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Typical Daily Protein Requirements for Pts Receiving Nutrition Support Therapy -ANSWER 1.) Protein-energy malnutrition, wound healing, and hypercatabolism--1.2-1.8g/kg. 2.) Continuous Renal Replacement Therapy -- 1.5-2.5g/kg. 3.) Hypocaloric feeding for critically ill pt with class 1 or 2 obesity -->2g/kg. 4.) Hypocaloric feeding for critically ill pt with class 3 obesity -->2.5g/kg. *No concensus of actual or IBW. Special Considerations for Formula Selection of EN in Pts with Normal Nutrition,Long-term/Diarrhea/Constipation, Volume Restriction, and Kidney Failure - ANSWER 1.) Normal Nutrition: Standard polymeric formula should be okay. 2.) Long-term/Diarrhea/Constipation: Fiber-containing 3.) Volume Restriction (CHF): Concentration. However, this may contain sucrose andcould lead to dumping. Controlled feeding on an enteral pump should help.
4.) Kidney Failure: Concentrated with low Na, K+, and Phos. Starting and Advancing Parenteral Nutrition -electrolytes and BG. ANSWER 1.) Start with normal serum
2.) Start with low Dextrose concentration (<150-200g Dex in 24 hrs) 3.) Advance slowly to goals for volume, Dex, AA< and fat emulsion over the next 2-3days.
4.) First 3-5 days of PN: monitor K+, phos, and magnesium to avoid refeeding syndrome. 5.) Provide IV vits and mins in standard amounts bc infusion eliminates the risk ofmalabsorption.
Indications for Nutrition Support in Bariatric Surgery Pts (P.N.) - 11 Indications. -ANSWER 1.) No PO for 7-10 days (5-7 days in ICU)
2.) Diffuse peritonitis 3.) Presence of enterocutaneous fistula where an enteral feeding tube cannot beinserted distal to fistula
4.) GI ischemia 5.) Ileus 6.) Obstruction 7.) Intractable vomiting or diarrhea 8.)Perioperative nutrition (PN for 7-10 days) for severely malnourished.
5.) Skin and Nail Conditions: Zinc, Vitamin A, Vitamin K, Iron. Benefits of Parenteral Nutrition -vitamin and mineral needs. ANSWER 1.) Can meet 100% of energy, protein,
2.) Easier to obtain access than EN. 3.) Can provide nutrition when EN is contraindicated. 4.) No risk of aspiration. Disadvantages of Parenteral Nutrition - ANSWER 1.) Higher risk of infection. 2.) High cost. 3.) Risk of mechanical complications associated with central venous access. 4.) In long term, may lead to intestinal atrophy, PN-associated liver disease, andmetabolic bone disease.
5.) Use of Omega-6 IVFE is proinflammatory and immunosuppressive. Managing Catheter-Related Bloodstream Infection with PN -technique for catheter care and insertion & when preparing IV infusion. ANSWER 1.) Use aseptic
2.) Designate one port for IV infusion only. Dehydration Management in PN - ANSWER 1.) Evaluate fluid needs.
2.) Add fluid losses (diarrhea, fistula output, etc) 3.) Daily weight & input/output 4.) Add supplemental IV fluid apart from PN, as needed. Essential Fatty Acid Deficiency Management in PN -appropriate IV fat emulsion to maintain essential fatty acid requirements. ANSWER 1.) Administer
2.) Fatty acid profile, including Triene:Tetraene ratio every 6 months. Activity Factors for Mifflin St. Jeor -1.4-1.69. ANSWER 1.) Sedentary or lightly active lifestyle:
2.) Active or moderately active lifestyle: 1.7-1.99. 3.) Vigorous or vigorously active lifestyle: 2-2.4. Biochemical Surveillance for Pre Bariatric Surgery -2.) Lipids ANSWER 1.) LFT's 3.) CBC4.) Ca, Alk Phos 5.) Serum Ferritin, Iron, and TIBC 6.) Folate, Plasma Homocystiene7.) HgbA1C 8.) B-1 (Thiamine) 9.) B-
- good tolerance of food despite poor eating style ("I can eat anything")
- Poor wt loss or wt gain 2.) Too Tight:
- Dysphagia or inability to tolerate solids or liquids-Nighttime cough
- Heartburn, reflux, vomiting, slimming
- Reliance on soft food intake Areas of Investigation in Nutrition Assessment of Stabilized Weight: Patterns andBehaviors Component - ANSWER -3-4 meals with snacks between?
-? snacking too frequently? Eating too quickly or not chewing food adequately may result in consuming a meal in20-30 minutes.
D/O eating patterns include night eating or grazing when not hungry. Increased volume of liquids with or immediately after meals. Frequency of meals away from home.RYGB Complications that may lead to wt regain - ANSWER 1.) Staple line disruption
2.) Stenosis of the pouch outline 3.) Gastro-gastric fistula
4.) Pouch or stoma dilation 5.) Poorly constructed bypass with short limb or pouch construction 6.) Reactive hypoglycemia Complications of SG that can lead to wt gain/suboptimal wt loss -line leakage ANSWER 1.) Staple
2.) Anatomically incorrect sleeves 3.) Severe GERD 4.) Stenosis 5.) Sleeve dilation Discuss Diet Stage 3: Soft Food Texture Progression -timing depends on surgery and response to foods. Think of this as a prescription. ANSWER Introduce soft foods -
Soft protein 3-5x/day 48-64oz fluid Add F&V a few days after protein. Non-starchy, well cooked vegetables. No stringy orfibrous. Avoid with skins, seeds, or membranes. Starches to avoid in stage 3 Promote eating pattern. Few bites (or liquid) if not hungry. Encourage to stop when full.
GLP-1 - ANSWER Acts synergistically with PYY: Causes satiety. Exercises insulin response to nutrients. Delays gastric emptying.Inhibits glucagon secretion.
Increased following RYGB and SG. Doesn't change with LAGB. Recommendations for wt gain during pregnancy - ANSWER When BMI is 25-29: Total wt gain of 7-11.5 kg (15-25 lbs). Wt gain/wk in 2&3 trimester: 0.3 kg (0.6lbs) When BMI is >30: Total: 5-9 lbs (11-18 lbs).Wkly: 0.2 kg (0.5 lbs).
What are some common vitamin and mineral deficiencies r/t obesity? -B-12, Zinc, Vitamin D ANSWER Iron,
Patient Selection Criteria for Bariatric Surgery in Adolescence -Status: ANSWER Health -BMI >35 with major comorbidities-BMI>40 w/ minor comorbidities -Physical maturity: -Tanner stg 4 or 5- Older than 13 y/o (female) or 15 y/o (male) --Exceptions made for less mature pts with severe complications
Other Considerations: ->6 months failure @ organized wt loss attempts -Commitment to comprehensibe medical and psych evals pre and post surgery-Capability and willingness to follow postop instructions --Able to make own decisions--Avoid preg x 18 months --Family Support --Pt and parent's informed consent Nutritional Factors to be considered in the assessment of pts with Type 1 DM -ANSWER Sliding scale vs. fixed insulin dose
Total CHO intake and carb-to-insulin ratio: -Calculate total insulin dose: actual wt (lbs) / 4-CHO:insulin dose (500 rule): 500 / total insulin dose
Timing of injection:- May benefit from injection at meal's completion
Exercise and PA
- Increased risk of hypoglycemia -Pre and post workout BG are useful Targets for glycemic control before bariatric surgery -vascular complications or comorbid conditions) ANSWER A1C <7% (7-8% w/ Use clinical judgment for any pts with >8% A1C Fasting BG <110mg/dL
Discuss Lab Surveillance Schedule for: Vitamin D, Ca, PTH, Insulin, TSH, Mg, Vitamin A, ZInc, Copper, Selenium -Vitamin D, Ca, & Mg: preop, 2-3 months (all surgeries) + 6& 9 months, & yearly for RYGB/ ANSWER
PTH & Zinc: RYGB only: preop, 2-3 months, 6 & 9 months, yearly. TSH & Insulin: Preop and as-needed. Vitamin A: Optional at all intervals based on symptoms.? Yearly for RYGB. Copper & Selenium: Optional at presurgery and 2-3 months for all surgeries.Recommended at 6&9 months and yearly for RYGB.
Standard Supplement Regimen for LAGB Pts - ANSWER -Menstrating women: Fe -B-12: amount in MVI unless abnorm labs -Calcium: 1200-1500 Ca Citrate or Carbonate (from diet and supplement).--include Vitamin D. --Divided doses of 500-600mg 4 hrs apart. -Vitamin D3: 3,000 IU/day or amount needed to bring lab to >30ng/mL.---2 hrs apart from Fe --Elemental Iron: 18-27mg/day. More if needed. Which labs should be monitored at presurgery, 2-3 months, 6-9 months, post surgery,and yearly - ANSWER Lipids, Kidney Fx, Liver Profile, CBC, Iron, Folate, B-12, phos, A1C Thiamin (B-1):?2-3 mos, 6&9 mos, yearlyVitamin K:? 6&9 mos, yearly
Vitamin and Mineral Supplementation in Stage 2 Diet (RyGB & SG) -chewable MVIs w/ mins ANSWER 2
Chew or liquid Ca Citrate (1200-1500 mg/day) with Vitamin D. In divided doses. Sublingual B-12: 350-500 mcg/day Vitamin D: 3000 IU/day total, including from Ca and MVI suppls Same for LAGB - does not specify for B-12. 100% DRI for men and women of: Vitamin K, Biotin, Zinc, Thiamin, Folic Acid, Fe, Copper -(men) & 90 mcg (women) ANSWER Vitamin K: 120 mcg Biotin: 30 mcg Zinc: 11mg (men) & 9 mg (women)Thiamin: 1.2 mg (men) & 1.1 mg (women) Folic Acid: 400 mcg Fe: 8mg (men) & 18 mg (women)Copper: 900 mcg
What are the 2 states of the human hair follicle? What are the different stages of hair loss? -Telogen = Dormant or resting stage ANSWER Anogen = growth phase
Early/post-op "shedding" is d/t telogen effluvium - alteration in normal hair cycle from
