Flashcards
Critical Care
Cards in this deck (28)
- 1Why are people admitted to intensive care unit (ICU)?*Major trauma e.g. Road Traffic Accident (RTA)
*Post-operative care e.g major vascular surgery
*Respiratory failure
*Post-cardiopulmonary resuscitation (CPR)
*Severe sepsis - 2How does the body respond to starvation?*Decrease BMR & N losses
*Slow weight loss - mainly fat stores
*Slow fall in glucagon & cortisol (after a slight increase) & insulin
*H2O and Na losses initially - 3How does the body respond to trauma?* Increase in BMR & N losses
*Rapid weight loss – 20% muscle (body protein) =catabolic
*Acute phase protein synthesis
* Increase in catecholamines, glucagon, cortisol, GH & insulin* Insulin resistance means relative insulin defic.
* H2O and Na retention - 4What are some special consideration when taking anthropometric measurements from ICU patients?Wt/ht – pre-ICU admission; oedema; wt history; weighing beds-?plaster casts(fractures)
BMI - ?accurate wt/ht
Skinfolds –impracticalities if bedbound & oedema
Circumferences – as above - 5What are some special consideration when interpreting biochem results from ICU patients?Fill in with Blessed
- 6What are some special consideration when interpreting clinical results from ICU patients?Functional-poor muscle function
Clinical-observation = v.difficult - 7What are some special considerations for diet from ICU patients?Pre-ICU admission diet
Unconscious patients- ?relatives/friends
‘Diet’ intake – enteral feed charts - 8What are the aims when providing nutrition support for ICU pts?1)Limit weight loss especially lean body mass
2) Promote wound healing
3) Support immune system
4) Provide appropriate micronutrient intake - 9Calculating Energy requirements for ICU ptsIf using Henry Eqns MUST account for additional factors:
>>Ventilation (decreases Energy expenditure)
>>Sedation (decreases Energy expenditure)
If using Henry Eqns MUST account for additional factors
Ventilation (decreases Energy expenditure)
Sedation (decreases Energy expenditure)
SIRS (increases Energy expenditure)
Systemic Inflammatory Response Syndrome - 10Calculating protein reqs...consider stress factors e.g. sepsis and thus higher N reqs. NOT above 0.2 for sepsis/trauma
- 11Calculating fluid reqs...consider raised temp.; outputs e.g. drains & any fluid restrictions
- 12What are advantages of early enteral feeding?Decrease in sepsis
Decrease in length of stay
Decrease in respiratory dysfunction
Decreased incidence of multiple organ failure
Prevention of paralytic ileus & gastric stasis - 13What are the different routes of feed an ICU pt?Oral e.g. food, fluid & nutr supplements
Artificial Enteral e.g. NG, NJ tubes, PEGs
Parenteral e.g. TPN, PPN
Depends on clinical condition e.g. G.I. surgery - 14What is the justification for feeding enterally?NCCAC, 2006:
inadequate or unsafe
oral intake
PLUS a functional, accessible
gastrointestinal tract should be fed via a tube into
the stomach unless there is upper gastrointestinal
dysfunction.” - 15What is the justification for feeding post-pyloric?NCCAC, 2006:
inadequate or unsafe oral
intake and a functional, accessible gastrointestinal
tract with upper gastrointestinal dysfunction (or an
inaccessible upper gastrointestinal tract) should be
considered for post-pyloric (duodenal or jejunal)
Feeding” - 16What are advantages of feeding enterally?*If the gut is working –use it!
*Safer
*Physiological
*Less expensive than PN
*Prevents villous atrophy (unlike PN):
gut mucosal integrity = maintained
>>Preserves normal gut functions
*Bacterial translocation is prevented - 17What are disadvantages of feeding enterally?*Invasive for those conscious
*Gastroesophageal regurgitation and aspiration risk
*Problems with ‘absorption’ means full rate takes time to be delivered - 18What are some complications of feeding enterally? NCCAC, 2006
- 19Advantages of post pyloric feeding...Physiologically small bowel recovers function quicker from G.I. trauma than stomach or colon
(≈4-8hrs post-op) Lewis et al, BMJ 2001
Feeding directly into jejunum – no need for bowel sounds/flatus presence Chan et al, Chest 1999
* Decrease in sepsis and length of stay Lewis et al, BMJ 2001
* Lower risk of gastroesophageal regurgitation Heyland et al, JPEN 2002
*Decrease in ventilator associated pneumonia Heyland et al, JPEN 2002 - 20What are some specialist feeds for GI surgery?Elemental =amino acids e.g. Elemental 028,
Semi-elemental =peptides e.g. Perative, Peptisorb, Survimed OPD - 21What is Parenteral nutrition?Parenteral nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates (sugars), fats, vitamins and minerals (such as calcium).
- 22When isit appropriate to use parenteral nutrition?1)MUST be determined by GI functioning
i.e. Intestinal failure
2)Malnourished/at risk of malnutrition AND Inadequate or unsafe oral/enteral nutritional intake
OR
Non-functional, inaccessible or perforated GIT - 23What conditions may be appropriate for the use of PN?*short bowel syndrome
*Extensive GI surgery
*Postoperative ileus(malfunction of intestinal motility after major abdominal surgery.)
*Severe malabsorption
*Enterocutaneous fistula(abnormal connection that develops between the intestinal tract or stomach and the skin.) esp. high output - 24How long can PN be used?<14days can be a peripheral line
>7-10 days =central line - 25Parenteral: Disadvantages>Invasive
>Non-physiological *
>Villous atrophy*
>Bacterial translocation*
>Expensive
>Infection risk
>Abnormal liver enzymes
*To overcome these issues 10mls/hr NG feed often initiated alongside PN - 26Evidence for using PN... NCEPOD (2010) Recommendations*PN should only be given when necessary
*When PN is needed recognise early and take action
*Patient assessment should be robust and purpose and goal documented
*Regular documented clinical and biochemical monitoring
*Additional IV fluids only if necessary
*Active education about the role of PN, its complications and side effects
All hospitals should have a PN proforma - 27What should be monitored with PN?Biochem & haematol & urinary electrolytes
Weight – if possible (fluid status)
CRP: Alb ratio – good prognostic tool
Rate & volume of feed
Any evidence of absorption problems
Changes in patient’s condition
Changes in treatment e.g. drugs; ventilation;
f fluid restrictions; temp.; - 28what are the ICU feeding protocols?24hr feeding
Due to strict blood glucose control using insulin infusion sliding scale (4.5-6mmol/l)
Rate of feed increased every 4hrs to reach prescription (based on aspirate volumes)
4hrly aspirations (>2-400mls feed rate is lowered; <2-400mls aspirate returned and feed rate increased)
Jejunal feeding (double or triple lumen)
Low enteral feed rate of 10mls/hr even if on PN