CNSC Exam Verified 100% Correct!!

CNSC Exam Verified 100% Correct!! Half life of albumin and pre-albumin - Answer Albumin: 14-20 days Prealbumin: 2-3 days List negative acute phase proteins - Answer Prealbumin Albumin Transferrin Retinol-binding protein (decreased in inflammation) List positive acute-phase proteins - Answer Cytokines CRP (c-reactive protein) Define sarcopenia - Answer Age-related muscle mass Cachexia - Answer Loss of muscle mass, irrespective of adipose tissue changes (not responsive to nutrition interventions/support) +1 edema - Answer 2 mm depression or less Rebound immediate +2 edema - Answer 2-4 mm deppression Rebound after a few seconds +3 edema - Answer 4-6 mm depression Rebound after 10-12 seconds +4 edema - Answer 6-8 mm depression Rebound in 20 seconds Electrolyte abnormalities with refeeding risk - Answer -Hypophosphatemia (in most cases) -Low K -Low mag -Low ca -Hyponatremia -Hyperglycemia Other symptoms of refeeding - Answer -Cardiac arrest/arrythmias -Thiamin deficiency -Hypotension -Fluid retention -Shortness of breath/resp failure Advancement of EN if at risk of refeeding - Answer Advancing to goal rate over 3-5 days What is volume-based feeding? - Answer When EN is prescribed in goal volume per day instead of per hour in critically ill patients. Protocols involve starting at goal rate or rapid advancement. CNSC Exam Verified 100% Correct!! When should EN be delayed in critically ill patients? - Answer If they are hemodynamically unstable -- MAPs 50, starting high dose/increasing rate of vasopressors (may result in gut ischemia due to low blood pressure to the gut) Definition of hypocaloric feeding - Answer 65-70% of energy needs based on indirect calorimetry for obese critically ill patients Benefit of hypocaloric feeding in obese patients - Answer Minimizes metabolic complications of feeding, mobilize adipose store and increases insulin sensitivity What factors can impact the accuracy of a nitrogen balance study? - Answer - Impaired renal function -Incomplete collection of GI losses through fistulas, stool or ostomies What are the essential fatty acids? - Answer 1. Linoleic acid 2. Linolenic acid What is osmolality? - Answer the concentration of a solution expressed as the total number of solute particles per kilogram. What is considered a hyperosmolar solution? - Answer 320 mOsm/kg -Can contribute to diarrhea (though this is only likely with formulas containing sucrose delivered into small intestine directly since formula gets diluted by saliva/gastric juices in stomach) Hang time for open system ready-to-feed formula - Answer 8-12 hours Hang time for reconstituted formula - Answer 4 hours Time allowed in refrigerator for reconstituted formula - Answer 24 hours Hang time for closed system formula - Answer 24-48 hours Target glucose levels in hospitalized patients - Answer 140-180 Composition of diabetic formulas and their use - Answer 1. High in fat/fiber to reduce gastric emptying and help glycemic control 2. Lower in carbohydrates *ADA does not recommend a specific macronutrient distribution for diabetes, instead should individualize based on the patient *Not studied for ICU patients -- this population can control BGs with insulin gtt Evidence to support elemental formulas in malabsorptive disorders - Answer ESPEN advises against elemental formula for Crohn's, short bowel or UC Recommendations for use of specialty/elemental formulas in ICU patient - Answer ASPEN does not recommend due to lack of clear benefit demonstrated in the literature CNSC Exam Verified 100% Correct!! Theory behind specialty formulas for hepatic encephalopathy - Answer -Higher BCAAs clear ammonia in the skeletal muscle, lower amounts of aromatic amino acids -Research does not show benefit of BCAA supplementation in improving patient outcomes When to use immune-modulating formulas - Answer -Potential benefit in surgical patients and SICU post-op to reduce infection -Contraindicated in severe sepsis/illness Composition of pulmonary formula - Answer Low carb, high fat, concentrated formulas (lower respiratory quotient of lipid vs. carb) Evidence to support pulmonary formulas - Answer Conflicting evidence/recommendations, use clinical judgement Benefit of HMB in wasting conditions and which specific conditions does evidence support - Answer -Help preserve/increase muscle mass in AIDS, cancer cachexia and sarcopenia Components of immune-modulating formulas - Answer -Arginine -Omega 3's -Antioxidants -Sometimes glutatmine Estimated calorie needs for hypocaloric feeding based on BMI if IC not available - Answer BMI 30-50: 11-14 kcal/kg actual BMI50: 22-25 kcal/kg Ideal BW Deciding between nasoenteric tube and permanent feeding tube (expected length of need( - Answer Naso-enteric tube: 4-6 weeks Permanent tube: 6 weeks expected Indications for J-tube feedings - Answer -Gastric outlet obstructions -Gastroparesis -Pancreatitis -Increased aspiration risk Indications for a G-J tube - Answer -Gastric outlet obstruction -Severe gastric reflux -Gastroparesis -Early post-operative feeding Polyurethane vs. silicone tube differences (comfort, stiffness, wall width, fungal degradation, common use) - Answer Polyurethane: Less comfort, more stiff, thinner wall width, more resistant to fungal degradation, used for nasal feeding tubes Silicone: More comfortable, less stiff, thicker wall width, less resistant to fungal degradation, used for percutaneous tubes What does french size indicate? - Answer Measure of external diameter CNSC Exam Verified 100% Correct!! Solid internal bolster vs. balloon internal bolster - Answer Solid: Common in initial tube placement because they last longer Balloon: More common in radiologic and surgical placement, used as replacement devices in the office because of ease of placement What type of bolster is preferred for jejunal tubes? - Answer -Solid to prevent obstruction in the small bowel -Balloon bolsters in the jejunum are filled with only 3-4 mL fluid to prevent occlusion Standard vs. low profile percutaneous tubes - Answer Standard: Less cosmetically appealing, long tube hanging out Low profile: Skin level tubes, ideal for patients concerned about cosmetic appearance of the tube, those who are active or sleep on their stomach. Requires good hand control or caregiver assistance to attach the connector to. Medications to hold prior to percutaneous tube placement - Answer Anti-coagulants 1. Warfarin held 5 days before procedure 2. Thienopyridine held for 5-7 days prior 3. Direct-acting anticoagulants held 48 hours before Contraindications for PEG placement - Answer -ascites -inadequate window -Active head/neck cancer -morbid obesity -gastric varices -inflammatory or neoplastic disease of the gastric wall Advantages of placing PEG using Ponsky (pull) technique - Answer -Can be done at bedside -No radiation Advantages of placing PEG via fluoroscopy - Answer -Don't need conscious sedation for some patients -Ability to perform in patients with severe stenosis/trauma of upper GI tract -Decreased risk of tumor seeding from upper GI tract cancers.