ECC2- ICU Nutrition

  1. What are the adverse effects of inadequate nutritional plane? (6)
    • transition to catabolic state- mobilization/ utilization of energy stores--> hypoglycemia in young patients, reduction in muscle mass in all patients
    • nutritional imbalance results in immune dysfunction- impaired cell-mediated responses, decreased IgA, diminished complement, decreased antibody affinity and cytokine production, increased risk of infectious complications
    • impaired tissue synthesis and wound repair
    • decreased live albumin production
    • altered drug metabolism
    • loss of intestinal mucosal barrier
  2. Why is there an increased risk of drug toxicity and decreased duration of action of drugs in patients with an inadequate nutritional plane?
    normally, drugs bind to albumin and are prevented from filtered out into the urine at the kidney, but with decreased albumin, more drug is free and available to be filtered into the kidneys—> faster drug loss and decreased DOA, increased free serum concs
  3. What severe underlying disease processes should trigger earlier nutritional intervention?
    • inflammatory- trauma, sepsis, peritonitis, acute pancreatitis
    • significant protein loss- diarrhea, protein-losing nephropathy, draining wounds, burns
  4. How do you calculate RER?
    70 x BW.75
  5. Would you ever provide more than RER?
    • illness factor- used to account for presumed increased in metabolic demand secondary to illness
    • this resulted in nutritional intolerance from excessive energy delivery--> hyperlipidemia or hyperglycemia
    • NO LONGER USED!!! just give RER
  6. _________ feeding is the preferred method of delivery of nutrition, even in cases of...
    Enteral; primary GI disturbance ("resting the gut" is not beneficial...early enteral nutrition!)
  7. Why is enteral feeding preferred over IV nutrition? (6)
    • decreased villous atrophy, promoted enterocyte growth
    • decreased risk of bacterial translocation
    • decreased risk of ileus, improved GI motility
    • cost-effective
    • easier
    • fewer complications
  8. When should you perform IV nutrition over enteral nutrition?
    • if patient is hemodynamically unstable or hypothermic
    • b/c these state result in GI hypoperfusion, and feeding can result in further mucosal injury
    • digestion increases enterocyte oxygen demand in the face of decreased oxygen delivery--> bad!
  9. How do you provide nutrition to a vomiting patient?
    • anti-emetic therapy to control vomiting, then if you successfully stop vomiting, enteral nutrition
    • Ondansetron, Maropitant, Metoclopramide, Butorphanol, Prochlorperazine
  10. What is the importance of pro-kinetic therapy? (2)
    What are pro-kinetic agents? (4)
    • ileus may decrease efficacy of enteral nutrition
    • ileus can be exacerbated by meds
    • Metoclopramide, Erythromycin, Ranitidine, Cisapride
  11. What are the pros and cons of oral/ forced feeding?
    • Pros: oral route most appropriate/ physiological
    • Cons: large patients not practical, not an option for critically ill or debilitated patients, may result in food aversion, may cause aspiration
  12. What are indications for oral/ forced feeding? (4)
    • needed as temporary measure for nutritional support
    • mentally alert, intact gag reflex
    • structurally and functionally normal esophagus
    • pediatrics, cats, small dogs, no vomiting/ nausea
  13. What appetite stimulants can we give to encourage eating? (4)
    • Diazepam- cats (benzo)
    • Prednisone- dogs and cats (steroid)
    • Cyproheptadine- cats (serotonin, histamine antagonist)
    • Mirtazapine- dogs and cats (tetracycline antidepressant)
  14. Describe the use of intermittent orogastric tube placement. (4)
    • short-term only (days)
    • better tolerated in neonates
    • use red rubber catheter
    • measure to lat rib for stomach
    • primary concern is aspiration
  15. Describe the use of NG tubes. (3)
    • short-term feeding (3-7 days)
    • small bore tube
    • requires liquid nutrition
  16. What are indications for an NG tube? (5)
    • unstable patients with increased anesthetic risks
    • normal esophagus
    • tube needed only for delivery of nutrition (not drugs)
    • gastric decompression/ checking residual volumes
    • confirm placement: radiograph, aspirate gastric contents
  17. When are NG tubes contraindicated? (2)
    • head trauma
    • intractable vomiting
  18. What are the potential complications of NG tubes? (7)
    • frequent clogging of small bore tubes
    • diarrhea secondary to liquid diets
    • rhinitis
    • esophageal irritation/ reflex
    • aspiration pneumonia (inappropriate placement- didn't confirm)
    • requires e-collar
    • poor patient tolerance!
  19. What are pros of NG over NE and vice versa?
    • Pro NG: gastric decompression, check residual volume, larger reservoir for filling, less likely to come back up tube, no need for rads if you can aspirate stomach fluid
    • Pro NE: does not cross LES- less reflux? (study said no)
  20. What are the principals of an esophagostomy tube? (7)
    • large bore tube
    • can use blenderized or liquid diets
    • can administer oral medications
    • improved comfort over NG
    • can use immediately after placement
    • no minimum time for tube to be in place
    • tube should terminate in the distal third of the esophagus (DON'T WANT PASSING LES)
  21. What are indications for an esophagostomy tube? (6)
    • long term nutrition (weeks to months)
    • better for cats and small dogs
    • easy for clients to use at home
    • structurally and functionally normal esophagus
    • relatively stable patient for general anesthesia
    • patients with disease/ trauma of oral or nasal cavity
  22. What are potential complications with an esophagostomy tube? (4)
    • incorrect placement into periesophageal space (hard to do)
    • infection or abscessation  at entry site
    • damage to local nervous or vascular structures
    • tube dislodgment or clogging
  23. Describe the principals of using a PEG tube. (6)
    • must wait 24 hours after placement before using (allow seal to form and decrease risk of leakage)
    • must keep in place for at least 14-28 days
    • can determine residual volume
    • large bore tube
    • blenderized or liquid diets
    • well-tolerated, clients can use at home
  24. What are indications for the use of a PEG tube? (5)
    • long-term nutritional support (months)
    • management of chronic liver/ kidney disease
    • oral, pharyngeal, or esophageal disease
    • stable patient to undergo anesthesia
    • comatose/ paralyzed/ ventilator patients
  25. What are potential complications of gastrotomy/ PEG tubes? (6)
    • peristomal skin infection
    • injury to adjacent organs
    • aspiration pneumonia
    • vomiting/ regurg/ reflux
    • improper placement causing pyloric outflow obstruction
    • leakage of gastric contents- abscess, peritonitis
  26. What foods do we usually feed through a tube?
    • Clinicare, a/d, Max Cal
    • we want an energy dense food
  27. Describe the clinical approach to providing nutrition in the ICU. (4)
    • depends on length of anorexia- may have decreased tolerance to feeding, risk of refeeding syndrome
    • start with 25-35% RER divided over multiple feedings
    • gradually increase by 25-35% daily until full RER provided
    • monitor blood glucose and electrolytes (especially K+- signs of refeeding)
  28. What are indications for use of parenteral nutrition? (5)
    • intractable vomiting
    • severe malabsorption
    • prolonged ileus
    • full RER cannot be provided by enteral nutrition
    • increased risk associated with enteral nutrition (ventilated/ comatose patients, poor tolerance to volume administered)
Card Set
ECC2- ICU Nutrition
vetmed ECC2