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Essential Proteins Histidine, Isoleucine, Leucine, Lysine, Methionine, Phenyalanine, Threonine, tryptophan and Valine
What protein supplementation is required for critical illness Glutamine
Alpha linolenic acid DHA and EPA omega 3's
Linoleic acid arachadonic acid omega 6
What is GALT? Gut Associated Lymphoid Tissue ( highest amount in ileum) host defense
What is required to absorb vitamin b12 Intrinsic factor secreted by the stomach binds b12 and allows absorbtion
What is the site of absorption of most nutrient particles? The Jejunum
What cells secrete insulin and glucagon Endocrine pancreatic Beta cells
What are the metabolic fates of proteins? 1. Protein synthesis ( the body makes them into useable AA's) 2.Deamination conversion into urea and NH3 3.Transamination: Ketoacids (carbon skeletons)
What are the metabolic fates of Lipids? 1. Beta oxidation 2. stored as triglycerides in adipose tissue
What are the metabolic fates of carbohydrates? 1. Glycolysis- oxidation: 1 the conversion to ATP for immediate use or 2.FA to be stored in adipose tissue 3. Glycogenesis: stored in liver and skel muscle 3.
Growth hormone GI Hormone that is secreted by the pituitary and acts on adipose and muscle tissue to increase muscle growth
EPI/ NOR epi and cortisol secreted from adrenals, acts to break down muscle
When can dysphagia occur? 24-48 hours after intubation post stroke speech therapist will do a barium swallowing test to determine
What is a MBS? modified barium swallowing test where different types and consistencies of food are mixed with barium to see what the patient can swallow
How many Kcal/Kg/day do we feed a normal healthy patient? 25kcal/kg/day
how many Kcal/Kg/day do we feed a patient under moderate stress? 30 Kcal/Kg/day
How many Kcal/Kg/day do we feed a patient with a major trauma? 35 Kcal/Kg/day
How many Kcal/Kg/day do we feed a burn victim? 40 Kcal/Kg/day
How many Kcal/Kg/day do we feed an obese patient? 11/14 Kcal/Kg/day
How much fat do we feed a patient per day <30% of total Kcal per day
How much fiber do we feed per day? 20-35 grams per day
how much water do we need per day 35 ml/kg/day
Non-inflammatory term for malnutrition? starvation
Inflammatory terms for malnutrition acute and chronic disease related
Marasmus malnutrition severe calorie deficit malnutrition
Kwashiorkor malnutrition Severe protein deficiency malnutrition
Starvation related malnutrition types and response anorexia and bulimia; responds to nutrition, non-inflammatory
Linoleic acid deficiency: Pn Deficiency scaly rash, increased infection and decreased wound healing
Vitamin A deficiency Night blindness, dry hair and pruritis
Vitamin A toxicity peeling skin, alopecia, gingivitis and jaundice absent yellow eyes
Vitamin d functions calcium absorbtion and regulation
Vitamin D deficiency RICKETS, osteomalacia and muscle weakness
Vitamin E function Antioxidant and normal RBC function
Vitamin E deficiency ANEMIA, muscle weakness and hemolysis
Vitamin E toxicity increased bleeding and bruising and decreased platelet aggregation
Vitamin K functions Synthesis of clotting factors
Vitamin K deficiency Increased bleeding and bruising
Vitamin K toxicity Jaundice
Vitamin B1 Thiamine
Vitamin B1 functions nucleic acid synthesis and carbohydrate metabolism
Vitamin B1 deficiency Beriberi and Wernicke-Korsakov syndrome
Vitamin B2 Riboflavin
Vitamin B2(riboflavin) functions energy production, niacin synthesis and antioxidant
Vitamin B2 (riboflavin) deficiency mucositis, cheilosis, photophobia and burning eyes
Vitamin B3 Niacin
Vitamin B3 (niacin) functions coenzyme in energy production
Vitamin B3 (niacin) deficiency Pellagra and Casal's necklace
Vitamin B3 ( niacin) toxicity Flushing and Liver damage at chronic high doses
Vitamin B5 Pantothenic acid
Vitamin B5 (pantothenic acid) functions synthesis of cholesterol and steroid hormones
Vitamin B6 Pyridoxine
Vitamin B6 (pyridoxine) functions Synthesis of neurotransmitters Synthesis of niacin from tryptophan Hemoglobin synthesis and function
Vitamin B6 (pyridoxine) deficiency mycrocytic anemia neuropathy seizures
Vitamin B6 (pyridoxine) toxicity neuropaties
Vitamin B9 Folic acid
Vitamin B9 (folic acid) functions synthesis of methionine from homocysteine and RBC formation
Vitamin B9 (folic acid) deficiency Neural tube defects glossitis (swelling of the tongue) stomatitis macrocytic anemia
Vitamin B12 Cyanocobalamin
Vitamin b12 (Cyanocobalamin) functions nervous system cellular division and growth
Vitamin B12 (Cyanocobalamin) deficiency PERNICIOUS ANEMIA glossitis peripheral neuropathy Focal neurological deficits
Biotin functions Cofactor in carbohydrate metabolism
Vitamin C functions collagen synthesis, norepinephrine synthesis, carnitine synthesis, antioxidant
Vitamin C deficiency Scurvy, poor wound healing and keratosis of hair follicle
Vitamin C toxicity kidney stones stomach cramping and diarrhea
Chromium Functions Promotes normal function of insulin
Chromium toxicities Insulin resistance(hyperglycemia) Increased LDL peripheral neuropathies
Copper functions enzyme catalyst, melanin production and iron metabolism
Copper deficiency microcytic anemia, neutropenia, decreased hair and skin pigmentation
copper toxicity kidney and liver failure
Iodine function Thyroid hormone
Iodine deficiency Goiter and hypothyroidism
Iodine toxicity hyperthyroidism and parotitis
Manganese functions cartilage synthesis and metabolism of fats and proteins
manganese deficiency bone malformation, infertility and seizures
Manganese toxicity parkinsonism difficulty concentrating
Selenium functions enzymatic processes and activation of T3
Selenium deficiency muscle pain and weakness cardiomyopathy and hypothyroidism
Selenium toxicity brittle hair and nails, hair loss and death
Zinc functions Various enzymatic processes Sense of taste and smell Immune function Growth and development
Zinc deficiency Decreased sense of taste and smell Impaired wound healing Dermatitis
Zinc toxicity metallic taste, N
Refeeding syndrome occurs when feeding after starvation, insulin increases drives ions intracellular = shut down of organs and possibly death
JNC requirement for assessment of nutrition all hospitalized patients within 24 hours
Prealbumin Carrier protein for thyroid hormone Sensitive to short-term changes in inflammation and protein nutrition (t½ is 2-3 days)
Nitrogen balance Direct marker of protein gain/loss Indirect marker of metabolic rate g of protein per day/ 6.25) – (UUN + 2
Ways to kill or seriously harm patients with nutrition Risk for refeeding syndrome – no electrolytes Renal impairment – too many electrolytes Fluid overload – no fluid restrictions Parenteral nutrition Exceeding Ca-Phos solubility Exceeding osmolarity max Exceeding dextrose-rate max All pts, no monitor
Harris benedict equation for REE overestimates in modern populations Underestimates in hospitalized patients
Mifflin St. Jeor equation More accurate in obesity NOT accurate in critical care patients
Ireton jones equation Most accurate in critically ill patients Do not use in healthy or moderately stressed patients
estimated Kcal requirement for all patients except obese 25 kcal/KG actual body weight/day
Estimated Kcal requirement for obese patients 11-14 Kcal/Kg actual body weight /day
How many Kcal per gram in each: protein, fat and carb Prot=4 Kcal/g Carb= 4 Kcal/g Fat = 9 Kcal/g
How many Kcal in D5 dextrose 0.17 Kcal/ml
How many Kcal of fat in propofol 1.1 Kcal/ml
How many kcal in dextrose PN 3.4 Kcal/G
How many Kcal in IVFE 10%= 11 Kcal/g 20-30%= 10 Kcal/g
How many total ml to be provided qday of fluid via PN 35ml/kg
formula to determine glucose infusion rate glucose in mg(grams 1000)/patient weight in kg/ minutes of administration (1440 for 24 hours, 720 for 12 hours...)
what must the glucose infusion rate be below to be acceptable? <5 mg/kg/min
formula for final concentration of macronutrients total grams of carb/total volume in ml total grams of protein/total volume in ml total grams of fat/ total volume in ml
Formula for osmolarity Total grams of protein/total volume in liters x factor 10 plus total grams of carbs/total vol in liters x 5 plus total grams of fat/total volume in liters x 1.5
what number must the total osmolarity be under to be given peripherally? <900
Contraindications for enteral nutrition severe short bowel <100 cm severe GIB gi obstruction illeus
when to start EN non critically ill within 7 days critically ill within 24-48 hours
short term methods of entry for EN oral and nasal
long term methods of entry for EN gastric and jejunal or duodenal distal from trietz point
closed system EN delivery method bottle containing sterile formula, can hang 24-36 hours used for continuous feeds
continuous feeds and who to give them to feeding at a constant rate over 24 hours, preferred in critically ill, intubated, risk of re-feeding, unable to tolerate bolus, poor glycemic control and j-tube atients
bolus feeding mimics natural feeding, given via syringe or can over 20-60 QID
cyclic feeding continuous feeds given <24 hours to promote daytime eating
trophic feeding delivers low rate< 30 ml/h to stimulate intestinal feeding, used in newborns and adults intolerable of goal EN rate
Regulation formula for EN considered medical food, not subject to strict claim and labeling regulations
polymeric/standard EN closest to real food, contains macro nutrients in original form
monomeric/hydrolyzed/elemental EN eliminates need to digest all nutrients, partially or completely predigested macronutrients.
frequency and rate of continuous EN feeds 20/50 ml/hr goal 50-60 ml/hr, advance 10 ml q4 until at goal
frequency and rate of bolus feeds start 125 ml per feed advance 125 ml/feed until at goal of 725 ml per feed
when to check residuals q4h
what volume of residuals will initiate a change and what is the change >250 consider prokinetic >500 hold 4 hours then if >250 consider prokinetic
Safe practices for enteral feeding A=aseptic technique L=label enteral equipment E=elevate head of bed 30' R=Right patient, right formula, right tube T=trace all lines and tubing back to patient
safe practices for enteral medications A=ask the pharmacist about interactions... W=water only for admin and flushing A=administer medications individually R=Right patient, Right med, Right dose E=establish evidence based protocols
enteral misconnections wrong tube for EN or EM, always trace to patient
common problem medications with EN warfarin, levo, phenytoin and FQ's
what does basic PN not contain? Iron, fiber, glutamine or phytochemicals
contraindications for PN Hemodynamic instability, working gut, acid base imbalance and electrolyte imbalance
PICC line Vs Central line for PN administration PICC risk of extravasation and phlebitis short term<2 weeks and <900 mosmol to be administered and < 10 % dextrose
things that affect the solubility, stability and compatibility of PN ph, light, temperature, concentration of admixture ingredients and medications
types of CHO used in PN dextrose or glycerol (glycerin)
concentrations of amino acids in PN standard 3.5-10% concentrated 15-20% pediatric 6-10%
contents of AA in PN > BCAA, less phenylalanine and methionine and lower PH
what protein is missing from PN L-cysteine, must supplement
TPN electrolytes come in salts or combo salts, must be added to custom PN bags
how to give NA ions in tpn In salt form with phosphorus until PH dose reached then based on acid base if acidotic give remainder as acetate if alkalotic give as chloride
Preferred method of calcium combination calcium gluconate
Phosphate increase if refeeding possible decrease in renal insufficiency
How to keep ca and Ph soluble lower PH, add l-cysteine, use ca gluconate, administer separately keep product <55 MEQ, use high conc of AA
acetate and chloride no requirements, use to maintain acid base balance
trace elements for TPN zinc, copper, manganese, chromium and selenium Selenium not found in pediatric TE supplement
aluminum contamination in PN toxicities can lead to osteomalacia and encephalopathy microcytic anemia; all concerns with long term TPN
Order of mixing when making a compounded PN 1. dextrose, AA's and sterile water 2. Phosphate 3. electrolytes 4. Trace elements then agitate 5. calcium then agitate and inspect for particles 6. IVFE, inspect for phase separation 7. Vitamins
compounded PN storage parameters store in fridge, good for 30 hours at room temp and 7 days in fridge avoid extreme light
IVEF: Creaming separation of TG to top of the bag
IVEF: aggregation clumping of TG particles
IVEF: coalescence clumping of TG particle into large fat globules
IVEF: crackling separation of oil and water phases
Hang time for PN TPN: change q 24H 2:1 can hang 72 hours IVFE <12 hours
how to calculate a cycle for tpn 50% of goal for first and last hours, then total volume / total middle hours plus the added 50% for first and last hours, EG goal 1800 = 1800/11 = 164 164 /2 = 82 so 163x 10plus 82x2 = 1804
Filter sizes for PN TPN or 3:1 1.2 micrometer 2:1 .22 Micrometer, catches bacteria will clog with IVFE IVFE alone+ not filtered
dextrose rates min 1mg/kg/min MAX 5MG/KG/MIN 10-14 in peds
some PN adverse effects steatohepatitis (fatty liver), infection, occlusion, bone disease hypo/per glycemia and hypertriglyceridemia
preventing hyperglycemia in TPN administer 1 unit of insulin/ 10G CHO, if diabetic make it 1.5-2 units/G CHO
Fatty liver signs and prevention elevated ast/alt 3x uln, prevent by not exceeding 30% IVFE, don't overfeed, reduce CHO rate, Cycle PN
Disease specific: Diabetes Mellitus Kcal: decrease CHO: not restricted may require insulin PROT: limit if nephropathy w/o dialysis FAT: limit sat fat to <7% Fluids/lytes: no recommendations Micro: do not supplement antioxidants give MVI
Disease specific: Renal failure Kcal: same, increase if stressed CHO: same as normal Prot: same if not dialysis Increase If dialysis Fat:sat fat <7%
organization responsible for all obesity information national heart, lung and blood institute at NIH
formula for BMI height in inches X weight in KG (ABW) all time 703
classification for overweight 25-29 bmi
classification for obese 30-34.9 stage 1 35-39.9 stage 2 >40 extremely obese stage 3
comorbidities for obese:cardiac HTN, stroke, HF and CAD
comorbidities for obese: metabolic DLD, DM, insulin resistance, polycystic ovarian syndrome and menstrual irregularities
Comorbidities for obese: respiratory COPD, sleep apnea, asthma and pulmonary HTN
waist circumpherences for obese men >40 inches women >35 inches
risk factors for obesity related diseases 3 or more of the following Cigarette smoking HTN High LDL, low HDL DM family history of CHD AGE men>45 women >50
goal intake of calories for obesity to lose weight women 100-1200 men 1200-1500 may be higher in very obese
Orlistat (ALLI)MOA pancreatic lipase inhibitor reduces fat absorbtion
Orlistat ADR fecal urgency, spotting, can be helped by increase of fiber
Orlistat CI pregnancy
Orlistat interactions supplement MVI and interacts with Warfarin
Apidex, suprenza (Phentermine) sympathomimetic, adrs similar to amphetamine, increased HR, tremor, insomnia, palpitations, blood pressure^ dry mouth
Apidex, suprenza (Phentermine CI) maoi's w/in 14 days, Preg, breast feeding, HTN, glaucoma, h/x substance abuse, CVD and hyperthyroidism
Qysmia (Phentermine/ topirimate) all similar to phentermine alone but added topirimate
Bontril (Phendimetrazine) similar to phentermine in everyway, add flushing to ADR.
Tenuate (Diethylproprion) similar to phentermine in everyway
Belviq (Lorcaserin)MOA %HT-2 agonist produces early satiety
Belviq (lorcaserin) ADR's HA, dizziness, dry mouth constipation and hypoglycemia
Belviq (lorcaserin) CI Pregnancy and concomitant use of ergot derivatives
Bitter orange evidence and moa this med not proven effective yet sympathomimetic appetite suppressant
Bitter orange ADR MI, stroke seizure
Bitter orange CI/warnings Preg, cardio problems, avoid with drugs that extend QT wave
Chitosan reduces fat absorption, good evidence, can cause gas, stinky stool, loose stool. works like orlistat so avoid combo. avoid in shellfish allergies
Raspberry ketones appetite suppressant, proven in animals only, can increase BP, tachycardia and palpitations, CI in prego
DHEA MOA endogenous adrenal hormone thought to be decreased in obesity
DHEA evidence good evidence
DHEA ADR's gynocomastea, masculinization, increased BP and Blood glucose
DHEA CI/ warnings Prego, risk or current prostate, ovarian or breast cancers
HOODIA appetite suppressant, unclear evidence, CI prego
Pyruvate evidence unclear,Increases metabolism, ADR's bloating, diarrhea, gas. CI in prego and cardiomyopathy
HCG good evidence
lapband creates a pouch to reduce volume consumed
biliopancreatic diversion creates malabsorbtion by decreasing intestine available toabsorb
rous en Y bypass reduces stomach size and reroutes past the duodenum
supplementation for bypass patients Vitamin B12, ≥ 350 mcg/day PO Vitamin D 400-800 IU/day PO Elemental iron 40-65 mg/day PO Calcium citrate 1200-2000 mg/day PO Folic acid 400 mcg/day Multivitamins 1-2 tablets/day PO
infant developmental milestones 6 months: sits unsupported 9 months: immature pincer grasp
growth charts to use in children WHO chart: <2 CDC chart: 2-20
frequency of breast feeding of infants 8-12 times qday 10-15 minutes per breast
Deficits in weight for age are called what? Underweight
Deficits in length for age are called what? Stunting
Deficits in weight for length are called what? Wasting
When does Sids most often occur? Ages 1-5
Similac go n grow is what kind of formula? traditional and soy
Enfamil prosobee is what kind of formula? Soy
pregestimil lipil is what kind of formula? semi elemental
Neocate infant formula is what kind of formula? Elemental
when calculating nutrition for infants and kids what do we calculate? Kcal and protein only
what is the tend for Kcal needs as kids age decreases as they age
what is the trend for kids for protein as they age Increases as they age 1-20
Created by: btrain67



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