Nutrition for Surgical Patients
Tough but Essential
Dr. Mahmoud W. Qandeel
Outlines
• Introduction
• Nutritional assessment
• Nutrition requirements
– Carbohydrates
– Lipids
– Protein and nitrogen
• Indications and contraindications
• Routes in details
• TPN in details
Dr. Mahmoud W. Qandeel
The addition of fat to carbohydrate in TPN will do all of the
following except:
A. Prevent essential fatty acid deficiency
B. Reduce the likelihood of respiratory distress from carbohydrate
infusion
C. Reduce the incidence of fatty liver infiltration
D. Improve nitrogen balance
E. Reduce the chance of glucose intolerance in diabetic patients
Dr. Mahmoud W. Qandeel
Introduction
• 30-50 % of hospitalized pt. are malnourished
• It is clearly increases morbidity and mortality
• Most healthy pt. can tolerate 7-10 days fasting
Dr. Mahmoud W. Qandeel
Wound healing & Nutrition
Dr. Mahmoud W. Qandeel
I. Assessment of Nutritional Status
A. History and physical examination
• Weight loss
– is a significant indicator of malnutrition.
– More than 10% unintentional weight loss
• in a 6 month period is significant.
– A 5% unintentional weight loss
• in 1 month is also significant.
Dr. Mahmoud W. Qandeel
Significant physical findings include
✓Muscle wasting
✓Loose flabby skin
✓Peripheral edema & ascites
✓Skin rash
✓Pallor
✓Glossitis
✓Hair changes
Dr. Mahmoud W. Qandeel
B. Evaluation of body composition
• Estimates of body weight (IBW) are:
✓ The body mass index (BMI)
– is used to characterize the degree of obesity.
– BMI = weight (kg)/total body surface area (m2).
– Patients with a BMI higher than 40 or over 35 with other comorbid
conditions
• are considered candidates for surgical treatment of morbid obesity.
– Severe obesity
• is associated with a significant increase in overall morbidity and mortality.
✓ Other measures include
– anthropometric measurements, including triceps skin fold or midarm
muscle circumference.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Anthropometric measurement
✓ Triceps skin fold thickness ( fat store )
✓ Mid arm circumference ( muscle mass )
✓ Hand dynometer
Dr. Mahmoud W. Qandeel
C. Laboratory markers of nutritional status
• Several serum proteins
– Serum albumin
• has a long half-life, and as such, it is not a reliable short-term marker for
nutritional assessment during nutritional support.
– Serial measurements of transferrin as well as prealbumin, and
retinol-binding protein
• are useful in monitoring the impact of nutritional support.
• Immune function (Lymphocyte count)
Dr. Mahmoud W. Qandeel
✓Albumin half-life 14-21 days
✓Transferrin half-life 7-10 days less than 200 mg/dl
✓Prealbumin half-life 2-3 days 10-15 mg/dl in mild
✓Retinol half-life hours
Dr. Mahmoud W. Qandeel
Serum Proteins Used as Markers of Nutritional Status
• Protein Half-life (days)
• Albumin 20
• Transferrin 8.5
• Prealbumin 1.3
• Retinol-binding protein 0.4
Dr. Mahmoud W. Qandeel
• C-reactive protein (CRP) should be checked because elevated
levels of inflammation (trauma/sepsis/burns) will alter visceral
protein production away from prealbumin synthesis.
Dr. Mahmoud W. Qandeel
Immune function
✓Delayed hypersensitivity
✓Total lymphocyte count = % of lymph. X WBC / 100
1500 – 1800 mild depletion
900 – 1500 mod. depletion
Less 900 sever depletion
Dr. Mahmoud W. Qandeel
• To estimate the adequacy of nutritional support measure the
respiratory quotient (RQ).
– RQ = carbon dioxide production (VCO2)/oxygen consumption (VO2).
– An RQ value
• of 1.0 is consistent with predominant glucose utilization.
• of 0.7 is consistent with fat utilization
• of 0.8 is consistent with protein utilization.
• higher than 1.0 suggest the presence of lipogenesis or overfeeding.
Dr. Mahmoud W. Qandeel
II. Nutritional Requirements
The basic assessment of patients' nutritional requirements includes:
✓ Total energy (kcal) requirements.
✓ Total protein requirements.
✓ The relative distribution of calories between carbohydrates, fats,
and protein.
Dr. Mahmoud W. Qandeel
Energy requirements
• Basal metabolic rate (BMR): amount energy used by an
unstressed, fasted individual at rest
• Resting energy expenditure (REE): amount energy used by an
unstressed, nonfasted individual at rest
Dr. Mahmoud W. Qandeel
Energy requirements
• The Harris-Benedict equation
– estimates the basal energy expenditure (BEE) or basic energy requirements
at rest in kcal/day.
– Men: 66 + (13.7 × weight [kg]) + (5 × height [cm]) – (6.8 × age [years]).
– Women: 655 + (9.6 × weight [kg]) + (1.7 × height [cm]) – (4.7 × age [years]).
Dr. Mahmoud W. Qandeel
• Total energy expenditure ( EE): actual amount energy an
individual uses
Dr. Mahmoud W. Qandeel
• Most patients at rest require 25–35 kcal/kg/day.
– Stress significantly increases these values.
• Low stress: 1.2 × BEE.
• Moderate stress: 1.2–1.3 × BEE.
• Severe stress: 1.3–1.5 × BEE.
• Major burn injury: 1.5–2.0 × BEE.
Dr. Mahmoud W. Qandeel
Energy requirements are increased by Energy requirements are decreased by
• Fever. • Sedation.
• Infection. • Paralysis.
• Activity. • β blockers.
• Burns.
• Head injury.
• Trauma.
• Renal failure.
• Surgery.
Dr. Mahmoud W. Qandeel
• Indirect calorimetry: Measures amount of oxygen inhaled
minus amount of oxygen exhaled to determine amount oxygen
consumed.
• Because oxygen consumption (VO2) measured in mL O2/min is
directly correlated to kcal/day (1 mL O2/min= 7 kcal/day).
• Measurement of the amount oxygen consumed can determine
daily caloric requirements.
Dr. Mahmoud W. Qandeel
• Fick equation: Amount of oxygen consumed, and therefore
kcal required, is determined by multiplying the cardiac output
by the arteriovenous oxygen content difference.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Energy Sources : Protein, Glucose , and Fat
I. Protein
• A. Requires conversion to glucose via hepatic gluconeogenesis to be
used as a caloric fuel source
• B. Adequate intake is important for muscle mass maintenance and other
protein-dependent, non–energy-producing processes.
II. Glucose : can be stored as glycogen and used as a short-term reservoir
of energy
III. Fat: Majority energy is stored as fat and to a lesser degree as protein
(skeletal muscle).
Dr. Mahmoud W. Qandeel
Differing amounts of kcal/g are produced by carbohydrates, proteins,
and lipids.
– Proteins
• Generally provide 4 kcal/g
– Carbohydrates
• Generally provide 4 kcal/g.
– Lipids
• Generally provide 9 kcal/g.
Dr. Mahmoud W. Qandeel
Proteins
• Most healthy individuals require 0.8–1.0 g protein/kg/day.
• 15 (10-20) % of calories ?!
• Biosynthesis of enzymes & immunoglobulin etc.
• Digested started by pepsin & pancreatic enz.
• 50 % absorbed by duodenum
• The rest by mid jejenum
• Amino acids metabolized primarily by liver
• But in TPN bypass the liver
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Phases – Physiological response
[ David Cuthbertson – 1930 ]
Injury
EBB FLOW RECOVERY
Hours Days Weeks
SHOCK CATABOLISM ANABOLISM
BREAKING DOWN BUILDING UP
ENERGY STORES USED ENERGY
Dr. Mahmoud W. Qandeel
Ebb and Flow Phases
Dr. Mahmoud W. Qandeel
Key catabolic elements of flow phase
• Hypermetabolism
• Alterations in skeletal muscle protein
• Alterations in Liver protein
• Insulin resistance
Dr. Mahmoud W. Qandeel
Insulin resistance
• Hyperglycaemia is seen :
↑ glucose production +↓ glucose uptake – peripheral tissues.
( transient induction of insulin resistance seen )
• Due – Cytokines & decreased responsiveness of insulin- regulated
glucose transporter proteins.
• The degree of insulin resistance is ∞ to magnitude of the injurious
process.
Dr. Mahmoud W. Qandeel
Changes in Body composition following surgery / critical ill pts.
• Catabolism – Decrease in Fat mass & Skeletal muscle mass.
• Body weight – paradoxically Increase because of expansion of
extracellular fluid space.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Proteins
• Most healthy individuals require 0.8–1.0 g protein/kg/day.
• Stress increases these requirements:
– Mild stress: 1.0–1.2 g/kg/day.
– Moderate stress: 1.3–1.5 g/kg/day.
– Severe stress: 1.5–2.5 g/kg/day.
• Patients with renal failure
– may also have a higher protein requirement compared with baseline.
• Patients with hepatic encephalopathy may require less protein (0.8
g/kg/day) to avoid additional encephalopathy.
Dr. Mahmoud W. Qandeel
Amino acids
– Essential amino acids cannot be produced by the body, but nonessential
amino acids can.
– Amino acid metabolism
• Most amino acids are metabolized by the liver.
• The branched-chain amino acids are metabolized by muscle.
– Patients require at least 20% of their protein intake as essential amino acids.
Dr. Mahmoud W. Qandeel
Total body proteins
About 10 kg
Daily turnover 300 g , decrease w age
Daily requirement 0.8-1 g/kg body wt.
6.25 g protein = 1 g nitrogen
1 g protein = 4 kcal.
Nitrogen loss 10-15 g / day
Dr. Mahmoud W. Qandeel
• Nitrogen balance is calculated by determining the difference
between net nitrogen intake and excretion.
– is a crude measure of protein consumption.
Positive nitrogen balance
• indicates more protein ingested than excreted (net protein anabolism)
Negative nitrogen balance
• indicates more protein is excreted than ingested (net protein catabolism).
– Neutral nitrogen balance
• is the goal, although positive nitrogen balance is frequently present during
the recovery phase of illness.
Dr. Mahmoud W. Qandeel
Nitrogen
• 80% of nitrogen is lost in urine.
• 2-4 g of nitrogen is lost in stool & skin.
• Nitrogen balance =
(dietary proteins x 0.16) - (urea nitrogen +2 g skin+2 g stool)
• Urine urea nitrogen= Urine urea mmol x 28
• Nitrogen requirements= 0.2 g/kg/day
Dr. Mahmoud W. Qandeel
Proteins
• To determine protein requirements:
1. Nitrogen balance
2. Visceral protein measurements
3. Weight gain
4. Overall condition
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Carbohydrates
• Should generally account for 30%–60% of total calories. (NMS 50%)
• A minimum of 100–150 g/day is necessary to provide the minimum needs of the
brain and red blood cells, which prefer glucose as an energy source.
• Glucose is stored
– As glycogen in the liver (40%) and in muscle (60%).
– The body stores 300–500 g of glycogen.
– These stores are depleted
• Within 48 hours during starvation (non-stressed patient.)
• In as little as 12–24 hours in the stressed patient.
Dr. Mahmoud W. Qandeel
Carbohydrates
• Primary energy source
• Digestion start by salivary amylase
• Absorbed by 1.5 meter of small intestine
• Deficiency is rare in surgical pt.
• Ciliac sprue & whipple disease may affect uptake
• Each g provides 4 kcal.
Dr. Mahmoud W. Qandeel
Lipids
• Lipids should provide
– 25%–40% of total calorie requirements during nutritional
supplementation.
• During starvation—lipids—ketone bodies—by liver converted to long
chain fatty acids
• Digestion by biliary & pancreatic secretion
• Major ileal resection—decrease bile salt pool—fat malabs.
• Each g = 9 kcal
Dr. Mahmoud W. Qandeel
1. Fatty acids
– are a major fuel for the heart, liver, and skeletal muscle.
• During times of starvation, liver oxidizes fatty acids to forms ketone
bodies (e.g., β-hydroxybuturate).
– These ketone bodies are used by the heart, skeletal muscle, and the brain.
– The essential fatty acids
• Are linoleic and linolenic acid.
• Act as precursors for prostaglandins and eicosanoids.
Dr. Mahmoud W. Qandeel
– Essential fatty acid deficiency may result in
• Dermatitis.
• Ecchymoses.
• Alopecia.
• Anemia.
• Edema.
• Thrombocytopenia.
• Respiratory distress.
– The manifestations of fatty acid deficiency may occur within 4–6 weeks if
nutritional support does not include lipids.
Dr. Mahmoud W. Qandeel
2. Triglycerides
– Long chain triglycerides
• Must be emulsified by bile salts to form micelles.
• Must be hydrolyzed by pancreatic lipase in the proximal small bowel before
absorption can occur.
• Are transported through the lymphatic system to thoracic duct to the heart.
– Medium chain triglycerides
• Are absorbed directly by the enterocytes.
• Are transported through the portal venous system to the liver.
• May be readily absorbed despite significant deficiencies in pancreatic
function (i.e., severe pancreatitis).
Dr. Mahmoud W. Qandeel
Other requirements
• Vitamins
– Potential vitamin deficiencies can occur
• In severely malnourished patients.
• Impaired wound healing may be a direct result of deficiencies in vitamin A,
vitamin C, and the mineral zinc.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Characteristics of Deficiency Function RDA Nutrient
Hypochromic anemia Component of hemoglobin, myoglobin, 10–18 mg Iron
and cytochromes
Impaired wound healing, Metalloenzymes involved in 15 mg Zinc
acrodermatitis enteropathica (bullous carbohydrate, protein, and nucleic acid
skin lesions of the face), hypogonadism synthesis
Hypothyroidism, goiter Thyroid hormone synthesis 150 mg Iodine
Menkes' syndrome, anemia, Metalloenzymes, iron uptake in 2.0–3.0 mg Copper
leukopenia hemoglobin
Unknown Enzyme cofactor in protein and energy 2.5–5.0 mg Manganese
metabolism
Increased caries Found in bone and tooth apatite 1.5–4.0 mg Fluoride
Glucose intolerance, hyperlipidemia Insulin cofactor 0.05–0.2 mg Chromium
Keshan disease (cardiomyopathy), Enzyme cofactor in hydrogen peroxide 0.05–0.2 mg Selenium
anergy detoxification
RDA = Recommended dietary allowance.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
III. Administration of nutrition
Indications for nutrition
• Malnourished patient
• Insufficient intake in last 7-10 days
• Anticipate no oral intake post operation for 7-10 days
Dr. Mahmoud W. Qandeel
Contraindicated
• Immediately after surgery or trauma (ebb phase)
• State of shock
• Serum lactate >3-4 mmol /L
• Hypoxia po2 <50 mmHg
• Acidosis pCO2 >80 mmHg, pH <7.2
Dr. Mahmoud W. Qandeel
Routes
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
IV. Enteral nutrition
• Preferred over TPN
• Simple
• Physiological( stimulate biliary & acute phase protein synth. )
• Inexpensive
• Well tolerated
• Support immunological function
• Maintain GIT Cytoarchitecture
Mucosal integrity
Absorptive function
Normal flora
• So less translocation & endotoxin release
Dr. Mahmoud W. Qandeel
Indications Contraindications
• Intestinal obstruction & Ileus
• GIT bleeding & Small bowel ischemia
• Functional GIT
• Sever diarrhea & Vomiting
• Unable to take oral diet
• High output fistula
• Multiple enterocutaneous fistulae
• Short bowel syndrome
• Hemodynamic instability
• Inability to access safely
Dr. Mahmoud W. Qandeel
Feeding tubes
• NGT
• Nasojejunal Tube
• Gastrostomy ( PEG or by fluoroscopy )
• Jejunostomy
Dr. Mahmoud W. Qandeel
PEG
Now the preferred method.
• It is safe,
• Less expensive,
• Less invasive.
Contraindications
• Total esophageal obstruction,
• Massive ascites,
• Intra-abdominal sepsis.
Dr. Mahmoud W. Qandeel
Enteral feeding products
• Standard solution provides 1 kcal / ml
• More than 1 kcal / ml if volume restricted
• Types
Polymeric ( blendarized & nut. complete formulas )
Chemical defined formulas ( elemental diet )
Modular formulas ( in special situation )
Dr. Mahmoud W. Qandeel
Pulmonary formulas
• The goal is to reduce CO2 production.
• In these formulas,
Fat content usually increased to 50% of the total calories,
And a corresponding reduction in carbohydrate content.
Dr. Mahmoud W. Qandeel
Renal formulas
• Lower fluid volume,
• Low concentrations of potassium,
• Low phosphorus,
• Low magnesium .
Dr. Mahmoud W. Qandeel
High protein formulas
• Proposed for critically ill or trauma patients with high protein
requirements.
Dr. Mahmoud W. Qandeel
Hepatic formulas
• Close to 50% of the proteins are branched-chain amino acids
(e.g., leucine, isoleucine, and valine).
• The goal is to reduce aromatic amino acid levels and increase
BCAA , which can potentially reverse encephalopathy.
• Protein restriction should be avoided.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Enteral feeding protocols
• Usually start w full strength formula at slow rate
A. Bolus feedings
B. Contineous infusion
C. Conversion to oral feeding
D. Administration of medication
Dr. Mahmoud W. Qandeel
Bolus
• Reserved for NG & gastrostomy
• Begin at 50-100 ml / 4 hrs
• Increase 50 ml until reach the goal (250-350 ml /4 hrs )
• Aspiration ?
• Gastric residual should measured
– If more than 50 % stop feeding
• Flushed the tube w 30 ml water
• Free water adjusted Na abnormalities
Dr. Mahmoud W. Qandeel
Continuous infusion
• Pump
• For nasojej. or gastrojej. or jej-jejunal
• Start w 20 ml / hr
• Increase 10-20 ml / hr every 4 hrs
• Flushed w water 30 ml / 4 hr
• If pain & distention ? Held
• Can be administered at night to let him ambulated
Dr. Mahmoud W. Qandeel
Conversion to oral
• Resumed gradually
• To stimulate appetite
• Holding day time feeding
• Feeding when oral intake provides 60-75% of calories and
100% of fluids requirement
Dr. Mahmoud W. Qandeel
Administration of medications
• Elixir form is preferred
• Medication not suitable are :
➢Enteric-coated
➢Gelatinous capsules
➢Sublingual drugs
➢Sustained release
Dr. Mahmoud W. Qandeel
Complications
• Metabolic
• Clogging (carbonates soda , pancreatic enz.,cranberry)
• Aspiration
• High gastric residual ( motility agent )
• Diarrhea 10-20 % Cl. defficile
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
V. Parenteral nutrition
• Who cannot meet their need by oral
• Pt. w contraindication to enteral feeding
• Enteral feeding not tolerated
➢Peripheral parenteral nutrition
➢Total parenteral nutrition
Dr. Mahmoud W. Qandeel
Access of TPN
✓CV catheter (subclavian, jugular, femoral (less to be used))
✓with the tip located in the vena cava
✓Single or multiple lumens
✓Replaced when unexplained fever or bacteremia
✓Frequent position change
✓Small gauge line
✓Heparin
Dr. Mahmoud W. Qandeel
TPN solutions
3 in 1 admixture
• Protein as amino acids ( 10 % , 4 kcal / g )
• Carbohydrate as dextrose ( 50 % , 3.4 kcal / g )
• Fat as lipid ( 40 % , 9 kcal )
Non-protein Kcal (carb. 70% -fat 30%)
Special solutions
• Low & high nitrogen
• Various amount of fat ,carbohydrate, D.M, renal, liver, etc)
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Additives
• Electrolytes adjusted daily
• Na
• K
• Cl
• Ca
• Mg
• Po4
• If serum bicorbonate low, the solution should contain acetate
Dr. Mahmoud W. Qandeel
Medication
• Albumin
• H2 – antagonist
• Heparin
• Iron
• Insulin as sliding scale
Dr. Mahmoud W. Qandeel
Other additives
• Trace element daily ( 1 ml trace element – 5 )
( copper, chromium, manganese , selenium , zinc )
• Multivitamins daily ( 10 ml MVI-12 )
• Vitamin K ( 10 mg once a week )
Dr. Mahmoud W. Qandeel
Physiological and lab. monitoring
1. Wt. daily
2. Vital signs / 2-4 hrs
3. S. glucose / 6 hrs
4. S. electrolytes & BUN daily
5. Triglycerides, CBC, PT, LFT weekly
Dr. Mahmoud W. Qandeel
Administration of TPN
Dr. Mahmoud W. Qandeel
Introduction
Gradually
Infuse over 24 hrs
1000 kcal in the first day
Increase over 1-2 days until the goal
Or Half the goal rate over 12 hours
before advancing to the full rate to avoid severe hyperglycemia.
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Case Calculation
Dr. Mahmoud W. Qandeel
Cyclic administration
For selected pt.
• Who discharge & receive home TPN
• Those w limited I.V access
• Those who r stable & need to be free
• Infuse over 8-16 hrs
• Should be done after metabolic stability
Dr. Mahmoud W. Qandeel
Discontinuation of TPN
• When 75% of calories is reached
• Infusion rate should halved for 1 hr.
• Halved again the next hr.
• Then D/C
➢This prevent hypoglycemia
Dr. Mahmoud W. Qandeel
Complications
Catheter related complications
• Catheter sepsis 45 %
• Vein thrombosis 15 %
• Bleeding
• Pneumothorax
• Arrhythmia
• Catheter embolism
• Air embolism
• Brachial plexus injury
• Thoracic duct injury
Dr. Mahmoud W. Qandeel
Metabolic complications
• Hypernatremia & CHF
• Electrolytes abnormality
• Hyperglycemia
• Hyper osmolality
• Coma & death
Dr. Mahmoud W. Qandeel
Refeeding Syndrome
• TPN to severely malnourished patient
• Lead to anabolism
• Leading to shifting of fluid
• From extracellular to intracellular
• Rapid depletion of ATP
• Present insidiously as respiratory failure
• K, Mg & Po4
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Others
• Increased serum lactate
• Trace elements – zinc, selenium
• Vitamins
o B1 and K deficiency
o Hypervitaminosis C
Dr. Mahmoud W. Qandeel
Hepatic dysfunction
Steatosis
Cirrhosis
↑transaminases: too much carbohydrates
↑alkaline phosphatase: too much calories, lipids.
Usually seen 2 weeks after parenteral feeding
What to do? Rule out sepsis
Do not discontinue, just slow down rate and/or volume
Dr. Mahmoud W. Qandeel
Cholecystitis
• Acalculas
– Cholecystostomy
– Cholecystectomy
– Cholecystokinin
– 0.02 microgram / Kg / day I.V
Dr. Mahmoud W. Qandeel
Special Substrates
Cytokines
Immunonutrition
• IL-1
• IL-6 • Arginine ( stimulate immune response &
improve gut integrity )
• α-TNF
• Glutamine ( the same of arginine )
• Omega-3-fatty acid ( ARDS )
Exogenous G.H
• Increase a.a. uptake
• Decrease N2 loss
• Hasten weaning from mechanical
ventilator
Dr. Mahmoud W. Qandeel
Regarding nutritional requirements, all the following
are true except:
A. Energy requirement is 25-30 kcal/kg/day
B.1 gram of fat gives 9 kcal
C.1 gram of protein gives 4 kcal
D.1 gram of carbohydrate gives 4 kcal
E. During hyperthermia the energy requirement decreased
Dr. Mahmoud W. Qandeel
Regarding nutritional requirements, all the following
are true except:
A. Energy requirement is 25-30 kcal/kg/day
B.1 gram of fat gives 9 kcal
C.1 gram of protein gives 4 kcal
D.1 gram of carbohydrate gives 4 kcal
E. During hyperthermia the energy requirement decreased
Dr. Mahmoud W. Qandeel
Concerning Starvation symptoms, all the following
are true except:
A. Food intolerance, hepatic gluconeogenesis
B. Hyperglycemia, increased insulin concentration
C. Diarrhea, increased protein catabolism
D. Acidosis, increased plasma glucagon, decreased energy
requirement
E. Low plasma insulin concentrations, lipolysis
Dr. Mahmoud W. Qandeel
Concerning Starvation symptoms, all the following
are true except:
A. Food intolerance, hepatic gluconeogenesis
B. Hyperglycemia, increased insulin concentration
C. Diarrhea, increased protein catabolism
D. Acidosis, increased plasma glucagon, decreased energy
requirement
E. Low plasma insulin concentrations, lipolysis
Dr. Mahmoud W. Qandeel
The addition of fat to carbohydrate in TPN will
do all of the following except:
A. Prevent essential fatty acid deficiency
B. Reduce the likelihood of respiratory distress from carbohydrate
infusion
C. Reduce the incidence of fatty liver infiltration
D. Improve nitrogen balance
E. Reduce the chance of glucose intolerance in diabetic patients
Dr. Mahmoud W. Qandeel
The addition of fat to carbohydrate in TPN will
do all of the following except:
• A. Prevent essential fatty acid deficiency
• B. Reduce the likelihood of respiratory distress from carbohydrate
infusion
• C. Reduce the incidence of fatty liver infiltration
• D. Improve nitrogen balance
• E. Reduce the chance of glucose intolerance in diabetic patients
Dr. Mahmoud W. Qandeel
Regarding the Parenteral feeding it’s given
usually through:
[Link] antecubital vein
[Link] caphalic vein
[Link] subclavian vein
[Link] saphenous vein
[Link] portal vein
Dr. Mahmoud W. Qandeel
Regarding the Parenteral feeding it’s given
usually through:
[Link] antecubital vein
[Link] caphalic vein
[Link] subclavian vein
[Link] saphenous vein
[Link] portal vein
Dr. Mahmoud W. Qandeel
How many Kcal contained in 1 liter of G/W
20% is:
A.100 Kcal
B.400 Kcal
C.800 Kcal
D.1000 Kcal
E.2000 Kcal
Dr. Mahmoud W. Qandeel
How many Kcal contained in 1 liter of G/W
20% is:
A.100 Kcal
B.400 Kcal
C.800 Kcal
D.1000 Kcal
E.2000 Kcal
Dr. Mahmoud W. Qandeel
A 27-year-old female patient with 90 kg weight and 1.5
meters length according to her BMI, she is
A. Under weight
B. Normal
C. Over weight
D. Obese
E. Morbidly obese
Dr. Mahmoud W. Qandeel
A 27-year-old female patient with 90 kg weight and 1.5
meters length according to her BMI, she is
A. Under weight
B. Normal
C. Over weight
D. Obese
E. Morbidly obese
Dr. Mahmoud W. Qandeel
Which of the following proteins is best to evaluate long
term nutritional status?
A. Retinol binding protein
B. Pre albumin
C. Albumin
D. Transferrin
E. Fibrinogen
Dr. Mahmoud W. Qandeel
Which of the following proteins is best to evaluate long
term nutritional status?
A. Retinol binding protein
B. Pre albumin
C. Albumin
D. Transferrin
E. Fibrinogen
Dr. Mahmoud W. Qandeel
A 50-year-old man is in the intensive care unit with necrotizing
pancreatitis. He is struggling to wean from the ventilator. As he
has been maintained on total parenteral nutrition (TPN), you
are suspicious of an overfeeding syndrome and elect to perform
indirect calorimetry. Which of the following values for the
respiratory quotient (RQ) would be consistent with an
overfeeding syndrome?
A. 0.65
B. 0.7
C. 0.8
D. 1
E. 1.3
Dr. Mahmoud W. Qandeel
A 50-year-old man is in the intensive care unit with necrotizing
pancreatitis. He is struggling to wean from the ventilator. As he
has been maintained on total parenteral nutrition (TPN), you
are suspicious of an overfeeding syndrome and elect to perform
indirect calorimetry. Which of the following values for the
respiratory quotient (RQ) would be consistent with an
overfeeding syndrome?
A. 0.65
B. 0.7
C. 0.8
D. 1
E. 1.3
Dr. Mahmoud W. Qandeel
