Elaine B. Trujillo, M.S., R.D., CNSD &Malcolm K. Robinson,
M.D., CNSP
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© 2007 Wolf Rinke Associates, Inc. All rights reserved for all portions of this program. Reproduction in whole or part without written permission, except for brief excerpts, is prohibited.
Customer Comments
Joanna Goan: "Very thorough and organizaed. Challenging, net not too difficult to get through the material."
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Marianne Reczek-Phoebus: "This is the first self study that I have completed, overall I was pleased with it."
Laura Stuman: "Relevant information and realistic case studies."
Angela Paison: "Easy to red and follow, definitely a good review of nutrition support skills."
Shannon Tsakalakis: "This information will help me have a more complete understanding of my job.
Laura Krainbill: "I like the way it was written in simple language and how the examples and diagrams enhanced the text."
Kris McKinzey: "The handbook-it's GOLD and will be very useful in my practice."
Overview and Instructions
This learning program is a Category II Continuing Professional Education (CPE)
program approved for 12 Continuing Professional Education Units (CPEUs). That
means that the reader has general knowledge of the literature and professional
practice within the area covered. The focus of the program is to enhance knowledge
and application.
To get the most benefit from this program, we suggest you follow these four
steps:
Step 1: Review the objectives for the learning program.
Step 2: Study each chapter. As you read, think of patients from your own practice
who fit the situation described.
Step 3: Assess what you have learned by completing the self-assessment instrument
at the end of this learning program.
Step 4: Compare your answers with the answer key that has been provided. If
you score at least 80% correct, transfer your answers to the Continuing Professional
Education Reporting Form. If you score less than 80% correct, re-read this learning
program until you are able to score at least 80% correct.
After you have successfully completed this program, mail or fax the completed
Continuing Professional Education Reporting Form to:
Wolf Rinke Associates, Inc.
P.O. Box 350
Clarksville, MD 21029
Fax (410) 531-9282
After your completed Continuing Professional Education Reporting Form has been
received, we will send you a Certificate of Completion for 12 CPEUs.
HAPPY LEARNING!
GOAL
To provide valuable information and tools to assist you in providing appropriate
nutritional support for critically ill patients.
OBJECTIVES
As a result of studying and applying the concepts presented in this accredited,
self-directed learning program, you will be able to:
" Identify the phases of the metabolic response.
" Differentiate between the metabolic response of critical illness and
starvation.
" Apply the components of energy expenditure.
" Predict energy and protein requirements of critically ill patients.
" Interpret results of indirect calorimetry.
" Propose reasons for feeding via the enteral or parenteral route.
" Predict potential complications of nutritional support in the critically
ill patient.
" Recognize different feeding strategies for various metabolic profiles
in the critically ill.
" Select methods of assessing the adequacy of nutritional support.
" Incorporate the use of specialized nutritional agents in the critically
ill.
" Formulate plans to manage the complications of nutritional support.
Table of Contents
Introduction 1
Chapter 1. Metabolic Response to Starvation, Stress and Injury 3
Phases of the Metabolic Response 3
Critical Illness versus Starvation 6
Chapter 2. Nutritional Assessment of the Critically Ill 7
Physical Examination 7
Laboratory Assessment 8
Anthropometrics 9
Components of Energy Expenditure 15
Determining Energy Expenditure 17
Protein Requirements 24
Vitamin and Mineral Requirements 26
Chapter 3. Feeding the Critically Ill 29
Glucose Intolerance 32
Pancreatitis 35
Acute Renal Failure 39
Hepatic Dysfunction and Liver Failure 43
Acute Respiratory Distress Syndrome 46
Chapter 4. Specialized Nutritional Treatments 49
Immune-Enhancing Nutrients 49
Anabolic Agents 52
Chapter 5. Common Complications and Management of Feeding 55
Parenteral Nutrition 55
Enteral Nutrition 61
Case Studies 71
References 95
For Your Continuing Learning 113
List of Abbreviations 115
Glossary 117
Resources 123
Self-Assessment Questions 125
Answer Key 135
Explanation to Questions 137
About the Authors 143
Tables
Table 1. Metabolic Response to Starvation and Critical Illness 6
Table 2. Example 1: Evaluating Laboratory Values in Nutritional Assessments
10
Table 3. Example 2: Evaluating Laboratory Values in Nutritional Assessments
11
Table 4. Degree of Malnutrition as Determined by Body Weight 12
Table 5. Degree of Malnutrition Determined by Body Weight and Weight Loss 12
Table 6. Examples of Body Weight Assessment 13
Table 7. Subjective Global Assessment 14
Table 8. Stress Factors Associated with Injury 18
Table 9. Example of How to Calculate TEE 18
Table 10. Example: Determining Energy Expenditure in an Obese Patient 20
Table 11. Example: Use of Indirect Calorimetry in the Clinical Setting 22
Table 12. Example: Determining Protein Requirements 26
Table 13. Recommendations for Daily Parenteral Vitamin and
Trace Element Intake 27
Table 14. Patient Groups that May Benefit from Glutamine Supplementation 50
Table 15. General Guidelines for Patient Populations where Growth Factors
May Be Beneficial 54
Table 16. Complications Associated with Catheter Insertion 57
Table 17. Usual and Modified Dosages for Electrolyte Additives in PN 59
Table 18. Compatible Medications and Vitamins/Minerals in Triple-Mix PN 60
Table 19. Guidelines for the Selection of Short-Term (<3 weeks) Enteral
Feeding Tubes and Routes of Feeding 61
Table 20. Guidelines for the Selection of Long-Term (>3 weeks) Enteral
Feeding Tubes and Routes of Feeding 62
Table 21. Prevention of Feeding Tube Occlusion 63
Table 22. Major Causes and Treatment of Diarrhea in the Tube Fed Patient 67
Figures
Figure 1. Determining Route of Feeding 31
Figure 2. Guidelines for Insulin Administration in Hyperglycemic Patients
in the ICU 34
Figure 3. Indirect Calorimetry Assessment 77
Figure 4. Protein Intake 93
Figure 5. Caloric Intake 93
Figure 6. Relationships in Fluctuations of Three Hepatic Proteins: Prealbumin,
C-Reactive Protein, and Retinol Binding Protein in a Critically Ill
Postoperative Patient 94
About the Authors
Elaine B. Trujillo is a registered dietitian with a Master of Science degree in nutritional science from Texas Woman's University. She currently is a nutritionist at the Nutritional Science Research Group, National Cancer Institute, National Institutes of Health in Rockville, Maryland and is a consultant dietitian at the Cardiac Rehabilitation and EECP Center, Shady Grove Adventist Hospital, Rockville, Maryland. Prior to her appointment at the NIH, she was a research dietitian for the Metabolic Support Service, Brigham and Women's Hospital, Harvard Medical School in Boston, Massachusetts. She authored numerous articles in professional journals, textbook chapters, and professional manuals and co-authored the book Eating for Lower Cholesterol: A Balanced Approach to Heart Health with Recipes Everyone will Love. She lectures frequently nationally and internationally. She serves as a reviewer for the Journal of the American Dietetic Association.
Malcolm K. Robinson currently is an Assistant Professor of Surgery at Harvard
Medical School and Director of the Metabolic Support Services and Program for
Weight Management at Brigham and Women's Hospital, Boston, Massachusetts. He
received a Doctor of Medicine from Harvard Medical School and trained in Surgery
at Brigham and Women's Hospital. He is an Associate Editor for the Journal for
Parenteral and Enteral Nutrition and his research interests include short bowel
syndrome, nutrition in multiple organ failure, and obesity. He authored and
co-authored several research abstracts, papers, and textbook chapters in the
area of metabolic and nutritional support.