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NUTR 620 Week 11
Critical Care & Pediatric Surgery
| Question | Answer |
|---|---|
| Identify the key elements in the cascade of critical illness | Injury triggers CNS to release cytokines;promotes catabolic metabolism by inhibiting growth hormone;stress increases serum conc. of glucagon, catecholamines&cortisol; body tries make all energy sources available to fight off illness, bd of LBM (anorexia) |
| Describe the relationship between critical illness and nutritional status | During critical illness, it is possible that nutritional needs are increased due to body being in a catabolic state to provide the nutrients needed to fight off disease & infection & to heal. Risk of malnutrition increases & LBM likely to be depleted |
| Identify the signs and symptoms of critical illness that impact nutrition interventions and delivery | burn injuries, increased losses with thoracic or peritoneal drains, severe wounds, or high stool/ostomy output may necessitate increased protein intake; issues with oral intake may necessitate EN or PN, coma/paralysis could decrease energy needs |
| Describe the role of nutrition in infants and children with congenital surgical anomalies | children with congenital surgical anomalies may deal with nutritional issues such as GERD, feeding tolerance, & delayed gastric emptying. Selection of formula, osmolarity, and EN additives should be considered to relieve symptoms & support adequate growth |
| How to calculate protein needs of the pediatric surgical patient | Minimum Protein Needs: 1.5g/kg/day Ideal Protein Delivery Infants and Children < 2yo: 2β3g/kg/day Children Ages 2β13y: 1.5β2g/kg/day Adolescents: 1.5g/kg/day |
| Identify nutritional additives that may benefit a pediatric surgical patient | sodium, LCTs, pectin |
| You are working with a child that is in respiratory failure and is on a ventilator. What is the relevant stress factor? | 0.9 |
| You are working with a child that recently underwent surgery for a late diagnosis of Hirschsprung Disease and prior to surgery was in a state of moderate malnutrition. What is the relevant stress factor? | 1.1-1.2+ |
| You are working with a child that is intubated due to complications with COVID-19. What is the relevant stress factor? | 0.8 |
| You are working with a child who just underwent cardiac surgery and required ECMO. What is the relevant stress factor? | 0.9 |
| You are working with a child that survived a house fire and has burns on 30% of their body. What is the relevant stress factor? | 1.0 |
| You are working with an infant that has a giant omphalocele. What is the relevant stress factor? | 1.1-1.2+ |
| You are working with a patient that is intubated due to a pulmonary injury. What is the relevant stress factor? | 1.0 |
| What are cytokines? | Cytokines are a group of proteins, glycoproteins, and peptides with short half-lives synthesized by tissues and white blood cells that have diverse cell-signaling functions |
| Explain the role of catecholamines on metabolism changes in critically ill patients | key agent of hypermetabolism; Causes hyperglycemia via hepatic glycogenolysis; Causes lipolysis to mobilize free fatty acids (FFA); leads to overall increase of basal metabolic rate |
| Explain the role of glucagon on metabolism changes in critically ill patients | alters CHO metabolism by inducing glycolysis and gluconeogenesis to make alanine and lactate available for regeneration of glucose |
| Explain the role of cortisol on metabolism changes in critically ill patients | Induces muscle proteolysis, promotes gluconeogenesis, & insulin resistance |
| List possible screening components for critically ill children | illness severity scores, comorbidities, BMI/weight, weight loss, nutritional history, inflammatory biomarkers |
| Why is MUAC being used more often in critical care setting? | not as influenced by fluid status as other indicators of malnutriton |
| What are the key elements of nutritional assessment? | Admission anthropometrics Growth history Feeding history Medical and medication history Allergies Functional status Gastrointestinal function, symptoms Biochemical indicators of metabolic stress Nutrition focused physical exam |
| List some alternatives measures that can be taken when height or weight is not possible? | knee-length, Mid upper arm circumference, skin trifold, bioelectrical impedance analysis |
| List some critical care factors that increase energy expenditure | Acute stress response Inflammation Wound healing Dysautonomia Continuous renal replacement therapy |
| List some critical care factors that decrease energy expenditure | Sedation Paralysis Ventilator support |
| What is the association between malnutrition in the PICU setting and patient outcomes | malnutrition related to increased infection morbidity, increased length of stay, increased ventilator days, increased risk of mortality |
| True or false: In critically ill children, no consistent relationships have been observed between commonly used nutrition related biomarkers and clinical outcomes | True: biomarkers are often affected by the disease state |
| What does SGNA stand for and what to parts compose it? | subjective global nutrition assessment consists of the nutrition focused medical history and nutrition focused physical exam |
| Explain the clinical indications & considerations for measuring weight in the critical care setting | use: standard growth reference Considerations: falsely affected by fluid shifts/edema, difficult to obtain in PICU |
| Explain the clinical indications & considerations for measuring height in the critical care setting | use: standard growth reference Considerations: difficult to obtain in PICU |
| Explain the clinical indications & considerations for measuring serum albumin in the critical care setting | use: visceral protein store & long term nutrition monitoring/assessment considerations: false lows due to immobility, capillary leak syndrome, renal/GI losses/hepatic disease |
| Explain the clinical indications & considerations for measuring serum prealbumin in the critical care setting | use: visceral protein store monitoring & detection of acute changes in nutritional status considerations: false lows during period of inflammation, influenced by liver & renal disease |
| Explain the clinical indications & considerations for measuring hemoglobin in the critical care setting | use: iron status consideration: false low w/ phlebotomy (drawing blood) & anemia of chronic disease |
| Explain the clinical indications & considerations for measuring transferrin in the critical care setting | use: reflects protein depletion considerations: influenced by liver disease and inflammation |
| Explain the clinical indications & considerations for measuring serum retinol-binding protein in the critical care setting | use: vitamin A status, often low with malnutrition considerations: false low during periods of inflammation, influenced by liver and renal disease |
| Explain the clinical indications & considerations for measuring urinary nitrogen excretion in the critical care setting | use: protein metabolism, monitoring daily protein losses considerations: affected by diuretics, renal function, protein intake |
| What are the nutritional consequences of using diuretics? | electrolyte wasting, long term use can affect bone density |
| What are the nutrition consequences of steroids? | hyperglycemia, long term use can affect bone density |
| What are the nutrition consequences of sedation? | can decrease GI motility |
| What are the nutrition consequences of paralytics? | can decrease GI motility |
| What are the nutrition consequences of antibiotics? | can cause diarrhea |
| What are the nutrition consequences of vasoactive agents? | at risk for decreased perfusion to the gut |
| What are the nutrition consequences of immunosuppressants? | hyperglycemia, electrolyte and mineral abnormalities |
| What are the nutrition consequences of H2 receptor antagonists? | hyperglycemia |
| What are the nutrition consequences of chemotherapy? | decreased appetite, increased nausea/vomiting, mucositis |
| What are the consequences of underfeeding? | delayed wound healing, increased risk of infection, delayed neurodevelopment, increased mortality risk |
| What are the consequences of overfeeding? | hyperglycemia, hypertriglyceridemia, hepatic steatosis, respiratory failure |
| What is the gold standard for determining a patient's resting energy expenditure in PICU? | indirect calorimetry |
| Explain indirect calorimetry | a calorimeter captures REE at that moment by measuring oxygen consumed (VO2) with carbon dioxide exhaled (VCO2), which is used to calculate REE using the Weir equation |
| What is the respiratory quotient? | the ratio of VCO2 to VO2, used to confirm clinical suspicion of overfeeding/underfeeding |
| What is the ideal RQ range? | 0.7 to 1.0 |
| What is considered high RQ? What does it indicate? | >1.0 overfeeding |
| When is indirect calorimetry contraindicated? | patient on extracorporeal membrane oxygenation therapy, high frequency ventilation; patient has large ventilatory leak, presence of chest tube, or non-invasive oxygen support |
| Which pediatric patients should be prioritized for indirect calorimetry during critical illness? | UW(BMI<5th%), at risk of OW (BMI>85%), OW(BMI>95%); > 10% weight loss/gain during PICU stay, inability to meet caloric goals, inability to wean/escalation in respiratory support, muscle relaxant use/ventilator support>7 days,neurotrauma,cancer, ICU >4wks |
| Loss of lean body mass related to protein breakdown can result in _________________ | longer ventilation days, higher risk of mortality |
| Why is it difficulty to appropriately monitor serum levels of antioxidants during periods of critical illness/metabolic stress? | levels can be falsely impacted by undesired fluid distribution, unanticipated losses, altered protein binding, inconsistent provision of nutrient intake before/during hospitalization |
| Nutrition diagnosis in a critically ill child should address | the most acute nutrition problem targeted by the nutrition intervention while the patient is in PICU |
| The dietitian's immediate change in PICU | optimization of energy and protein intake w/i the confines of fluid allotment & tolerance |
| Considerations for EN should be made between ____ to ____ hours after admission to PICU | 24 to 48 |
| Suboptimal EN delivery in PICU is related to what clinical outcomes | greater number of days on mechanical ventilation, increased infection risk, mortality |
| Who should be considered for PN support in critical care? | patients for whom EN is contraindicated or who have failed to advance to adequate EN for energy & protein goals |
| General guidelines suggest avoiding PN support within the first __ hours of PICU admission | 24 |
| What is adequacy of intake based on? | what the patient actually received at bedside compared with prescribed values |
| What is the gold standard in determining if a child is receiving adequate energy and protein | anthropometric measurements: weight, length/height, head circumferences (children under 2 yrs), MUAC, and triceps skinfold |
| Recognize potential causes of retching in the pediatric patient following fundoplication | |
| What is physiological scaling? | Any physiological function that varies by math (m) can be approximated by a scaling factor (A) multiplied by mass raised to a scaling exponent (b), all multiplied by the error term E π(π)β (π΄ Γγ πγ^π ) Γ π |
| Why is Physiological Scaling Important? | When you are working with children, they wonβt function as adults β so you need to account for what changes are occurring if you are going to meet their needs correctly. |
| How to calculate energy needs in children post-surgery? | Use equation π΄πΈ=200 Γ π^(β0.4) where M = body mass in kg and then multiply by stress factor |
| What patients may benefit from sodium additive? | in surgical patients with ostomies(Surgical NEC, Imperforate anus, Trauma to the bowel, Hirschsprungβs Disease), sodium intake can positively influence growth |
| What is the recommendation for sodium additives? | 4-8 mEq/kg/day has been shown to help resume normal weight gain |
| What are the benefits of a pectin additive? | Helps to prolong gastric transit time by improving fluid absorption & increasing SCFA production (ex. butyrate) in the colon |
| What patients may benefit from LCT additives? | patients with osmotic sensitivity, reduced mucosal surface area, or volume restrictions (Post fundoplication, Intestinal resection, Cardiac patients) |
| How to calculate fluid needs of the post-surgical patient? | F = 300 x M^-0.5 where M is mass in kg and F is fluid in mL/kg/day |
| True or False: use of immunonutrition is recommended in pediatric patients | false, limited evidence showing benefit |
| True or False: surgery increases energy expenditure in children | false |
| True or False: protein turnover is higher in newborns (6 g/kg/day) compared with adults (3.5 g/kg/day) | true |
| Which protein source is better for gastric emptying? whey or casein | whey |
| How does osmolarity affect gastric emptying? | hyperosmolarity delays gastric emptying, increasing gastric irritation |
Created by:
jamescj
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