Parental Nutrition
9 PARENTERAL NUTRITION
Margaret M. McQuiggan M.S., R.D., CNSD, Frederick A. Moore M.D.
1. What is parenteral nutrition?
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Parenteral nutrition is the provision of protein as amino acids (4 kcal/g), dextrose (3.4 kcal/g), and fat (lipid 20% solution delivers 2 kcal/mL), vitamins, minerals, trace elements, fluid, and sometimes insulin through an intravenous (IV) infusion. Acid-base status may be influenced by the amount of chloride and acetate used in providing sodium and potassium. The concentrations of calcium and phosphorus are limited to avoid precipitation of a calcium phosphate salt.
Nutritional Assessment & Enteral Nutrition. Controversies
CONTROVERSIES
23. How fat is fat?
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Lean body mass is three times more metabolically active than adipose tissue. Multiple definitions of clinical obesity exist: > 120% ideal body weight (IBW), > 130% IBW, body mass index (BMI) > 30, body fat > 24-28% of body weight in men and > 30-35% in women. Measured weight is a poor indicator of relative adiposity. Self-reported weights or weights reported by family members are often erroneous in the ICU setting. Fluid resuscitation and edema make visual assessment challenging and limit the usefulness of noninvasive technology such as bioelectrical impedance (BIA) for measuring body composition. Although measured energy expenditure in kcal/kg of actual weight may sometimes approach that of normal-weight patients, feeding at the measured body weight level may be associated with profound hyperglycemia, hypercapnea, and the inability to clear triglycerides.
Nutritional Assessment & Enteral Nutrition. Enteral Nutrition
ENTERAL NUTRITION
10. When should enteral nutrition be considered?
Show answer
Always, but especially when a patient is unlikely to meet > 70% of nutritional needs by mouth. Patients who have sustained major head injury (Glasgow Coma Scale score < 8), major torso trauma, major trauma to the pelvis and long bones, or major chest trauma benefit from enteral nutrition. Approximately 85% of postoperative patients (even those undergoing gastrointestinal [GI] surgery) tolerate early enteral feeding (within 24 hours).
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Nutritional Assessment & Enteral Nutrition. Nutritional Assessment
8 NUTRITIONAL ASSESSMENT AND ENTERAL NUTRITION
Margaret M. McQuiggan M.S., R.D., CNSD, Frederick A. Moore M.D.
NUTRITIONAL ASSESSMENT
1. What does a nutritional assessment include? Show answer
Fluids, Electrolytes, Gatorade & Seat
7 FLUIDS, ELECTROLYTES, GATORADE, AND SWEAT
Alden H. Harken M.D.
1. What is hypertonic saline?
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Normal saline is 0.9% sodium chloride. Hypertonic saline is 7.5% sodium chloride (eight times as concentrated as normal saline).
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Why Get Arterial Blood Gases?
6 WHY GET ARTERIAL BLOOD GASES?
Alden H. Harken M.D.
1. Is breathing really overrated?
Show answer
It may be. A Japanese yoga master survived just fine breathing once per minute for an hour (see reference 1)!
2. Mr. O’Flaherty has just undergone an inguinal herniorrhaphy under local anesthesia. The recovery room nurse asks permission to sedate him. She says that he is confused and unruly and keeps trying to get out of bed. Is it safe to sedate Mr. O’Flaherty?
Show answer
No. A confused, agitated patient in the recovery room or surgical intensive care unit (SICU) must be recognized as acutely hypoxemic until proved otherwise.
3. Mr. O’Flaherty is moved to the SICU, and at 2:00 a.m. the SICU nurse calls to report that he has a Po2 of 148 mmHg on facemask oxygen. Is it okay to roll over and go back to sleep?
What Is Pulmonary Insufficiency?
5 WHAT IS PULMONARY INSUFFICIENCY?
Alden H. Harken M.D.
1. What is pulmonary insufficiency?
how answer
The alveolar-capillary surface of the lung is the size of a singles tennis court. The purpose of the lung is to match alveolar ventilation (Va) to blood flow (Q). Mismatching leads to pulmonary insufficiency.
2. How is Va/Q mismatching characterized?
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Shunt: decreased ventilation relative to regional blood flow; pulmonary arterial (unoxygenated) blood “shunts” by hypoventilated alveoli
Dead space: decreased pulmonary regional blood flow relative to ventilation
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How to Think About Shock?
4 HOW TO THINK ABOUT SHOCK
Alden H. Harken M.D.
1. Define shock. Show answer
Shock is:
* Not just low blood pressure
* Not just decreased peripheral perfusion
* Not just limited systemic oxygen delivery
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Evaluation & Treatment Of Cardiac Dysrhythmias
3 EVALUATION AND TREATMENT OF CARDIAC DYSRHYTHMIAS
Alden H. Harken M.D.
1. Are cardiac dysrhythmias and cardiac arrhythmias the same?
Show answer
Yes. Some purists will tell you that an arrhythmia can be only the absence of a cardiac rhythm. But these are the same purists who use the word iatrogenic to mean “caused by a physician,” when, of course, the only thing that can truly be “iatrogenic” is a physician’s parents.
Cardiopulmonary Resuscitation
2 CARDIOPULMONARY RESUSCITATION
Norman A. Paradis M.D., Alden H. Harken M.D.
1. Define sudden cardiac death.
Sudden ventricular fibrillation (VF) or pulseless electrical activity (PEA). Acute coronary ischemia and preexisting cardiac disease are the most common causes. VF is becoming less common.
2. What is the predominant determinant of successful cardiopulmonary resuscitation (CPR)?
Show answer
Time to restoration of spontaneous circulation, which itself is a function of the time to effective chest compression and time to defibrillation of VF. The chance of a good outcome decreases by 10% per minute. Successful outcomes are more likely if CPR is initiated promptly and if preexisting hypothermia is present.
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1 Are You Ready For Your Surgery Rotation?
Unlike medical rounds, where in order to “keep up” you need to “one up” by quoting a current (preferably yesterday’s) journal article, in surgery, you can flourish by knowing the following references-but you need to know them cold.
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ARE YOU READY FOR YOUR SURGERY ROTATION?
Surgery is a participatory, team, and contact sport. Present yourself to patients, residents, and attendings with enthusiasm (which covers a multitude of sins), punctuality (type A people do not like to wait), and cleanliness (you must look, act, and smell like a doctor). Read more
Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
