Therapeutics IV Tutoring Nutrition Lisa Hayes lhayes3@uthsc.edu April 9th 2016

Outline Metabolic Concepts/Nutritional Assessment Nutritional Requirements Parenteral Nutrition Enteral Nutrition

Which of the following is not correct? A – Ethanol is 7kcal/gm B – Dextrose is 2kcal/gm C – Protein is 4kcl/gm D – Fat is 10kcal/gm B – it is 3.4kcal/gm

A – RQ will remain unchanged B – RQ will increase C – RQ will decrease Unfortunately, you miscalculated the number of dextrose calories to be provided to patient CG. CG has been receiving twice the daily recommended amount. What will likely happen to their RQ? A – RQ will remain unchanged B – RQ will increase C – RQ will decrease RQ = respiratory quotient Want it to be close to 1 (oxygen equal to CO2) Bad if extra CO2 being produced So will increase  B (fat synthesis from overfeeding)

Which of the following acts as a precursor to nitric oxide (a vasodilator)? A – omega-3-fatty acids B – arginine C – glutamine Omega – anit-inflammatory props Answer is B – arginine which also is secretagogue of GH and insulin Glutamine – conditionally essential critical illness  pancreas, kidney, wbc users of glutamine (enhance immune fxn)

A – 1300 dextrose calories B – 1700 dextrose calories What is the maximum dose of dextrose for 63kg patient (using the max 5mg/kg/min or 25kcal/kg/day). A – 1300 dextrose calories B – 1700 dextrose calories C – 1575 dextrose calories D – 1845 dextrose calories C Minimum glucose reqt  100-130g/day; 80-150 additonal for surgery wound

What is the goal blood glucose based on the NICE-SUGAR trial? A – under 110mg/dL B – under 180mg/dL C – 70-100mg/dL D – 70-130mg/dL B Note that trauma pt and pt with corticosteroid may benefit from more intensive therapy

Determine the BMI for a patient who is 5ft, 4 inches tall and 143 pounds. 2.2 pounds in 1 kg 2.54 cm in 1 inc  cm to m is 10-2 OR 39.37 in is 1meter B – answer

Which of the following is the best indicator for acute changes in nutritional status? A – albumin B – prealbumin C – transferrin B – prealbumin – short half life (2 days) will tell you how pt is responding to acute therapy (normal 15-40) Albumin – good predictor of long term nutritional status; will increase if albumin IV is given; good for am care; long ½ life  21 days

A – 35 kcal/kg (stressed pt) B – 1.5 x BEE (stressed pt) TH is a patient who has been admitted to the ICU at Vanderbilt secondary to burns from a work injury. He is burned over 30% of his body. Which of the following is the most appropriate method to determine the calories to provide this patient? (75kg) A – 35 kcal/kg (stressed pt) B – 1.5 x BEE (stressed pt) C – Xie equation D – Penn State equation C – this is for thermally injured pt (niche)

A – 25kcal/kg/day B – 1.2 BEE C – 20kcal/kg/day D – 1.5 BEE RT is a 57 y/o patient who has been admitted with ileus. IBW is 68kg. Current body weight 60kg. Which of the following would be most appropriate for this patient? A – 25kcal/kg/day B – 1.2 BEE C – 20kcal/kg/day D – 1.5 BEE D Argument could be made for 30kcal/kg/d also but usually in underweight this is an overestimate so BEE is better

A – 4.8 kcal/day B – 138 kcal/day C – 554kcal/day D – 333kcal/day Calculate the number of calories/day that come from propofol when a 70kg patient is on a drip rate at 30mcg/kg/min.(concentration: 10mg/mL) A – 4.8 kcal/day B – 138 kcal/day C – 554kcal/day D – 333kcal/day How many kcal/day is this? D 30*70*60*24*1.1/(1000*10) 30mcg*70kg*60min*24hr*1.1kcal/ (1000mcg*10mg)

Refeeding is an issue of which electrolyte? A – potassium B – phosphorus C – calcium D – sodium B

A – 0.8 g/kg/day B – 1.5g/kg/day C – 2g/kg/day D – 3g/kg/day HP is post-op from a small bowel resection and is to be receiving TPN. He is 61kg. Determine the amount of protein to be added to his TPN. A – 0.8 g/kg/day B – 1.5g/kg/day C – 2g/kg/day D – 3g/kg/day C 0.8-1.2 is maintenenace 1.5-2 is protein depeletd – cachexic 2-2.5 is postop/infx 2.5-3 is major trauma

Which of the following is not a valid reason starting PN? A – hyperemesis gravidarum B – pancreatitis, moderate C – ileus D – patient unable to take PO for over 7 days B – severe pancreatitis is a cause for PN

What percentage of calories are required to come from fat (linoleic acid)? B – 2-4% C – 10% D – 12-15% B Though 15- 20% of calories can come from fat as optimal amount 2-4% are required to prevent EFAD Issue with EGG allergy

A – no, no additional supplements required B – selenium C – copper TG is a patient on TPN. He has been having severe diarrhea for the past 3 days. Should any of the following supplements be increased in his TPN? A – no, no additional supplements required B – selenium C – copper D – zinc D

C – hold copper and manganese in TPN You are managing the TPNs today at UTMC. You are reviewing the labs for the patients this morning and notice that RT’s bilirubin has increased significantly from yesterday (direct bili is 4 today). What should you plan to do? A – hold TPN B – hold fat in TPN C – hold copper and manganese in TPN D – hold calcium in TPN due to risk for precipitate C

Which of the following is NOT a risk associated with total nutrient admixture? A – decreased compatibility of additives B – not a good growth media for microorganism C – cannot visualize particulate matter D – cannot filter with 0.22micron filter B

A – Add long-acting insulin to TPN bag Which of the following is not a way to manage hyperglycemia associated with TPN administration? A – Add long-acting insulin to TPN bag B – start patient on sliding scale insulin C – decrease dextrose concentration of bag D – start patient on insulin drip A – can add REGULAR insulin to TPN bag

A – potassium phosphate B – potassium chloride C – potassium acetate TR has been on TPN for several days. Today his pH is 7.3. His K+ is 3.1. How do you wish to provide his potassium in his TPN? A – potassium phosphate B – potassium chloride C – potassium acetate So is this acidosis or alkalosis  acidosis AC  ACetate aLk  chLoride C

In what population is it commonplace to start both EN and PN simultaneous? A – elderly B – burns C – neonates D – obesity C

Which type of tube can you cycle EN with? A – gastrostomy B – permanent jejunostomy C – NG tube D – NJ tube A or B

When is it appropriate to recommend a concentrated EN product? A – patient needs fiber B – CHF or ARDS C – AKI D – dehydration B

A – polymeric, fiber containing formula HB is a patient who has difficulty digesting food due to his SBS as a result of significant bowel resection secondary to Crohn’s disease. Which of the following EN formulations would be appropriate? A – polymeric, fiber containing formula B – concentrated, polymeric formula C – chemically defined, nutritionally complete formula D – concentrated, low-protein C

B – metoclopramide 20mg IV q12 hours What can be done when elevated gastric residuals are noted in a patient on EN? A – half the rate of EN B – metoclopramide 20mg IV q12 hours C – erythromycin 50mg IV q6hours x 48hours D – change to PN D Don’t half the rate – would be huge compromise in therapy Is metoclopramide 10mg q6h Emycin 250mg iv q6h if refractory to metoclopramide Can change to PN if reqd

How would you treat hyperglycemia associated with EN? A – add regular insulin to EN formula B – look for other sources of dextrose in patient’s regimen and eliminate C – consider long-acting insulin D – change to high-carb formula E – B and C E

A – 960kcal B – 2400 kcal C – 816kcal D – 840kcal A patient, NH, has the following formula for their TPN. Calculate the number of dextrose calories that come from their TPN. 240g dextrose, 40g lipid, 140g protein. A – 960kcal B – 2400 kcal C – 816kcal D – 840kcal C

A – 400kcal; 15% B – 400kcal; 22.5% C – 136kal; 4% D - 136kcal; 8% How many calories come from fat? What percentage of daily calories is this? (reminder: 240g dextrose, 40g lipid, 140g protein. ) A – 400kcal; 15% B – 400kcal; 22.5% C – 136kal; 4% D - 136kcal; 8% B

THANKS! lhayes3@uthsc.edu