p.17
Short Bowel Syndrome: Management and Treatment
What is the main challenge with surgical treatments for Short Bowel Syndrome (SBS)?
They have not been well-studied in high quality trials.
p.12
Enteral Nutrition: Access and Formulas
What is the first step in selecting an EN formula?
Focusing on meeting the caloric and protein needs of the patient.
p.3
Signs of Macronutrient and Micronutrient Deficiencies
What vital signs are consistent with malnutrition?
Fever, hypothermia, and tachycardia.
p.4
Nutritional Assessment Techniques
What signals the switch from catabolism to anabolism?
Mobilization of fluid from the third space and an increase in serum protein values.
p.4
Nutritional Screening Tools
What tools have been developed to assess nutritional risk?
Several scoring tools validated alongside history, physical, laboratory, and anthropometric measurements.
p.7
Enteral Nutrition: Access and Formulas
What techniques can be used for placing enterostomy tubes?
Endoscopic, fluoroscopic, open, or laparoscopic techniques.
p.5
Importance of Nutrition in Medical Care
Why is nutrition important in preventing surgical complications?
It helps maintain anabolic state and supports recovery post-surgery.
p.17
Short Bowel Syndrome: Management and Treatment
What surgical procedure may cure SBS in patients with an enterocutaneous fistula?
Resection of the fistula with primary anastomosis of the bowel.
p.4
Nutritional Assessment Techniques
What does a positive nitrogen balance indicate?
Adequate protein intake and anabolic metabolism.
p.17
Short Bowel Syndrome: Management and Treatment
What surgical option may be considered for patients with dilated intestine?
Intestinal tapering or plication.
p.17
Short Bowel Syndrome: Management and Treatment
When is intestinal transplantation increasingly performed for SBS?
Especially when concomitant liver failure is present.
p.4
Nutritional Assessment Techniques
Which proteins can be used to gauge a patient’s response to therapy after the acute phase?
Albumin, prealbumin, transferrin, and retinol binding protein.
p.4
Nutritional Assessment Techniques
How is nitrogen balance calculated?
Nitrogen balance = (protein/amino acid intake (g) / 6.25) - (urine urea nitrogen + 4).
p.7
Enteral Nutrition: Access and Formulas
What is a GJ tube used for?
To provide gastric decompression and enteral nutrition in cases like pancreatitis or motility issues.
p.3
Nutritional Assessment Techniques
What does grip strength indicate?
Overall nutritional and functional status.
p.7
Enteral Nutrition: Access and Formulas
What is a key benefit of using a GJ tube?
It allows for enteral nutrition while draining the stomach, especially in high aspiration risk patients.
p.17
Short Bowel Syndrome: Management and Treatment
What is the survival rate after intestinal transplant for appropriately selected SBS patients?
Exceeds the natural history of SBS at that point.
p.2
Malnutrition in Hospitalized Patients
What is the impact of inflammation on nutrient absorption?
It decreases the gastrointestinal tract’s ability to absorb nutrients.
p.3
Nutritional Assessment Techniques
What are some other body composition assessment tools?
Water displacement, impedance analysis, CT, MRI, and ultrasound.
p.9
Parenteral Nutrition: Indications and Complications
Where are central venous catheters typically placed?
At the bedside in the ICU, Emergency Department, or operating room using ultrasound guidance.
p.12
Nutritional Support for Surgical Patients
What conditions may require increased nutritional support through enteral nutrition (EN)?
Respiratory failure, burns, spinal cord injuries, and obesity.
p.12
Nutritional Assessment Techniques
What factors should be assessed when selecting an EN formula?
Alterations to the GI tract and evidence or suspicion of malabsorption.
p.12
Nutritional Support for Surgical Patients
What considerations are important for a malnourished patient with a history of alcohol abuse?
They need an EN formula with increased kcal density and possibly an elemental or semi-elemental formula.
p.12
Parenteral Nutrition: Indications and Complications
What type of formula is recommended for a patient with liver failure and renal issues?
A concentrated formula with low potassium and phosphorus (renal-specific formula).
p.16
Short Bowel Syndrome: Management and Treatment
What is important to resume once acute fluid/electrolyte imbalances have been corrected in SBS patients?
Tube feeding or oral intake.
p.11
Enteral Nutrition: Access and Formulas
What is a key characteristic of the proteins in elemental and semi-elemental formulas?
They are pre-digested, requiring less enzymatic activity for absorption.
p.7
Enteral Nutrition: Access and Formulas
What is the most common method for placing a gastrostomy tube?
Percutaneous endoscopic gastrostomy (PEG).
p.12
Nutritional Support for Surgical Patients
Why do patients undergoing surgery or trauma require increased kilocalories?
They have increased energy needs compared to non-stressed healthy adults.
p.7
Enteral Nutrition: Access and Formulas
How can jejunostomy (J) tubes be placed?
Typically surgically (open or laparoscopic), but endoscopic and percutaneous techniques have also been described.
p.3
Nutritional Assessment Techniques
What body measurements can help estimate nutritional needs?
Height, body weight, and body mass index (BMI).
p.3
Nutritional Assessment Techniques
How is BMI calculated?
BMI = weight (kg) / height (m²).
p.6
Enteral Nutrition: Access and Formulas
What are the types of feeding tubes mentioned?
Gastric, jejunal, or gastrojejunal.
p.6
Enteral Nutrition: Access and Formulas
What are Dobhoff tubes used for?
Feeding without the need for drainage or decompression.
p.6
Nutritional Assessment Techniques
How can nasogastric tube placement be facilitated?
By having the patient swallow air or a sip of water during placement.
p.6
Nutritional Assessment Techniques
What is essential to confirm before using a feeding tube?
Proper placement verified radiographically.
p.16
Short Bowel Syndrome: Management and Treatment
What is teduglutide used for in the treatment of SBS?
To promote intestinal adaptation and improve quality of life.
p.1
Signs of Macronutrient and Micronutrient Deficiencies
What is a common physical manifestation of Vitamin A deficiency?
Dermatitis and night blindness.
p.1
Signs of Macronutrient and Micronutrient Deficiencies
What condition is associated with Vitamin B1 (thiamin) deficiency?
Wernicke-Korsakoff syndrome and peripheral neuropathy.
p.17
Short Bowel Syndrome: Management and Treatment
What is the purpose of reversing a segment of intestine in SBS treatment?
To increase contact time and improve nutrient absorption.
p.14
Parenteral Nutrition: Indications and Complications
What is refeeding syndrome and when was it first described?
Refeeding syndrome is a condition that can occur after reintroducing nutrition to individuals who have been in extreme starvation, first described in World War II concentration camp survivors.
p.14
Parenteral Nutrition: Indications and Complications
What are some symptoms of full-blown refeeding syndrome?
Cardiopulmonary failure, seizures, encephalopathy, and coma.
p.5
Nutritional Assessment Techniques
What does the Nutrition Risk Screening 2002 (NRS) tool assess?
Nutritional history and severity of illness.
p.14
Parenteral Nutrition: Indications and Complications
How often should blood glucose be monitored when initiating PN?
At minimum every 4 hours until a stable trend has emerged.
p.3
Nutritional Assessment Techniques
What role do laboratory values play in nutritional assessment?
They assist with initial assessment and monitoring progress but are not absolute indicators.
p.5
Malnutrition in Hospitalized Patients
Which patients are at increased risk of developing postoperative complications due to malnutrition?
Patients with significant comorbidities like diabetes, cancer, or chronic inflammatory syndromes.
p.2
Malnutrition in Hospitalized Patients
What is refeeding syndrome and who is at risk?
A condition that can occur in patients with alcoholism when reintroducing food.
p.5
Enteral Nutrition: Access and Formulas
What are the two main options for enteral nutrition access?
Nasoenteric tube for short-term and percutaneous tube for long-term feeding.
p.9
Parenteral Nutrition: Indications and Complications
What are implantable port devices used for?
Chemotherapy administration, offering lower infection risk and greater convenience.
p.13
Parenteral Nutrition: Indications and Complications
What is the daily sodium requirement for PN?
Approximately 1-2 mEq/kg per day.
p.8
Complications Related to Nutritional Support
How can the risks associated with nasoenteric tube placement be minimized?
By confirming tube placement with a chest X-ray.
p.8
Complications Related to Nutritional Support
What are long-term complications of nasoenteric tubes?
Ischemic necrosis, ulceration of the nare, sinusitis, malfunction, and unplanned removal.
p.9
Malnutrition in Hospitalized Patients
What is the consequence of prolonged periods of starvation in postoperative patients?
Increased overall morbidity and mortality.
p.4
Nutritional Assessment Techniques
What should be interpreted with caution when assessing nutritional status?
Many nutritional markers, as they are acute phase reactants altered by the inflammatory response.
p.17
Short Bowel Syndrome: Management and Treatment
Name one bowel lengthening procedure described for SBS.
Kimura, Bianchi, or STEP (serial transverse enteroplasty).
p.2
Nutritional Assessment Techniques
What is required for a good nutritional assessment?
A thorough history and physical examination.
p.2
Nutritional Assessment Techniques
Why is weight history important in nutritional assessment?
It helps identify intentional or unintentional weight changes and their context.
p.6
Complications Related to Nutritional Support
What complications can arise from leaving a nasoenteral tube in place for too long?
Sinus infection and skin necrosis at the nare.
p.13
Parenteral Nutrition: Indications and Complications
What is the first step when initiating Parenteral Nutrition (PN)?
Obtain an accurate current body weight (CBW).
p.13
Nutritional Assessment Techniques
How is Adjusted Body Weight (ABW) calculated?
Subtract the Ideal Body Weight (IBW) from the Current Body Weight (CBW), divide by 3, and add to the IBW.
p.16
Short Bowel Syndrome: Management and Treatment
What are the symptoms and complications of Short Bowel Syndrome (SBS) related to?
Fluid, electrolyte, macronutrient, and micronutrient deficiencies.
p.16
Short Bowel Syndrome: Management and Treatment
What can excessive diarrhea or ostomy output lead to in SBS patients?
Dehydration and electrolyte imbalances.
p.10
Nutritional Assessment Techniques
What is the first step in selecting the type of nutritional support?
Assessment of the patient’s ability to tolerate enteral support.
p.11
Enteral Nutrition: Access and Formulas
What is the purpose of immune modulating formulas (IMF)?
To augment or alter a patient’s inflammatory disease process.
p.2
Malnutrition in Hospitalized Patients
What factors can lead to malnutrition in patients?
Eating disorders, fad diets, restricted access to food, and social situations.
p.5
Nutritional Support for Surgical Patients
What interventions may be recommended for patients at nutritional risk?
Prehabilitation diet and exercise or full nutritional support via enteral or parenteral nutrition.
p.9
Nutritional Assessment Techniques
What factors influence device selection for nutritional support?
Duration of therapy and clinical setting.
p.13
Parenteral Nutrition: Indications and Complications
What is the daily potassium requirement for PN?
Approximately 0.5-1 mEq/kg per day.
p.9
Nutritional Assessment Techniques
Why is it important to assess a patient's tolerance for enteral or parenteral nutrition?
To determine the appropriate type of nutritional support based on the patient's clinical picture.
p.15
Complications Related to Nutritional Support
What screening is recommended for patients on long-term PN?
Bone mineral density measurements.
p.15
Short Bowel Syndrome: Management and Treatment
What is intestinal failure (IF)?
Reduction of gut function below the minimum necessary for absorption, requiring intravenous supplementation.
p.8
Parenteral Nutrition: Indications and Complications
What is the advantage of midline catheters?
They can stay in for up to 6 weeks.
p.7
Enteral Nutrition: Access and Formulas
What are some contraindications for placing a PEG tube?
Inability to transilluminate the abdominal wall, ascites, esophageal obstruction, head and neck cancer, coagulopathy, gastric varices, or gastric ulcer disease.
p.4
Nutritional Assessment Techniques
What is the purpose of calorie counts in nutritional assessment?
To measure the adequacy of nutritional intake for patients receiving an oral diet.
p.12
Enteral Nutrition: Access and Formulas
What type of EN formula is appropriate for a patient with a traumatic brain injury and intact GI tract?
A standard polymeric formula without the need for supplementation.
p.11
Enteral Nutrition: Access and Formulas
What are elemental and semi-elemental formulas designed for?
Patients with decreased absorptive and digestive capacity, such as those with active inflammatory bowel disease, radiation enteritis, or short bowel syndrome.
p.14
Parenteral Nutrition: Indications and Complications
What is parenteral nutrition-associated liver disease (PNALD)?
A condition resulting from steatosis and liver dysfunction due to long-term PN, potentially leading to liver failure.
p.5
Importance of Nutrition in Medical Care
What are the consequences of inadequate nutrition during the healing process?
Impaired wound healing and increased risk of surgical site infection.
p.11
Enteral Nutrition: Access and Formulas
What modifications are made in diabetic formulas?
They contain lower carbohydrates and higher fat concentrations.
p.5
Nutritional Assessment Techniques
What should be done for patients identified at increased nutritional risk before surgery?
They should undergo nutritional evaluation and optimization.
p.9
Parenteral Nutrition: Indications and Complications
What is the primary long-term complication of non-tunneled catheters?
Catheter-associated blood stream infection (CLABSI).
p.6
Enteral Nutrition: Access and Formulas
What techniques can increase the likelihood of passing a nasoduodenal or nasojejunal tube past the pylorus?
Rotating the patient onto the right side and insufflating air.
p.10
Enteral Nutrition: Access and Formulas
What are the benefits of enteral nutrition compared to parenteral nutrition?
No requirement for central venous access, prevention of gut mucosal atrophy, and reduced cost.
p.16
Short Bowel Syndrome: Management and Treatment
What types of medications are used in the medical treatment of SBS?
Antimotility agents, anti-secretory agents, and medications to promote intestinal adaptation.
p.8
Complications Related to Nutritional Support
What complications can arise from percutaneous enterostomy tubes?
Leakage, chronic skin and abdominal wall wounds, infection, buried bumper syndrome, and accidental removal.
p.15
Short Bowel Syndrome: Management and Treatment
What defines Short Bowel Syndrome (SBS)?
Less than 200 cm of remaining small bowel.
p.15
Short Bowel Syndrome: Management and Treatment
What are the three types of intestinal failure?
Type 1: short-term; Type 2: prolonged; Type 3: chronic.
p.2
Malnutrition in Hospitalized Patients
What types of medical conditions can alter metabolism and place patients at nutritional risk?
Acute conditions like sepsis, burns, trauma, and chronic conditions like diabetes and celiac disease.
p.9
Parenteral Nutrition: Indications and Complications
What is the advantage of traditional multi-lumen central venous catheters?
They have multiple ports for access to medications and hemodynamic monitoring.
p.13
Nutritional Assessment Techniques
What should be used for feeding an overweight individual?
Adjusted Body Weight (ABW) to avoid underfeeding or overfeeding.
p.13
Parenteral Nutrition: Indications and Complications
What is the initial starting volume for PN?
30-40 cc/kg/day based on actual body weight.
p.14
Parenteral Nutrition: Indications and Complications
What are the two main culprits implicated in the development of PNALD?
Carbohydrates and phytoesterols.
p.10
Enteral Nutrition: Access and Formulas
What is the adage that guides the decision to use enteral nutrition?
If the gut works, use it.
p.15
Parenteral Nutrition: Indications and Complications
What essential fatty acids are contained in soy-based IVLE?
Linoleic acid and alpha-linolenic acid.
p.1
Signs of Macronutrient and Micronutrient Deficiencies
What are common signs of protein-calorie malnutrition?
Low BMI, loss of muscle mass, muscle weakness, peripheral edema, hair loss, temporal wasting.
p.14
Parenteral Nutrition: Indications and Complications
What is a recommended strategy to reduce liver exposure to glucose in PN?
Cycling the PN to less than 24 hours per day.
p.9
Nutritional Support for Surgical Patients
What are the main goals of nutritional support for surgical patients?
Preservation of lean body mass and immune function while preventing metabolic complications.
p.1
Signs of Macronutrient and Micronutrient Deficiencies
What are the signs of Vitamin D deficiency?
Osteoporosis and fractures with minimal trauma.
p.8
Complications Related to Nutritional Support
What complications can jejunostomy tubes cause?
Internal hernia or volvulus.
p.15
Short Bowel Syndrome: Management and Treatment
What adaptive changes occur in the intestine after surgery for SBS?
Increases in villi height, crypt depth, and enterocyte mass.
p.2
Malnutrition in Hospitalized Patients
What are some anatomical changes that can interfere with nutrient uptake?
Fistulas, short bowel syndrome, ostomies, and oropharyngeal disorders.
p.2
Nutritional Assessment Techniques
How can medications affect nutritional status?
Some medications can alter metabolism and nutrient uptake.
p.2
Nutritional Assessment Techniques
What role does a physical exam play in nutritional assessment?
It is a critical part of evaluating a patient's nutritional status.
p.10
Enteral Nutrition: Access and Formulas
What is the preferred route of nutritional support when a patient can tolerate it?
Early enteral nutrition (EN).
p.11
Enteral Nutrition: Access and Formulas
What is a concern regarding the use of immune modulating formulas?
There appears to be an increased risk of mortality with their use.
p.11
Enteral Nutrition: Access and Formulas
What are blenderized diets?
Original enteral nutrition formulas made by blending foods into a liquid for enteral delivery.
p.11
Enteral Nutrition: Access and Formulas
What factors must be considered when planning for blenderized diets?
Patient's ability to tolerate bolus feedings, stable weight, tolerance of commercially available formulas, support system, and financial means.
p.10
Parenteral Nutrition: Indications and Complications
What do guidelines recommend for initiating parenteral nutrition?
Initiate PN if the patient has been intolerant of EN for 7 days or more, or if malnourished pre-procedure and able to undergo PN for 7-10 days before an elective procedure.
p.8
Parenteral Nutrition: Indications and Complications
Why is central vein access required for parenteral nutrition?
To administer hyperosmolar fluids and prevent thrombophlebitis.
p.8
Parenteral Nutrition: Indications and Complications
What are the signs of thrombophlebitis in peripheral angiocatheters?
Pain, erythema, redness, or palpable cord.
p.11
Enteral Nutrition: Access and Formulas
What are specialty formulas designed for?
Specific clinical entities and scenarios requiring tailored nutritional support.
p.16
Short Bowel Syndrome: Management and Treatment
What happens if a patient cannot meet nutritional requirements in SBS?
Catabolism will ensue, leading to weight loss in adipose tissue and skeletal muscle.
p.13
Parenteral Nutrition: Indications and Complications
What is the maximum percentage of total daily calories that can come from lipids?
30% to avoid liver damage.
p.8
Complications Related to Nutritional Support
What are the complications associated with nasoenteric tubes?
Vomiting on insertion, aspiration, misplacement into the airway, ischemic necrosis, ulceration of the nare, sinusitis, malfunction, and unplanned removal.
p.10
Enteral Nutrition: Access and Formulas
When is enteral nutrition considered early?
When feeding is initiated within the first 24 to 48 hours postoperatively or after ICU admission.
p.10
Parenteral Nutrition: Indications and Complications
What are accepted indications for parenteral nutrition?
Intolerance of enteral feeding, inadequate EN support, pre-procedural nutritional support in malnourished patients, and intestinal failure.
p.1
Importance of Nutrition in Medical Care
What is the significance of nutrition in medical care?
It is an important component and malnutrition is associated with worse clinical outcomes.
p.10
Enteral Nutrition: Access and Formulas
What are the basic types of enteral formulas?
Polymeric, elemental, semi-elemental, blenderized, and specialty formulas.
p.1
Malnutrition in Hospitalized Patients
What is the impact of malnutrition in the acute care setting?
It is often under-recognized and de-prioritized.
p.9
Parenteral Nutrition: Indications and Complications
What are some complications associated with central venous catheters?
Pneumothorax, air embolism, hematoma, bleeding, and catheter-associated blood stream infection (CLABSI).
p.9
Parenteral Nutrition: Indications and Complications
What is a tunneled catheter?
A catheter that separates the site of skin insertion from the vein, usually with a cuff that promotes scarring to secure it.
p.6
Nutritional Assessment Techniques
What is the estimated length for nasogastric tube insertion?
Typically between 50-60 cm.
p.11
Enteral Nutrition: Access and Formulas
What are some components included in immune modulating formulas?
Glutamine, arginine, antioxidant micronutrients, and omega-3 polyunsaturated fats.
p.16
Short Bowel Syndrome: Management and Treatment
Why is the use of teduglutide discouraged in patients with gastrointestinal malignancy?
It may enhance neoplastic spread.
p.15
Parenteral Nutrition: Indications and Complications
What is SMOFlipid®?
A mixed lipid emulsion containing soy, medium chain, olive oil, and fish oil.
p.15
Parenteral Nutrition: Indications and Complications
What condition does SMOFlipid® aim to prevent or treat?
Parenteral Nutrition-Associated Liver Disease (PNALD).
p.11
Nutritional Assessment Techniques
What is essential for the prescription of enteral nutrition formulas?
Understanding the patient's metabolic demands, including pre-hospital nutritional status and changes due to surgery or injury.
p.1
Signs of Macronutrient and Micronutrient Deficiencies
What are the common signs of iron deficiency?
Microcytic anemia, glossitis, and brittle nails.
p.1
Complications Related to Nutritional Support
What is a common complication related to enteral and parenteral nutrition?
Infection or mechanical complications.
p.8
Parenteral Nutrition: Indications and Complications
What are the disadvantages of nontunneled peripherally inserted central catheters (PICC)?
Difficult for patient care at home and can cause sclerosis of veins in patients with renal failure.
p.15
Complications Related to Nutritional Support
What is the incidence of metabolic bone disease in long-term PN patients?
As high as 50% after 6 months of PN therapy.
p.10
Enteral Nutrition: Access and Formulas
What factors should be considered when selecting an enteral formula?
Protein requirements, caloric needs, current disease state, comorbidities, electrolyte and metabolic derangements, and ability to tolerate the formula.
p.10
Enteral Nutrition: Access and Formulas
What is the kilocalorie density range for polymeric formulas?
1.0 kcal/mL to 2.0 kcal/mL.
p.8
Parenteral Nutrition: Indications and Complications
Where does the catheter tip lie for central venous catheters?
In the superior vena cava (SVC) or right atrium.
p.1
Nutritional Assessment Techniques
What is the focus of the nutrition module for medical students?
Recognizing signs of macronutrient and micronutrient deficiencies and understanding nutrition screening tools.
p.15
Short Bowel Syndrome: Management and Treatment
What is a common cause of Short Bowel Syndrome?
Extensive small bowel resection.
