Procedures for Nutritional Support
Allows for stomach decompression while feeding into the small bowel
What is Nasogastric Tube?
When initiated with 48hrs, has been shown to improve outcomes following traumatic brain injury
What is Enteral Nutrition?
Best marker of nutritional status in stable patients in the outpatient setting
What is albumin?
When extracellular ions are rapidly transferred intracellularly with the availability of glucose and subsequent release of insulin to resume normal cellular metabolic processes (ie, create ATP) and synthesis of glycogen, fat, and protein in cells at the detriment of serum concentrations
What is refeeding sydrome?
You've been consulted for a Trach and PEG.
***If senior or attending, steps for PEG as if you're writing in Op note in <120sec***
Everyone else: The ideal spot for gastrostomy tube placement.
:)
What is: a location on the anterior gastric wall; approximately two-thirds of the distance between the lower esophageal sphincter and the pylorus is ideal.
Establishes long-term feeding access
What is Gastrostomy and jejunostomy tubes?
Non-nutritional Benefits of EN in Critical Illness
What is preserves the structure and function of the GI tract?
Also acceptable:
What is helps maintain IgA levels?
What is reduce intestinal dysfunction?
What is reduce inflammation?
Your pt is requiring Parenteral Nutrition!
Quick! Describe the appropriate procedure you will do step by step.
***If senior or attending, must describe in <120sec***
Everyone else, 3 min :D
:D
Cause of deficiency in iron, zinc, and selenium, as well as vitamins B1, B2, B6, and C, A, D, K, E
What is small intestine high output?
Also acceptable: What is Malabsorption?
A 34-year-old morbidly obese woman is admitted to the surgical ICU with intra-abdominal sepsis secondary to perforated sigmoid diverticulitis. She undergoes a Hartmann procedure with an end colostomy and an abdominal washout. Her course is complicated by pneumonia and difficulties with a trial of extubation. A metabolic cart is performed to assess her nutritional status. The results of indirect calorimetry reveal a respiratory quotient (RQ) of 1.2. What does this value imply for this patient’s overall nutrition?
What is the patient is being overfed?
What are the 3 vessels for access for administration of Parenteral Nutrition
What is internal jugular, subclavian, and femoral vein?
Parental Nutrition should be initiated 7-10 days in these patients.
What is well-nourished, stable adult patients who have been unable to receive significant oral or enteral nutrients
May be need to be replaced in malnourished pts with cirrhosis
What is phosphate, vitamin B1, and zinc?
Bonus points: If patient has D bili >5 or T Bili >10, add copper and manganese.
*******Double Jeopardy************
A well-nourished 70-year-old patient is admitted to the hospital and evaluated by the nutrition support team. The team recommends enteral nutrition with a daily protein requirement of 0.8 g/kg/d. Which condition would explain this patient’s protein requirement?
•A. Intra-abdominal sepsis
•B. Burns involving 25% of total body surface area
•C. Acute kidney injury requiring initiation of hemodialysis
•D. Biliary colic
What is biliary colic
The risks and benefits of different types of feeding access: NG vs PN
What is:
Just need to describe 3 if Junior
Seniors and attendings should describe 5
A 73-year-old woman develops dysphagia after sustaining a perioperative stroke associated with an urgent above-knee femoral popliteal bypass. She is hemodynamically normal. She has a history of severe GERD. She has been NPO for the past week without improvement in her dysphagia. What is the most appropriate way to initiate feeding?
•A. Placement of a small-bore nasogastric tube with gastric tube feeds
•B. Placement of a percutaneous endoscopic gastrostomy tube with gastric tube feeds
•C. Placement of a right internal jugular central venous catheter and initiation of parenteral nutrition
•D. Placement of a small-bore nasojejunal tube with jejunal tube feeds
•E. Continued NPO status until her dysphagia improves
What is placement of a small-bore nasojejunal tube with jejunal tube feeds?
A 62-year-old man with advanced tonsillar adenocarcinoma and moderate protein-calorie malnutrition presents for evaluation of access for nutritional support. He is currently receiving radiation therapy. He has read that he should avoid transoral passage of a feeding tube to prevent inadvertent spread of cancer cells. Which option would be best for him, considering his wishes?
•A. Percutaneous endoscopic gastrostomy tube using a “pull” method
•B. Surgical jejunostomy
•C. Surgical gastrostomy
•D. Tunneled central line placement for parenteral nutrition
•E. He is not a candidate for nutritional support.
What is surgical gastrostomy?
Your patient has SBO! Quick!
Describe procedure for NGT placement
***If senior or attending, must be done in <60 seconds***
Everyone else gets 120 seconds
:)
Start it with What is...?
A 54-year-old woman is admitted to the ICU with gallstone pancreatitis. She is intubated, given fluid resuscitation, and started on vasopressors. She develops abdominal compartment syndrome and undergoes decompressive laparotomy. During the operation, her small intestine is lacerated, and a small bowel resection and anastomosis are performed. Her abdomen is left open, and she is transferred back to the ICU. During the operation, a small-bore feeding tube past the ligament of Treitz is placed. Which of the following is a relative contraindication for initiating enteral nutrition in this patient?
•A. High-dose vasopressors
•B. Pancreatitis
•C. Lack of bowel sounds
•D. Open abdomen
•E. Recent small bowel anastomosis
What is high-dose vasopressors
A 32-year-old man is involved in a house fire. On examination in the trauma bay, he is noted to have a 60% total body surface area burn and inhalation injury. He is intubated for airway protection and admitted to the burn intensive care unit. Which of the following will most accurately determine his energy needs?
•A. Fick equation
•B. Direct calorimetry
•C. Curreri formula
•D. Harris-Benedict equation
•E. Indirect calorimetry
What is indirect calorimetry?
A 55-year-old woman is postoperative day 16 from exploratory laparotomy and splenectomy for splenic laceration after a motor vehicle crash. She has had a traumatic brain injury and has impaired swallowing function secondary to this injury and intubation. She has had return of bowel function, and her team has placed a percutaneous gastric feeding tube for enteral nutrition. Which of the following complications is she at risk for as a result?
•A. Aspiration
•B. Cholestasis
•C. Bacterial overgrowth in the small intestine
•D. Bacteremia from line infection
•E. Mucosal disuse atrophy
What is Aspiration?
******Double Jeopardy******
A 35-year-old woman with a BMI of 45 kg/m2 is intubated in the ICU with COVID-related acute respiratory distress syndrome. She has been receiving enteral nutrition, but there is concern that overfeeding may be contributing to her high ventilator requirements. Indirect calorimetry is performed, and her respiratory quotient (RQ) is 0.93. Which change should be made to her enteral nutrition regimen based on the RQ?
•A. Increase the hourly tube feed rate.
•B. Increase the amount of daily free water.
•C. Make no changes to the current regimen.
•D. Decrease the hourly tube feed rate.
•E. Change the tube feed formula to include essential amino acids.
What is make no changes to the current regimen.
A 58-year-old undomiciled man is admitted to the surgical ICU after colon resection for perforated diverticulitis. He remains intubated and sedated with vasopressor requirements. He has a BMI of 22. Which technique is an optimal method to assess his risk for adverse events that can be modified with aggressive nutritional therapy?
•A. Measuring triceps skinfold thickness
•B. Calculating his Nutrition Risk in the Critically Ill (NUTRIC) score
•C. Measuring his serum albumin level
•D. Measuring his hand grip strength
•E. Measuring indirect calorimetry
What is calculating his Nutrition Risk in the Critically Ill (NUTRIC) score?
A 45-year-old alcoholic man presents to the emergency department with acute abdominal pain. On examination, he is noted to have tenderness in his epigastrium and is diaphoretic and hypotensive. Laboratory values are significant for a lipase of 3000 U/L and a white blood count of 18,000/µL. A computed tomography scan shows severe inflammation of the pancreas and peripancreatic fluid. He is admitted to the intensive care unit for resuscitation. On rounds, you discuss the optimal plan for nutrition in this patient. What is the best initial mode of nutrition after the patient has been adequately resuscitated?
•A. Strictly NPO during episodes of pancreatitis
•B. Total parenteral nutrition
•C. Postpyloric jejunal tube feeding with a small-bore feeding tube
•D. Gastric tube feeds with a small-bore feeding tube
•E. Regular diet with nutrition supplements
What is regular diet with nutrition supplements?
A 64-year-old woman undergoes placement of a gastrojejunostomy tube because of severe gastroparesis, with a plan for gastric decompression and distal jejunal feeding. If she is well nourished and weighs 70 kg, how many grams of glucose should be administered in her enteral nutrition to meet 55% of her daily total caloric requirements as carbohydrate?
What is 240g?