal graft
* persistently high liver functions (ALT, AST, conjugated bilirubin/unconjugated bilirubin) for liver TX

67
Q

Energy needs in the chronic period of intestinal/liver treatment

A

30-35 kcal/kg
* unless have chronic rejection; then may be higher

68
Q

Protein needs in the chronic period of intestinal/liver treatment

A

1 g/kg/d
* may vary depending on corticosteroid dosing
* Need to consider nephrotoxicity of drugs as well; renal function is often compromised by the drugs

69
Q

Glucose and lipid complications with Intestinal/Liver TX

A
  • Glucose and Lipid Metabolism; May have chronic insulin resistance (caused by immunosuppressive therapy)
  • Hyperlipidemia, insulin resistance, obesity are common long term complications in organ recipients
  • Omega 3 therapy helpful to reduce inflammation in organ graft
70
Q

Chronic nutrition support with intestinal/liver transplantation

A

Tapering of parenteral/IV support with progression of enteral support
* Slow increase of enteral support- continuous
* Monitor electrolyte & fluid balance
* Monitoring of feeding tolerance (stomal outputs) + nutrient absorption

71
Q

Clinical variables to consider in cases when considering nutrition support.

A
  • medication effects
  • metabolic phase of stress
  • other metabolic changes and function
  • ventilation/ respiratory status
  • GI function
  • hemodynamic stability/ instability
  • type of injury/ relevant co-morbid conditions
  • presence of infection/sepsis
  • lab work
  • fluid status/ TFI
  • transplant type
72
Q
A

NUTR 476 Advanced Clinical (23 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions