86 Questions
What is the current recommendation regarding selenium, zinc, and antioxidant supplementation in sepsis?
It is not recommended due to conflicting studies.
What is the effect of selenium supplementation on mortality in septic patients according to the aggregated data from 9 studies?
It has no effect on mortality.
What is the optimal dose of selenium for critically ill patients?
500-750 mcg/d
What is the correlation between plasma zinc levels and the magnitude of the inflammatory response following systemic infection?
Inversely correlated
What is the significance of decreased plasma selenium levels in septic patients?
It is a potent antioxidant agent.
What is the duration of supplementation recommended for critically ill patients?
1-3 weeks
What is the controversy surrounding lower zinc levels in septic patients?
Whether it reflects the acute-phase response or relative deficiency.
What is the significance of the study by Huang et al in the context of selenium supplementation?
It showed a significant reduction in mortality.
What does serum albumin concentration not reflect in a postoperative patient?
Nutrition status
What is the role of the NRS 2002 in postoperative patients?
Predicting postoperative complications
What is the benefit of providing EN early in the postoperative setting?
Better outcomes compared to PN or STD
In what situations is EN not feasible postoperatively?
Continued obstruction of the GI tract
What is the goal of goal-directed conservative fluid management?
Decreasing likelihood of overhydration and bowel wall edema
What is the effect of inadequate arginine supply on T-cell function?
Immune suppression
Why is arginine important in immune-modulating formulas?
It reverses arginine depletion
What is the quality of evidence supporting the use of immune-modulating formulas in postoperative patients?
Moderate to Low
What is the effect of early EN on mortality in postoperative patients?
Reduces mortality from 6.8% to 2.4%
What is the effect of EN on complications in postoperative patients?
Decreases complications excluding nausea and vomiting
What is the suggested protein requirement for septic patients in the acute phase of management?
1.2-2 g/kg/d
What is the recommended initial energy goal for septic patients?
10-20 kcal/h or up to 500 kcal/d
What is the purpose of using indirect calorimetry (IC) in septic patients?
To measure energy expenditure
What is the potential risk of using arginine in septic patients?
Hemodynamic instability and organ dysfunction
What is the suggested nutrition risk indicator for postoperative patients in the ICU?
NRS 2002 or NUTRIC score
Why are traditional visceral proteins, including albumin, prealbumin, and transferrin, not useful in the postoperative setting?
They reflect the dynamic and catabolic response to surgery, stress, injury, infection, or organ failure
What is the recommended energy goal for septic patients after 24-48 hours?
60-70% of target energy goal
What is the benefit of zinc supplementation in septic patients?
Preventing innate immune suppression and risk of secondary infection
What is the suggested method for predicting energy expenditure in septic patients when IC is not available?
Harris-Benedict and Schofield published equations
What is the potential benefit of using arginine in septic patients?
Promoting perfusion of tissues and increasing cardiac output
What is the effect of omega-3 fatty acids EPA and DHA on immune cells?
They downregulate the expression of nuclear factor-kappa B, intracellular adhesion molecule 1, and E-selectin
What is the effect of enteral feeding on anastomoses?
It makes anastomoses stronger with greater collagen and fibrin deposition and fibroblast infiltration
What is the effect of early enteral feeding on postoperative ileus?
It attenuates postoperative ileus
What is the recommendation for PN use in postoperative ICU patients?
It should be used only when EN is not feasible and the duration of therapy is anticipated to be ≥7 days
What is the effect of resolvins on bacteria?
They enhance phagocytic clearance of bacteria
What is the effect of omega-3 fatty acids on cardiac arrhythmias?
They decrease the incidence of cardiac arrhythmias
What is the effect of EPA and DHA on neutrophil attachment and transepithelial migration?
They decrease neutrophil attachment and transepithelial migration
What is the effect of early enteral feeding on mortality?
It decreases mortality
What is the effect of EPA and DHA on systemic inflammation?
They reduce systemic inflammation
What is the effect of enteral feeding on bowel wall edema?
It prevents bowel wall edema
What is the time frame recommended for early EN initiation in obese patients who cannot sustain volitional intake?
Within 24-48 hours of ICU admission
What is a significant factor contributing to malnutrition in obese patients?
Lack of attention from clinicians due to high BMI
What is an important parameter to assess in obese ICU patients beyond routine elements of assessment?
Waist circumference
What is a high-risk indicator for obese patients in the ICU?
Central adiposity
What is a consequence of obesity in critically ill patients?
Increased technical difficulties in management
What is the goal of high-protein hypocaloric feeding in obese ICU patients?
To preserve lean body mass
What is a challenge in providing nutrition care to obese ICU patients?
All of the above
What is a physiologic consequence of obesity in critically ill patients?
Reduced vital capacity
What is a comorbidity that correlates with higher obesity-related risk for cardiovascular disease and mortality?
All of the above
Why is waist circumference measurement important in obese ICU patients?
To determine metabolic syndrome
What is the primary role of artificial nutrition and hydration in end-of-life situations?
To respect patient autonomy and dignity
According to expert consensus, when is ANH considered obligatory?
Never, as it is not considered essential in any situation
What is the impact of ANH on terminally ill patients, according to studies?
It increases patient distress and does not improve outcomes
What is the primary reason for intentional permissive underfeeding of calories in obese ICU patients?
To assess nutrition efficacy and maintain energy provision at 65%–70% of REE
What is the recommended frequency for monitoring serum micronutrient levels?
Annually
Why is ANH often provided in terminally ill patients, despite the lack of evidence?
To address patient volitional intake reduction anxiety in care providers and families
What is the major challenge in glycemic control in obese ICU patients?
Postreceptor insulin resistance and accelerated gluconeogenesis induced by critical illness
What is the purpose of repeating IC measurements in obese ICU patients?
To maintain energy provision at 65%–70% of REE
What is the primary concern of care providers and families in terminally ill patients?
Addressing reduction in patient volitional intake
What is the outcome of the study by Bruera et al on IV hydration in terminally ill patients?
IV hydration did not improve quality of life, symptoms, or survival in terminally ill patients
What is the recommended supplementation in obese ICU patients with a history of bariatric surgery?
Supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy
What is the primary concern in obese ICU patients with a history of bariatric surgery?
Risk of micronutrient deficiency
In which type of patients has a consistent benefit of PN over STD been seen?
Patients undergoing major upper GI surgery with evidence of preexisting protein-energy malnutrition
What is the impact of dehydration and poor oral intake on terminally ill patients?
It is well-tolerated and generates little symptomatology
What is the suggested approach for advancing the diet postoperatively in ICU patients?
Allowing solid food as tolerated and eliminating the need for clear liquids
What is the recommended monitoring in obese ICU patients receiving EN?
Serum glucose concentrations, serum triglyceride concentrations, and arterial blood gases
What is the purpose of tracking the cumulative energy deficit in obese ICU patients?
To assess nutrition efficacy and maintain energy provision at 65%–70% of REE
What is the effect of early advancement to oral diet on postoperative dysmotility?
It attenuates postoperative dysmotility
What is the rationale for additional monitoring in obese critically ill patients receiving EN?
Because of the risk of worsening of hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation
What is the suggested nutrition therapy approach for chronically critically ill patients?
Aggressive high-protein EN therapy with a resistance exercise program
Why is it important to identify a possible thiamine deficiency prior to administration of dextrose-containing IV fluids?
Because thiamine deficiency can exacerbate the condition if not identified and treated prior to administration of dextrose-containing IV fluids
What is the duration of ICU stay that is commonly used to define chronic critical illness?
≥21 days
What is the recommended supplementation in addition to thiamine in obese ICU patients with a history of bariatric surgery?
Calcium, vitamin D, and a daily multivitamin with iron and vitamin B12
What is the significance of placement of an elective tracheostomy in the context of chronic critical illness?
It is a common delineation to identify chronic critical illness
What is the effect of early EN on obese ICU patients in the first week of hospitalization?
They benefit less from early EN due to their increased nutrition reserves
What is the primary goal of nutrition therapy in chronically critically ill patients?
To improve functional outcomes
What is the significance of postoperative nausea in the context of advancing the diet postoperatively?
It is a common symptom that occurs with the same frequency regardless of the type of diet
What is the relationship between the time to resume bowel function and early advancement to oral diet?
Early advancement to oral diet shortens the time to resume bowel function
What is the primary goal of providing high-protein hypocaloric feeding in hospitalized patients with obesity?
To increase insulin sensitivity and facilitate nursing care
What is the suggested protein requirement for adult obese ICU patients with a BMI of 30-40?
2.0 g/kg ideal body weight per day
What is the recommended energy goal for adult obese ICU patients with a BMI of 30-50?
11-14 kcal/kg actual body weight per day
What is the primary benefit of using high-protein hypocaloric feeding in adult obese ICU patients?
All of the above
What is the recommended method for calculating energy requirements in adult obese ICU patients?
Indirect calorimetry (IC) when available
What is the primary indication for using specialty enteral formulations in adult obese ICU patients?
Low caloric density and reduced NPC:N
Why is achieving nitrogen equilibrium important in adult obese ICU patients?
To preserve nitrogen balance and allow for adequate wound healing
What is the potential risk of providing low protein intake in combination with a hypocaloric diet in adult obese ICU patients?
Worsened mortality
What is the recommended method for adjusting protein recommendations in adult obese ICU patients?
Using nitrogen balance studies
What is the primary benefit of using low-energy dense formulas in adult obese ICU patients?
Meeting increased fluid requirements
Study Notes
Sepsis and Antioxidants
- Plasma concentrations of selenium, zinc, and other antioxidants are decreased in septic patients.
- Selenium has antioxidant capabilities and is believed to be one of the most potent in clinical settings.
- The optimal acute selenium dose for critically ill patients may range between 500-750 mcg/d, with ideal duration of supplementation being 1-3 weeks.
- Zinc supplementation in septic patients may help prevent innate immune suppression and risk of secondary infection.
Nutrition in Sepsis
- For septic patients in the acute phase of management, trophic feeding (10-20 kcal/h or up to 500 kcal/d) is suggested for the initial phase, advancing to >80% of target energy goal over the first week.
- Protein delivery of 1.2-2 g/kg/d is suggested.
- Immune-modulating formulas are not recommended for routine use in patients with severe sepsis.
Postoperative Major Surgery
- Determination of nutrition risk (e.g., NRS 2002 or NUTRIC score) is suggested for all postoperative patients in the ICU.
- Traditional visceral protein levels (serum albumin, prealbumin, and transferrin concentrations) are not valid markers of nutrition status in the postoperative setting.
- EN is suggested when feasible in the postoperative period, within 24 hours of surgery, as it results in better outcomes than use of PN or STD.
- Immune-modulating formulas containing arginine and fish oils may be used in the SICU for postoperative patients who require EN therapy.
- EN may be feasible in difficult postoperative situations, such as OA, bowel wall edema, fresh intestinal anastomosis, vasopressor therapy, or ileus, but individualized case-by-case decisions are required.
- PN may be used in patients who have undergone major upper GI surgery and EN is not feasible, but only if the duration of therapy is anticipated to be ≥7 days.
Chronically Critically Ill
- Chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS >21 days) should be managed with aggressive high-protein EN therapy and, when feasible, a resistance exercise program.
- Early EN start within 24-48 hours of admission to the ICU is suggested for obese patients who cannot sustain volitional intake.
Obesity in Critical Illness
- Obese ICU patients may benefit from early EN, despite their nutrition reserves.
- Nutrition assessment of the obese ICU patient should focus on biomarkers of metabolic syndrome, evaluation of comorbidities, and determination of level of inflammation, in addition to routine parameters.
- Factors that identify obese patients in the ICU at high risk include evidence of central adiposity, metabolic syndrome, sarcopenia, BMI >40, SIRS, or other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality.### Obesity in ICU Patients
- Obesity alters drug metabolism, increases technical difficulties in management, and changes the pattern of comorbidities.
- Obese ICU patients require special teams and highly specialized equipment for daily routine nursing care.
Physiologic Consequences of Obesity
- Obesity negatively impacts organ function, predisposing to:
- Congestive heart failure (reduced left ventricular contractility, decreased ejection fraction, and increased left ventricular end-diastolic volume)
- Respiratory abnormalities (obstructive sleep apnea, higher airway resistance, decreased vital capacity, total lung capacity, and chest wall compliance)
- Hepatopathy (nonalcoholic fatty liver, steatosis, and cirrhosis)
Nutritional Support for Obese ICU Patients
- High-protein hypocaloric feeding is recommended to:
- Preserve lean body mass
- Mobilize adipose stores
- Minimize metabolic complications of overfeeding
- Energy targets: 65%–70% of target energy requirements or 11–14 kcal/kg actual body weight per day for BMI 30–50, and 22–25 kcal/kg ideal body weight per day for BMI >50
- Protein targets: 2.0 g/kg ideal body weight per day for BMI 30–40, and 2.5 g/kg ideal body weight per day for BMI ≥40
Specialty Enteral Formulations
- Use of enteral formula with low caloric density and reduced NPC:N is suggested
- Low-energy dense formulas (1 kcal/mL) may be more appropriate for obese critically ill patients
Monitoring for Obese Critically Ill Patients
- Additional monitoring is recommended to assess:
- Worsening of hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation
- Nutrition efficacy and intake/output
- Cumulative energy deficit to maintain energy provision at 65%–70% of REE
Patients with a History of Bariatric Surgery
- Obese ICU patients with a history of bariatric surgery require:
- Supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy
- Evaluation and treatment of micronutrient deficiencies (calcium, thiamin, vitamin B12, fat-soluble vitamins, and folate)
Artificial Nutrition and Hydration in End-of-Life Situations
- ANH is not obligatory in cases of futile care or end-of-life situations
- Decisions regarding ANH should be based on evidence, best practices, clinical experience, and respect for patient autonomy and dignity
This quiz covers the relationship between sepsis and antioxidants, including selenium and zinc supplementation in critically ill patients. It explores the optimal doses and durations of supplementation to prevent immune suppression and secondary infections.
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