stress and critical care part 2

sepsis

dysregulated host response to infection that leads to acute organ dysfunction

septic shock

associated with circulatory and metabolic dysfunction with a high rate of mortality

pro-inflammatory cytokine release, hypotension, hypo perfusion, altered cellular metabolic, imbalance of coagulation factors

what are the 5 etiologies for sepsis?

systemic inflammatory response syndrome (SIRS)

widespread, non-specific inflammatory response that occurs in infection, pancreatitis, MI, ischemia, burns, multiple trauma, shock, and organ injury

hypermetabolic

patients with SIRS are _______.

SIRS + infection

____ + ______ = sepsis (systemic response to infection)

WBC >12000, HR >90 bpm, fever (>100.4) or hypothermia (<96.8), abnormal inflammation markers (CRP, APPs)

what are the clinical manifestations of sepsis?

SIRS, sepsis, severe sepsis, septic shock

what are the 4 steps of sepsis?

initiated by original source of infection/trauma. when individual cell recognizes microorganism, systemic response causes release of inflammatory mediators (TNF, IF, ILs). inflammation results in vascular permeability which allows shift in fluid into lungs and third spaces. high levels of nitric oxide and coagulation imbalances cause other issues. As sepsis continues, shift from inflammatory to anti-inflammatory response.

explain the pathophysiology of sepsis.

inability to mount an immune response and organ dysfunctions, increase rate of GNG causing significant muscle catabolism, hyperglycemia, increased serum lactate

what are the 4 outcomes of sepsis?

increased WBC, HR, Resp.; fever or hypothermia; increase +AP (CRP, fibrinogen); decrease - APP (albumin, pre-albumin, transferrin, RBP); massive edema; increase serum lactate and glucose

what do we see clinically in sepsis?

treat source of infection or trauma, lung-protective ventilation, hemodynamic/renal/metabolic support, fluid resuscitation, vasoactive agents, insulin, antimicrobial agents, coagulation drugs, nutrition support

what is the medical treatment for sepsis?

hypermetabolic

patients with significant burns are _____ due to catabolic response that occurs after injury.

20

___% of body protein can be lost within the first 2 weeks of a burn injury.

protein, calories, fluid imbalance, pain, immobility

what are the main concerns in burn patients?

medical status, extent of burns, medical history, weight, high protein loss form wound, high kcal and protein needs, micronutrient deficients

what is important for the nutrition assessment of a burn patient?

5-7

energy demand peaks ____ days post burn.

1.5-2 g/kg IBW

protein for burns: ________. amounts of >2.2 g/kg in adults and 3 g/kg in children do not demonstrate improved outcomes.

glutamine, omega-3s

what nutrients can be helpful in burns?

daily kcal, wound closure, acceptance of engraftment

what can be monitored as measurements of adequate nutrition support?

follow nutrition protocol, micronutrients could be helpful for wound healing, PN is not recommended unless patient cannot meet nutritional needs

what are the interventions for burns?

thiamin, folate, zinc, selenium, vitamin C, vitamin E, vitamin D

what micronutrients are included in nutrient protocol for burns?

low BMI (<18.5), >10% weight loss in past 6 months, reduced oral intake (>50% in past week), perioperative serum albumin <3.0

what makes up the perioperative nutrition screen (PONS)?

kcal: 25-30 kcal/kg/day. protein: 1.5-2.5 g/kg IBW

what are the general nutrition needs during surgery?

initiation of early EN and avoid use of early PN

what is the EN/PN recommendation?

assist in modulating inflammatory response, reduce skeletal catabolism, support wound healing, assist in GI and pulmonary mucosal barriers to bacteria

what does nutrition therapy do?

10-20 mL/hr

where should trophic feeds start?

initiate EN when anticipated patient will be unable to adequate intake in 3-5 days, PN should be reserved for those that EN will not work and cannot PO within 4-5 days, PN is associated with greater risk of infection and mortality

what are the 3 ASPEN guidelines for critical care?

higher

early feedings have _______ percent survival.

nutrients needs gasified, improved tube feeding tolerance, decreased incidence of bacterial translocation, decreased number of infection, enhanced visceral protein status, improved nitrogen balance, reduced urinary catecholamines, diminished serum glucagon, suppress hyper metabolic response

what are the benefits of early nutrition support?

5-7 mg/kg/min

what is the maximum rate of glucose infusion?

fatty liver

above 5-7 mg/kg/min glucose, _________ can develop.

fats

caution the use of ____ in stressed and trauma patients.

immunosuppressant

high fat feedings can be an _______ and newer formulas are focusing on omega-3s

fat

propofol provides calories via ____.

15-20

fat should be ___-__% total calories in critical are.

2.5

fat should be limits to ______ g/kg/day.

30-40 mL/kg or 1-1.5 mL/kcal expended

what are the fluid recommendations?

renal failure, cardiac failure, pulmonary edema

restrict fluids in…

48-72

when staring trophic feeds, advance to goal rate over the next ___-_____ hours.

50-65

overall target for intake is ______-_____% of goal in first week.

high protein, low fat, use MCT, high in vitamins and minerals

what are the characteristics of a good critical care formula?

propofol

lipid-soluble, short-acting IV hypnotic/sedative administered continuously to provide sedation

1.1

propofol provides _______ kcal/mL from fat.

physical assessment, functional status, vital signs, actual nutrient intake, weight and weight changes, pertinent labs, medication administered, changes in GI function, wound healing, tolerance

what should be monitored?

medical team

oral feeds can begin when patient is able and the ____________ approves.

>60%

nutrition support can be weaned after patient can meet ___ of nutrition requirements with oral feedings.