Objectives:
● Not given
Resources:
● Lecture slides
● Davidson’s
● Surgical recall
Done by: A bdula Abdulrahman AlFuraih & Shadn Alomran
Sub-leader: Omar Alotaibi
Leaders: A bdulrahman Alsayyari & Monerah Alsalouli
Reviewed by: Luluh Alzeghayer
[ Color index | Important | Notes | Extra ]
[ Editing file ]
Nutrition
Introduction:
So what is the importance of nutrition? If pts stays in the hospital for a treatment or a surgery, and was not well nourished,
the outcome of the treatment will not go well,
Nevertheless, approximately one-third of all patients admitted to an acute hospital will have evidence of protein-calorie
malnutrition and two-thirds will leave hospital either malnourished or having lost weight.
Nutrition:
It’s the provision of all basic nutrients and energy required for growth, repair and maintenance of the body.
Energy VS nutrition: we can get energy from many sources you can take carbs, fats, proteins… and generate energy,
but at the same time patients can take a lot of alcohol and will get tremendous amount of calories but has no nutritional
value to it. So the goal is having a nutritional value and providing the pt with the energy to sustain their self.
Who needs Nutrition Support?
● Patient at malnutritional risk or already Malnourished
● Patient with postoperative complications:
○ Ileus > 4 days
○ Sepsis
○ Fistula formation
○ Massive bowel resection
● Intractable vomiting
● Maxillofacial trauma
● Traumatic Coma
● Multiple trauma
● Burns
Sources of nutrition:
1. Carbohydrates 4. Electrolytes
2. Protein 5. Minerals
3. Fat 6. Vitamines
The Basal Metabolic Rate [BMR]: (Basically, how many calories you'd burn if you were to do nothing but rest for 24
hours) I t increases tremendously during illness [e.g. infections, malignancies, altered hormonal states, etc..]. In this state,
more energy is burnt than consumed [imbalance] making the body prone to develop malnutrition. It affects all body
systems.
When BMR increases it means your body is utilizing lots of calories, if you can't provide these calories, What will happen to you?
1) Let's say you have a body storage of glycogen (major storage of quick calories), but it will last only for 2 days, after that the
body will start utilizing fat and protein, the fat will provide you with calories but some organs like the brain (or cells that
doesn’t have mitochondria) requires glucose to run.
2) Glucose will be derived from gluconeogenesis (breaking down proteins) so the protein catabolism increase thus to drive
energy, so think of it all the body muscles especially the cardiac and respiratory muscles be affected, eventually the pt will
deteriorate.
So in major trauma, sepsis, burn pts the protein catabolism increase and with that there will be consequences.
**Keeping pt without providing them calories inventory the body will utilize glucose > glycogen > fat > protein > severe malnutrition
Malnutrition:
Malnutrition is a broad term that can be used to describe inadequate consumption of nutrients (either
overnutrition or undernutrition). (but in the lecture we mainly mean undernutrition)
There are two ways for someone to get malnourished:
1- Pt not taking calories (energy) and ends up malnutrition
2- Pt taking a lot of calories but still go into malnutrition! Pts with high BMR.
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● There are three methods for a person to get malnutrition:
1. Restriction of oral intake (fasting, pain on swallowing or physical and mental impairment)
2. Malabsorption (Excessive loss from gut, GI Carcinoma, short gut)
3. Altered metabolism (trauma, burns, sepsis or surgery)
Observed up to 40-60% of surgical patient on admission/remines under-diagnose in 70% of patient in hospital settings
● Malnutrition seen in hospitalized patients is often a combination of cachexia (disease related) and
malnutrition (inadequate consumption of nutrients) as opposed to malnutrition alone.
● Cachexia can be defined as a multifactorial syndrome characterized by severe body weight, fat and
muscle loss and increased protein catabolism due to underlying disease.
Types of malnutrition:
This isn’t in this year’s lecture slides but it’s an easy concept that you might get in the exam
Kwashiorkor Marasmus
Inadequate protein intake in the presence of fair to good A severe protein-calorie malnutrition characterized by
calories intake in combination with the stress response calories deficiency
Common causes: Common causes:
● Chronic kidney disease (limit ● Burns, injuries, systemic infections,
protein intake) cancers …etc
● Liver cirrhosis (unable to ● Conditions where the patient does not
synthesize protein) eat (e.g. anorexia nervosa and
● Acute stress: Trauma, burns, starvation).
hemorrhage, and critical illness
(need lots of protein to repairing)
Clinical manifestations: Clinical manifestations:
● Marked hypoalbuminemia ● Weight loss the hall mark
● Edema and ascites (low oncotic pressure caused by ● Depletion of skeletal muscles and adipose tissue (fat)
hypoalbuminemia) stores
● Muscle atrophy ● Bradycardia
● Delayed wound healing ● Hypothermia (compensatory mechanism to consume
● Impaired immune function less calories)
Adverse effects of Malnutrition:
Pts come to the hospital for something and end up with something else due to malnutrition, pt who are malnourished even
tend to develop more complications then other nourished pt, which will cause longer stay, higher cost, and medical
complications like cardiac arrhythmias, GI bleeding, infection and respiratory failure.
● Impaired wound healing.
● Increases risk for morbidity and mortality that might cause prolonged recovery time and longer hospital stay
● Impaired host immunity (infections)
● Thoracic muscle mass wasting depresses respiratory efficiency and increase risk for pneumonia
● Albumin level decrease leading to generalized edema.
● Small bowel mucosa atrophy
● Impaired mental function that will lead to depression
● Postoperative complications rate is higher
How to detect Patient at risk of malnutrition?
Nutritional risk screening in all patients on hospital admission or first contact:
● BMI < 18 kg/m2
● Combined: weight loss >10% or >5% over 3 months and reduced BMI or a low fat free mass index (FFMI)
● Preoperative serum albumin < 30 g/l (with NO evidence of hepatic or renal dysfunction)
General Assessment of Nutritional Status:
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History Physical Examination
● Weight change ● Loss of subcutaneous fat
● Dietary intake change ● Muscle wasting
● GI symptoms ● Ankle edema
● Functional capacity ● Sacral edema
● Underlying disease (+ metabolic demand) ● Ascites
Lab tests
● Serum proteins such as:
○ Prealbumin t1/2 = 2-3 days : ⬇ in malnutrition, infection, hepatic failure. ⬆ renal failure
○ Albumin t1/2 = 20 days : ⬇ in malnutrition, infection, burns, fluid overload, hepatic failure, cancer, nephrotic
syndrome
● Transferrin t1/2 = 10 days : ⬇ Protein energy malnutrition and iron status
● Indicators of inflammation:
○ C-reactive protein (CRP): Acute phase reactant, helps in determining whether prealbumin, albumin, or transferrin
levels are low because of an inflammatory process or due to inadequate substrate (e.g. malnutrition)
○ Total lymphocyte count (TLC)
● Retinol-binding protein (RBP)
● Nitrogen balance
● Total cholesterol
Enhanced Recovery After Surgery (‘‘ERAS’’):
● Multimodal perioperative care pathway designed to achieve early recovery for patients undergoing
major surgery.
● From a metabolic and nutritional point of view, the key aspects of perioperative care include:
○ Avoidance of long periods of pre-operative fasting
○ Re-establishment of oral feeding as early as possible after surgery
○ Integration of nutrition into the overall management of the patient metabolic control, e.g. of blood
glucose
○ Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal
function
○ Early mobilization
Preoperative ● Pts with severe nutritional risk shall receive nutritional therapy prior to major surgery, appropriate
period of (7-14) days
● Fasting from midnight is unnecessary in most patients
● Allow clear fluids until 2 hours before anaesthesia (clear fluids empties the stomach within 60-90
min)
Postoperative ● Oral intake, including clear liquids, can be initiated within hours after surgery in most patients.
● Early normal food or EN, including clear liquids on the first or second postoperative day, does not
cause impairment of healing of anastomoses in the colon or rectum
● Early tube feeding (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be
started, and in whom oral intake will be inadequate (patients undergoing major head and neck or
gastrointestinal surgery for cancer , severe trauma, including brain injury, patients with obvious
malnutrition at the time of surgery)
Energy and protein needs stable VS ICU patients: you don’t have to memorize the numbers
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BMI (kg/m2) Weight (kg) Kcal/kg Protein*(gm/kg)
Stable Non-ICU < 30 Actual 25-30 1.2-1.5
patients ≥ 30 Adjusted* 20-25 1.2-1.5
< 30 Actual 20-25 1.2-2.0
ICU patients 30-50 Actual 11-14 1.9-2.0 (IBW)
> 50 Ideal 22-25 2.5 (IBW)
Ideal body weight (IBW):
Male: 50 + 2.3 (height in inches - 60)
Female: 45.5 + 2.3 (height in inches - 60)
*Adjusted body weight: IBW + [(actual weight – IBW) x 25%]
Calculate ur ideal body weight ȩ here
Fluid requirements: How much fluid should you be drinking? As much as you want as long you have a functional
kidney and pee it out, but suppose a pt with renal impairment or CHF the requirement will be very different.
● The average requires approximately
○ 18 - 65 years → 30-35 ml/kg/day
○ 65+ years → 25-30 ml/kg/day
○ Hemodialysis → 1000 + output
● National Research Council (NRC) recommends 1 to 2 ml of water for each kcal of energy expenditure
● 4/2/1 formula: (per hour) *forgot ? check the IV fluid lecture ● 100/50/20 formula: (per day)
○ f irst 10 kg of body weight requires 4 ml/kg/h ○ 1st 10 kg 100 ml/kg
○ second 10 kg 2 ml/kg/h ○ 2nd 10 kg 50 ml/kg
○ rest, each kg of body requires 1 ml/kg/h
○ Rest 20 – 30 ml/kg
Fluid needs should be determined by evaluating the patient’s clinical condition
● Decreased fluid needs (20-25 ml/kg actual BW): renal failure, dialysis, edema, CHF.
● Increased Fluid needs (30-35 ml/kg actual BW): short gut syndrome, high output ileostomy or
fistula,excessive diarrhea, high NGT output, large draining wounds, chest tube and JP drain losses
Calculating Fluid Needs for Obese (BMI ≥ 30):
Adjusted Weight Fluid per day
40-60 kg 1500 - 2000 ml
60-80 kg 2000 - 2500 ml
> 80 kg 2500 - 3000 ml
OR 30-35 ml/kg Adjusted body weight with allowances for extra losses via drains (draining wounds, chest tube and JP
drain losses)
Routes of Nutrition support
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The nutritional needs of patients are met through:
● Parenteral (PN)
● Enteral (EN)
“Enteral nutrition should be first choice for nutritional
support in
the critically ill surgical patient”
Very important ⇒
* parenteral route in case of GI obstruction, paralysis,
crohn's disease, and cancer patients who suffer severe
nausea and vomiting or after GI surgery to rest the GI
e.g: severe pancreatitis
*short term = few days to 2 weeks
Enteral Nutrition:
enteral doesn’t always mean taken by mouth, some pt in the ICU can;t take food orally but have functioning GI tract so we
give them nutrition by NGT. Or in case of esophageal cancer you can’t use the NGT! So what should we do? You put a
tube directly into the stomach (gastrostomy tube)
● Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF)
● The enteral feeding should always be preferred over Parenteral Nutrition
● The gastrointestinal tract is always the preferred route of support (Physiologic)
● EN is safer, more cost effective, and more physiologic than PN
● Nutrients are metabolized and utilized more effectively via the enteral than parenteral route
● EN provides proteins while PN provides nitrogen which is equivalent to protein
Rule of thumb: If the gut works, Use It. If the Gut Works Partially, use It Partially.
● Before embarking on tube enteral feeding, it is important to manage actively any symptoms that can be
treated (e.g. oral thrush with nystatin, nausea with antiemetics, provision of adequate dental hygiene or
artificial dentures).
Indications of Enteral Nutrition: Contraindications of Enteral Nutrition:
● Inability to eat adequate amounts to achieve goal ● Severe acute pancreatitis
nutritional intakes. Ex.dysphagia & stroke pt.(long time) ● Severe GI bleeding
● Lack of bowel sounds, flatus or bowel movement ● High-output proximal fistulas
● Refusal to eat/anorexia ● Intractable nausea/vomiting or osmotic diarrhea
● Malnourished patient expected to be unable to ● Intestinal obstructions or ileus,
eat adequately for > 5-7 days ● Severe shock
● Adequately nourished patient expected to be ● Intestinal ischemia
unable to eat > 7-9 days
● Adaptive phase of short bowel syndrome
● Following severe trauma or burns
● Early oral nutrition cannot be started, (patients undergoing major head and neck or gastrointestinal surgery
for cancer , severe trauma, including brain injury, patients with obvious malnutrition at the time of surgery )
Complications of Enteral Nutrition:
● Diarrhea
● Vomiting
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● Aspiration pneumonia1
● Excessive infusion of nasogastric feed may cause marked abdominal bloating, resulting in splinting of the
diaphragm and impaired respiratory function.
Parenteral Nutrition: Pts who can’t orally needs to take it intravenous, parenteral nutrition is complete
whole thing (carbs, fat, protein..) not as IV fluid which only contains electrolytes.
● For the surgical patient PN is beneficial in the following:
○ Undernourished patients in which EN is not feasible or not tolerated
○ Patients with postoperative complications impairing gastrointestinal function who are unable to
receive and absorb adequate amounts of oral/ enteral feeding for 5-7 days
● PN should only be initiated if the duration of therapy is anticipated to be >7 days.
● provision of PN of 25 kcal/kg and 1.5 g/kg protein presented no increased risk of hyperglycaemia
and infectious complications
● In some cases, Combined EN/PN showed clinical benefits when compared with EN or PN alone, NOT
necessary if expected time period for PN <4 days
General Indications of PN:
Let's say you have a pt with partial bowel obstruction, so you'll put the pt on NPO for couple of days to investigate to do or
not to do the surgery, put the pt on IV fluid (mostly dextrose & NS), if investigation takes longer time (more than 5-7 days)
the pt should be on parenteral nutrition.
● Requiring NPO > 5-7 days.
● Severe gut dysfunction “ex. Intestinal failure” or inability to tolerate enteral feedings.
● Can not eat ( such as dysphagia), will not eat (N/V), or should not eat ( GIT obstruction).
Special Indications of PN:
● After major surgery ● Renal, hepatic, respiratory, and cardiac
● Patient with bowel obstruction failure (rarely)
● Patient with enterocutaneous fistulas (high and low) ● Short bowel syndrome
● Massive bowel resection ● Severe paralytic ileus
● Malnourished patients undergo chemotherapy ● Gut ischemia
● Refractory diarrhea or vomiting
● Necrotizing pancreatitis
● Intolerance to enteral feeding
● Burns, sepsis, trauma, long bone fractures ● If the energy and nutritional requirements
● Premature newborn cannot be met after maximizing enteral support
● Failure to Thrive
Immunonutrition:
● Immunonutrition involves the administration of nutrients via enteral or parenteral routes in supranormal amounts, to
achieve a pharmacological effect on one or more components of the patient’s response to surgery, trauma or
infection.
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since the patient is not moving, the food will move on to the lungs (Only with NGT)
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ICU morbidity and mortality classification: Grade A (Excellent), Grade B (Very good), Grade C (Good), Grade D (Fair), Grade E (Poor): 0
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● In the preoperative phase, formulas enriched with arginine, omega-3 fatty acids and nucleotides have been shown to
improve postoperative immune response, gut oxygenation and intestinal microperfusion
Glutamine: Arginine :
● Glutamine is essential amino acid and the preferred fuel ● L-arginine, a dibasic amino acid, has numerous
for rapidly replicating cells such as gastrointestinal important roles in the transport, storage, and excretion of
mucosal cells (enterocytes and colonocytes) and immune nitrogen; formation of nitric oxide; mediation of
cells (lymphocytes and macrophages) macrophage function after injury; and regulation of
● Further prospective, randomized trials are necessary to wound healing
recommend widespread utilization of glutamine in
nutritional support
● Antioxidants, including vitamins C and E, betacarotene, and selenium are often added in an effort to reduce
oxidative stress among patients with acute metabolic stress.
Use enteral nutrition with immuno-modulating substrates (arginine, nucleotides and
long-chain n-3 fatty acids) perioperatively in:
● patients undergoing major neck surgery for cancer
● patients undergoing major abdominal surgery for cancer.
● Majer upper GI surgery
● Elective upper gastrointestinal surgical patients
● Patients with mild sepsis/AVOID in severe sepsis
● Patients with trauma
● Patients with acute respiratory distress syndrome
● Avoid Immune Enhancing formulas in actively septic patients.
● No recommendation for immune-modulating formula can be given in burned patients due to insufcient data.
● ICU patients with very severe illness who do not tolerate more than 700ml enteral formula per day should not
receive an immune-modulating formula
Formula selection: just for reading
Ensure
Nutren 1.0
Standard Osmolite RTF Standard formula can be used via ENETRAL FEEDING OR orally
1kcal/1ml Energy zip 1.0 - Can be used for all cases
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Jevity
Trophic with fiber
Ensure Plus
Dens-calories Fortisip For stressed patients and those requiring low-volume feedings
1.5g/ml Resource Plus
Ensure Two-Cal
Modified carbohydrate Glucerna
1kcal/1ml Resource Diabetic Diabetes Mellitus, Hyperglycemia, Glucose Intolerance
Diamax
Low elctrolyets Novasource Renal Dialysis / Renal Failure / Renal Disease, Electrolyte and Fluid
1.5-2kcal/1ml HD Max restriction
Branched-Chain Amino Acid Nutrihep Hepatic Encephalopathy, Nutrition support for hepatic disease with
1.5kcal/1ml elevated ammonia level
Low carbohydrate Oxepa modulate the inflammatory response in critically ill, mechanically
1.5kcal/ml Pulmocare ventilated patients, especially those with SIRS (systemic inflammatory
response syndrome, eg, sepsis, trauma, burns), ALI (acute lung injury)
or ARDS (acute respiratory distress syndrome)
Nutrient Dense/ IMPACT RECOVERY For faster recovery ( before and after surgery),Severe trauma/injury,
Immunonutrients FORTICARE support colonic health, Pressure ulcer/wound, Dietary mgt of Cachexia
1.2-1.6kcal/ml in cancer, pancreatic cancer, lung cancer undergoing chemotherapy
Clear Liquids with Protein/ Resource Breeze Clear Liquid High Protein, bowel prep,
Fat-Free Fortijuice fat malabsorptive/fat restricted, pre or post-surgical ,
1.5kcal/ml nausea/vomiting/oncology
Semi-Elemental Perative 1.3 Malabsorption syndrome, impaired gastrointestinal function, short
Pivot 1.5 bowel syndrome, inflammatory bowel disease, pancreatic insufficiency,
Peptamen Complete chronic diarrhea, radiation enteritis, HIV/AIDS-related malabsorption,
Alitraq transition diet from TPN
Protein Beneprotein Protein-calorie malnutrition, wound healing e.g. burns, pressure ulcers
6g per scoop Prosource
Prebiotics Banatrol Diarrhea and loose stool associated with tube feeding, antibiotics ,
oncology treatment and Clostridium difficile
Summary:
● Nutritional support in the ICU (surgical setting) represents a challenge but it is fortunate that its delivery and
monitoring can be followed closely.
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● Parenteral (PN) represents an alternative approach when other routes are not succeeding or when it is not possible
or would be unsafe to use other routes.
● The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications.
The doctor didn’t go through the rest, read it just in case.
1) Should we use (PN)? When should we start PN in patients?
Patients should be fed because starvation or underfeeding in ICU patients is associated with increased morbidity and
mortality. (Grade C)
Reasons:
● Increased metabolic needs related to stress in ICU pt. are likely to accelerate the development of malnutrition which
associated with impaired clinical outcome.
● In a randomized study, 300 patients undergoing major surgery received continuous total PN or exclusively glucose
250–300 g/d intravenous administration for 14 days.
● Those on PN had 10 times less mortality than those on glucose.
2) Should we wait for recovery and the ability of the patient to take normal nutrition or should we start
PN in pt. who have not resumed normal intake within 10 days?
All patients who are not expected to be on normal nutrition within 3 days should receive PN within 24–48 h if EN is
contraindicated or if they cannot tolerate EN.(Grade C).
Comments:
● PN is associated with more hyperglycemia than EN
● Hyperglycemia reduces neutrophil chemotaxis and were found to be an independent risk factor for short-term
infection in patients undergoing surgery.
● Tight glucose control can over come such infection in ICU.
3) Should we use central venous access or peripheral line for PN administration?
Peripheral venous access devices may be considered for low osmolarity (<850 mOsmol/L) mixtures designed to cover a
proportion of the nutritional needs and to mitigate negative energy balance (Grade C).
If peripherally administered PN does not allow full provision of the patient’s needs then PN should be centrally
administered (Grade C).
Comments:
● PN is usually administered into a large-diameter vessel, normally the superior vena cava or right atrium, accessed
via the jugular or subclavian vein.
● For longer-term ICU use,a tunneled-catheter or implanted chamber is occasionally used as alternatives to a standard
central venous access device.
● PICCs were associated with a lower risk of CVC-associated BSI.
● Antimicrobial-impregnated CVC reduced the risk of CVC-associated BSI2.
● PICC lines offer a suitable middle way between peripheral catheters & conventional central lines.
4) How much parenteral nutrition should critically ill patients receive?
ICU patients should receive: 25 kcal/kg/day increasing to target over the next 2–3 days (Grade C).
5) Carbohydrates: which level of glycemia should we aim to reach?
● Hyperglycemia (glucose >10 mmol/L) contributes to death in the critically ill pt and should also be avoided to prevent
infectious complications (Grade B).
● Tighter glucose control (4.5-6.1 mmol/L) increases in mortality rates have been reported in ICU patients.
● No unequivocal recommendation on this is therefore possible at present.
6) Should we use lipid emulsions in the parenteral nutrition of critically ill patients?
Lipid emulsions should be an integral part of PN for energy and to ensure essential fatty acid provision in long-term ICU
patients. (Grade B).
7) Is it safe to administer lipid emulsions (LCT without or with MCT, or mixed emulsions) and at which
rate?
intravenous lipid emulsions can be administered safely at a rate of 0.7 g/kg up to 1.5 g/kg over 12–24 h (Grade B)
2
BSI: bloodstream infections
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8) How much should be administered to meet protein requirements?
When PN is indicated, a balanced amino acid mixture should be infused at approximately 1.3–1.5 g/kg ideal body weight
per day in conjunction with an adequate energy supply (Grade B)
*4 pictures were in the slides but the doctor didn’t mention them, check them here
Recall :
What is the motto of surgical nutrition?
If the gut works, use it
What are the normal daily dietary requirements for adults of the following:
● Protein = 1 g/kg/day
● Calories = 30 kcal/kg/day
What are the calorie contents of the following substances:
● Fat = 9 kcal/g
● Protein = 4 kcal/g
● Carbohydrate = 4 kcal/g
What is the formula for converting nitrogen requirement/loss to protein requirement/loss?
Nitrogen X 6.25 = protein
Where is iron absorbed?
Duodenum (some in proximal jejunum)
Where is vitamin B12 absorbed?
Terminal ileum
What are the surgical causes of vitamin B12 deficiency?
Gastrectomy, excision of terminal ileum, blind loop syndrome
Where are bile salts absorbed?
Terminal ileum
Where are fat-soluble vitamins absorbed?
Terminal ileum
What are the signs of the following disorders:
● Vitamin A deficiency: Poor wound healing
● Vitamin B12/folate deficiency: Megaloblastic anemia
● Vitamin C deficiency: Poor wound healing, bleeding gums
● Vitamin K deficiency: Decrease in the vitamin K–dependent clotting factors (II, VII, IX, and X); bleeding; elevated PT
What are the vitamin K–dependent clotting factors?
2, 7, 9, 10 (think: 2+7=9, and then 10)
What is in TPN?
Protein Carbohydrates Lipids (H2O, electrolytes, minerals/vitamins, insulin, H2 blocker)
How much of each in TPN:
● Lipids = 20% to 30% of calories
● Protein = 1.7 g/kg/day (10%–20% of calories) as amino acids
● Carbohydrates = 50% to 60% of calories as dextrose
What are the possible complications of TPN?
Line infection, fatty infiltration of the liver, electrolyte/glucose problems, pneumothorax during placement of central line, loss of
gut barrier, acalculous cholecystitis, refeeding syndrome, hyperosmolarity
What is “refeeding syndrome”?
Decreased serum potassium, magnesium and phosphate after refeeding (via TPN or enterally) a starving patient
What is the major nutrient of the gut (small bowel)?
Glutamine
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1) Enteral nutrition is preferred over parenteral nutrition for all of the following reasons EXCEPT:
A. Lower risk of electrolyte abnormalities
B. EN is safer
C. EN provides Nitrogen
D. Stimulate gut function
2) Which one of the following options represents potential complications of enteral nutrition?
A. Osteoporosis and refeeding syndrome
B. Diarrhea and cholestasis
C. Esophagitis and pancreatitis
D. Aspiration
3) Which of the following nutritional strategies can prevent gut mucosal atrophy and subsequent
bacterial translocation ?
A. Parenteral nutrition enriched with glutamine.
B. Parenteral nutrition with branched chain AAs.
C. Enteral nutrition.
D. Zinc supplementation.
4) Which of the following parenteral nutrition formula can be safely administered through peripheral
catheter?
A. 10% dextrose and 3% amino acid .
B. 20% dextrose and 3% amino acid.
C. 10% dextrose and 10% amino acid.
D. 20% dextrose and 10% amino acid.
Answers:
1- C
2- D
3- C
4- A
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