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119 Cards in this Set
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A state induced by alterations in dietary intake or nutrient utilization resulting in changes in subcellular, cellular, and/or organ function that expose the individual to increased risks of morbidity and mortality and that can be reversed by appropriate nutritional support.
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Malnutrition
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What is the significance of hospital malnutrition?
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1. Increased morbidity and mortality
2. Increased infection risk 3. Decreased rate of wound healing 4. Worsened end organ response |
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Risk factors for protein calorie malnutrition (PCM)
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1. Usual weight 20% above or below IBW
2. Recent loss of more than 10% usual weight 3. Excessive alcohol intake 4. Chronic diseases 5. NPO for more than 7-10 days 6. Increased metabolic needs 7. Protracted nutrient loss 8. Intake of anti-nutrient or catabolic drugs (steroids) 9. Protracted emesis |
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What can metabolic stress result from?
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1. trauma
2. surgery 3. infection 4. tumor 5. chemotherapy 6. radiation therapy |
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What are the metabolic effects of stress?
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1. Increased demand for protein synthesis
2. Increased demand for fuel substrates |
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What are the effects of stress on nutritional status?
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Accelerates time-course of "nitrogen death." Adding stress to malnutrition makes it 10 times worse.
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What are some benefits of nutritional support?
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1. Reversal of weight loss
2. Restoration of immunocompetence 3. Suppression of gluconeogenesis 4. Enhanced tolerance for antineoplastic therapy |
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What are some factors that contribute to malnutrition?
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1. age
2. alcohol or drug abuse 3. disease (cancer, diabetes, depression, GI disorders, HIV) 4. drug therapy 5. low socioeconomic status |
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What are the major goals of nutritional assessment?
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1. To identify patients with or at risk of developing malnutrition, including problems arising from nutrient deficiencies, obesity, or impaired metabolism
2. To determine the risk of malnutrition-associated complications 3. To establish estimated nutrition needs 4. To establish baseline parameters to measure nutrition therapy outcomes |
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A chronic condition resulting from a prolonged deficiency in total energy intake and/or utilization of food (protein and calories).
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Marasmus
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Define marasmus
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A chronic condition resulting from a prolonged deficiency in total energy intake and/or utilization of food (protein and calories).
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What are the characteristics of marasmus?
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1. marked weight loss (greater than 10% of well weight)
2. depleted fat stores 3. muscle wasting 4. visceral proteins usually spared 5. impaired cell-mediated immunity in severe cases 6. starved, cachetic appearance 7. usually ~85% of ideal body weight |
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Condition common in patients who have adequate calorie intake, but a relative protein deficiency and who are catabolic.
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Kwashiorkor
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Define kwashiorkor
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Condition common in patients who have adequate calorie intake, but a relative protein deficiency and who are catabolic
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What are the characteristics of kwashiorkor?
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1. appears well-nourished, often obese
2. intake usually high calorie (mostly CHO or alcohol) 3. visceral proteins depleted 4. preservation of fat stores 5. hypoalbuminemia and edema 6. may have impaired immune function 7. may develop rapidly in response to protein deprivation with stress |
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A form of severe protein-calorie malnutrition in chronically ill, starved patients who are undergoing hypermetabolic stress.
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Mixed marasmus/kwashiorkor
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Define mixed marasmus/kwashiorkor
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A form of severe protein-calorie malnutrition in chronically ill, starved patients who are undergoing hypermetabolic stress.
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What are the characteristics of mixed marasmus/kwashiorkor?
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1. decreased visceral protein synthesis
2. wasting of somatic protein and fat stores 3. decreased immunocompetence 4. increased incidence of infection 5. poor wound healing |
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Define obesity
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BMI > 30 kg/m2
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Define overweight
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BMI > 25 kg/m2
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Formula for lean body mass
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Males: 50 kg + 2.3 kg for every inch over 5 feet tall
Females: 45.5 kg + 2.3 kg for every inch over 5 feet tall |
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What is the formula for adjusted lean body weight and when is it used?
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Adjusted weight is used if the patient weighs more than 120% of the LBW.
Adjusted LBW = [(Actual weight - LBW) X 0.25] + LBW *Use this for dosing |
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When do we use lean body weight?
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-If actual body weight is less than calculated LBW or 100% to 120% of LBW, use actual body weight for dosing. If over 120%, use adjusted LBW.
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Formula for BMI
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kg/m^2
1 inch = 2.54 cm then convert to meters 1 kg = 2.2 lbs |
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What is zinc's main function in the body?
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Zinc is a component of many enzymes and proteins. It has a role in gene expression and DNA and RNA synthesis.
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What can zinc deficiency be due to?
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1. inadequate intake
2. malabsorption 3. extensive losses 4. Crohn's disease 5. Fistulae 6. ulcerative colitis |
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Signs and symptoms of zinc deficiency
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1. alopecia
2. dermatitis 3. diarrhea 4. impaired wound healing 5. immunosuppression 6. growth retardation |
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Normal serum levels of zinc
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70-130 mcg/dl
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How do we estimate GI zinc losses
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2 + 17.1a + 12.2b
2 = urinary zinc loss a = stool or ileostomy output in kg b = small bowel fluid lost via fistula, etc., in kg |
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Treatment of zinc deficiency
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40 mcg - 32 mg zinc/day
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Zinc RDA
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Males: 11 mg
Females: 8 mg Pregnancy and Lactation: 11-12 mg |
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What is the main function of copper in the body?
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Copper is an essential component of enzymes involved in iron metabolism
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Normal Serum Levels of Copper
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70-150 mcg/dl
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Predisposing factors to Copper Deficiency
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1. malabsorptive states
2. prolonged diarrhea 3. malnutrition 4. copper-free nutrition 5. ulcerative colitis 6. nephrotic syndrome |
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Signs and Symptoms of Copper Deficiency
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1. anemia
2. hypercholesterolemia 3. neurologic abnormalities |
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Copper RDA
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900 mcg/day
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Treatment of Copper Deficiency
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20-30 mcg elemental copper/kg/day
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Normal Serum Levels of Chromium
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1-3 ng/ml
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Treatment of Chromium Deficiency
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250 mcg chromium/day for 2 weeks
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Chromium RDA
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25-30 mcg/day
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Signs and Symptoms of Chromium Deficiency
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1. impaired glucose tolerance
2. lipid abnormalities |
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Normal Serum Levels of Selenium
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0.10-0.34 mcg/ml
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Treatment of Selenium Deficiency
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100 mcg selenium/day for 24 days
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Signs and Symptoms of Iron Deficiency
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1. fatigue and weakness
2. nail changes 3. tachycardia 4. paresthesias |
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Iron RDA
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Males: 8 mg/day
Females: 18 mg/day Pregnant: 27 mg/day Over 50: 8 mg/day |
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Treatment of Iron Deficiency
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150-200 mg elemental iron daily for 3-6 months
(325 iron sulfate = 65 mg elemental iron) |
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What is the main function of iron in the body?
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Iron is a vital component of most metabolic processes. It is important for oxygen transport, muscle iron storage, and cellular energy production.
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Reasons for Iron Deficiency
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1. inadequate intake
2. malabsorption 3. blood loss |
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Vitamin deficiency is mostly commonly seen with which vitamins?
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1. folic acid
2. B12 3. Vitamin K |
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What is the mechanism of Essential Fatty Acid Deficiency (EFAD)?
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Continuous infusion of hypertonic dextrose (without long-chain fatty acids, specifically, linoleic acid) causes an increase in circulating insulin levels causing an inhibition of lipolysis and fatty acid mobilization.
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What are some manifestations of EFAD?
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1. Dermatological including rash or dry, cracked, scaly skin
2. Hematological including thrombocytopenia or increased hemolysis 3. Alopecia 4. Impaired wound healing |
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What biochemical parameter can assess EFAD?
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If triene:tetraene ratio is greater than 0.4, this indicates EFAD
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Prevention of EFAD during TPN
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Patients should receive at least 500 ml of 10% fat emulsion or 250 ml of 20% fat emulsion twice weekly during TPN. EFAD can easily be prevented with this regimen.
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Normal albumin levels
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3.5 - 5.0 grams/dl
*mild depletion 2.8-3.5 gm/dl *moderate depletion 2.1-2.7 gm/dl *severe depletion <2.1 gm/dl |
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Advantages of albumin
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1. Good correlation with malnutrition with low albumin
2. It provides baseline and means to monitor 3. It is in common use 4. It is easy |
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Disadvantages of albumin
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1. long half-life, so it is slow to reflect early changes
2. It is an insensitive indicator of protein-calorie malnutrition. 3. It also can be falsely elevated from administration of exogenous albumin. |
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Factors resulting in increased albumin
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Dehydration, anabolic steroids, insulin, and infection
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Factors resulting in decreased albumin
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Overhydration, edema, kidney dysfunction, nephrotic syndrome, poor dietary intake, impaired digestion, burns, congestive heart failure, cirrhosis, thyroid/adrenal/pituitary hormones, trauma, sepsis
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Prealbumin Normal values
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20 – 40 mg/dl
Mild depletion is 10-20; moderate 5-10; and severe depletion is <5 |
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Albumin Half-life
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~20 days
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Prealbumin half-life
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~ 2 days
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Utilization of prealbumin
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Prealbumin rapidly responds to changes and sudden demands for protein synthesis (trauma, infection). It is altered in chronic renal failure, and falsely elevated due to decreased renal metabolism.
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Factors resulting in increased prealbumin
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Fe deficiency, pregnancy, hypoxia, chronic blood loss, and estrogens
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Factors resulting in decreased prealbumin
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Chronic infection, cirrhosis, burns, enteropathies, nephrotic syndrome, cortisone, and testosterone
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Transferrin Normal values
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200 – 400 mg/dl
Mild depletion is 150-200; moderate 100-150; and severe depletion <100 |
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Transferrin half-life
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7-10 days
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Transferrin utilization
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Low transferrin correlates with low albumin, but it has faster response to changes in nutritional status. It is more sensitive than albumin and convenient to follow weekly.
But, it is altered by transfusions, dilution, and Fe overload. It is decreased by infection, trauma, and acute stress. It is increased by Fe administration, pregnancy, and acute hepatitis. |
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Factors resulting in increased transferrin
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Kidney dysfunction
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Factors resulting in decreased transferrin
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Cirrhosis, hepatitis, stress, surgery, inflammation, hyperthyroidism, cystic fibrosis, kidney dysfunction, zinc deficiency
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Which immune function tests are used to classify nutrition?
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1. Total lymphocyte count
2. Delayed hypersensivity reaction (no response = anergy which correlates with malnutrition) |
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Factors Influencing Energy Requirements
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1. Basal metabolic expenditure
2. Physical activity 3. Stress 4. Maintenance versus anabolism 5. Environment |
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What is RQ?
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RQ is indirect calorimetry and is equal to CO2 produced/O2 consumed. It is especially useful in obese, paralyzed, or stressed patients.
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RQ values
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RQ over 1 indicates lipogenesis or hyperventilation
RQ of 0.85 indicates mixed substrate oxidation RQ less than 0.7 indicates fat or EtOH oxidation or ketogenic diet |
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Calories needed per body weight (per kg)
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-healthy, normal nutrition status maintenance: 20-25 calories/kg/day
-malnourished or mildly metabolically stressed: 25-30 calories/kg/day -critically ill, hypermetabolic: 30-35 calories/kg/day -major burn injury: 35-40+ calories/kg/day |
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NPC:N values
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Maintenance: 150:1
Stress: 90-120:1 |
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Estimated adult protein requirements
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Over 18: 0.8 grams/kg/day
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Amount of nitrogen in protein
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6.25 grams of protein provides 1 gram of nitrogen
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Nitrogen balance equation
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nitrogen intake - nitrogen output
Nitrogen intake is protein intake/6.25 Nitrogen output is 24 hour urinary urien nitrogen (UUN) + 4 (fudge factor) SO Nitrogen balance = (protein intake/6.25) - (UUN + 4) |
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What is the goal nitrogen balance?
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+2 to +5
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Daily fluid requirements
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Active adults: 35cc/kg/day
Sedentary adults: 30cc/kg/day Elderly: 25cc/kg/day |
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Reasons for increased fluid requirements
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1. Increased insensible losses (fever, excessive sweating, increased metabolism, hyperthyroidism)
2. Increased GI losses (vomiting, diarrhea, high-output fistula) |
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Reasons for decreased fluid requirements
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1. Renal failure
2. Expanded extracellular fluid volume 3. Hypoproteinemia with starvation |
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What percent of daily calories should be essential fatty acids?
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2-4%
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What percent of daily calories should be from fat?
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10-35%
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What effect does amphotericin B have on nutrients?
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decreased magnesium, zinc, and sodium
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What effect do thiazide diuretics have on nutrients?
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decreased potassium, magnesium, and zinc
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What effect do loop diuretics have on nutrients?
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decreased potassium, calcium, magnesium, and zinc
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What effect do glucocorticoids have on nutrients?
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decreased potassium and calcium
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What effect does spironolactone have on nutrients?
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increased potassium
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What effect does ticarcillin or piperacillin have on nutrients?
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increased sodium
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What are the main drugs that cause hyperglycemia?
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corticosteroids
furosemide phenytoin |
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What are the main drugs that cause hypoglycemia?
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anabolic steroids
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What effect do antineoplastics have on vitamins?
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folic acid antagonism and malabsorption (deficiency)
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What effect does isoniazid have on vitamins?
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vitamin B6 deficiency
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mEq per 24 hours of:
Sodium Potassium Calcium Phosphorus |
Sodium: 60-100
Potassium: 60-100 Magnesium: 8-24 Phosphorus: 10-15 |
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What causes increased requirements of Na, K and Cl?
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1. vomiting
2. nasogastric suction 3. gastrostomy output |
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What causes increased requirements of Na, K, and HCO3?
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1. diarrhea
2. ostomy losses 3. high-output fistula |
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What causes decreased requirements of Na?
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1. congestive heart failure
2. ascites |
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What causes decreased requirements of Na, K, Mg, Phos, and Cl?
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renal failure
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How many calories are in dextrose?
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3.4kcal/gram
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What is the maximum vein tolerance of parenteral nutrition?
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Peripheral: 600-900 mOsm/L
Central: ? |
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How many calories are in fat?
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9kcal/gram
10% fat emulsion: 1.1cal/cc 20% fat emulsion: 2 cal/cc 30% fat emulsion: 3 cal/cc |
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Advantages of Fat emulsions
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1. Can be infused via peripheral vein and possibly protective of peripheral vein
2. May be mixed with other nutrients |
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What groups of people are fat emulsions especially useful in?
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1. fluid restricted
2. respiratory compromised 3. glucose intolerant patients |
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Contraindications to fat emulsion
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1. severe liver failure
2. egg allergies 3. pathologic hyperlipidemias 4. acute pancreatitis associated with hyperlipidemia 5. lipoid nephrosis |
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How many calories are in protein?
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4kcal/gram
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Hepatamine 8% indications
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Hepatamine 8% is an amino acid solution for use in hepatic failure. It has increased concentrations of branched chain amino acids and decreased concentrations or aromatic amino acids.
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Freamine HBC 6.9% indications
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Freamine HBC 6.9% is marketed for use in hypermetabolic patients. It has increased concentrations (approximately 45%) of the branched chain amino acids.
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Aminosyn HBC 7% indications
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Aminosyn HBC 7% is marketed for use in hypermetabolic patients. It has 45% branched chain amino acids (BCAA) by weight.
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Branchamin 4% indications
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Branchamin 4% is marketed for use as an additive to standard AA solutions to produce a final solution with increased concentrations of branched amino acids. It contains only branched chain amino acids in equimolar amounts.
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TrophAmine 6% and 10% indications
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TrophAmine 6% and 10% is marketed for use in neonates and infants. It includes taurine, formulated to normalize plasma amino acid profile to approximate that of a breast-fed infant.
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An amino acid solution for use in hepatic failure. It has increased concentrations of branched chain amino acids and decreased concentrations or aromatic amino acids.
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Hepatamine 8%
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Marketed for use in hypermetabolic patients. It has increased concentrations (approximately 45%) of the branched chain amino acids.
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Freamine HBC 6.9%
Aminosyn HBC 7% |
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Marketed for use as an additive to standard AA solutions to produce a final solution with increased concentrations of branched amino acids. It contains only branched chain amino acids in equimolar amounts.
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Branchamin 4%
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Marketed for use in neonates and infants. It includes taurine, formulated to normalize plasma amino acid profile to approximate that of a breast-fed infant.
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TrophAmine 6% and 10%
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What individual electrolyte salt additives are available?
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Sodium as chloride, acetate, lactate, phosphate
Potassium as chloride, acetate, phosphate Magnesium as sulfate Calcium as gluconate, gluceptate, chloride Phosphate as sodium, potassium |
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Electrolyte incompatibilities
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1. Bicarbonate is not compatible with TPN solutions. (Acetate may be substituted 1 for 1 for bicarbonate)
2. Calcium and phosphorus can be in the same solution to a maximum sum of 45 mEq/L. (1 mmol Phos = 2 mEq Phos) |
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What additional things can be added to TPNs?
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1. regular insulin
2. H2 antagonists 3. metoclopramide 4. albumin |
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Define and list conditionally essential amino acids.
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Eight amino acids are generally regarded as essential for humans: phenylalanine, valine, threonine, tryptophan, isoleucine, methionine, leucine, and lysine. Additionally, cysteine (or sulphur-containing amino acids), tyrosine (or aromatic amino acids), histidine and arginine are required by infants and growing children. Essential amino acids are so called not because they are more important to life than the others, but because the body does not synthesize them, making it essential to include them in one's diet in order to obtain them. In addition, the amino acids arginine, cysteine, glycine, glutamine, histidine, proline, serine and tyrosine are considered conditionally essential, meaning they are not normally required in the diet, but must be supplied exogenously to specific populations that do not synthesize it in adequate amounts.
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