Medical Nutrition Therapy Final Exam Study Guide Spring 2014 There will be 100 multiple choice and true false questions each worth 1 point 55 will be old material and 45 will be new material Metabolic stress o What is Metabolic Stress MS Sepsis infection Trauma car accidents burns gunshots stab wounds falls Surgery Sepsis o What are the different types of MS Describe the characteristics of each type When a patient has a documented infection and an identifiable organism Leads to a systemic infection whole body inflammation Caused by bacteria virus fungi and parasites Bacteria and their toxins cause stronger inflammatory responses SIRS systematic Inflammatory Response Syndrome Syndrome group of causes symptoms SIRS is the widespread inflammatory response that occurs in infection not only in infection like sepsis pancreatitis ischemia burns multiple trauma hemorrhagic shock and organ injury Inflammation is present in areas away from the primary site of infection Common complication MODS Multiple organ dysfunction syndrome o Begins with lung failure and leads to liver intestine and o May be accompanied by hematologic myocardial and CNS kidney failure failures Abdominal compartment syndrome Can be a complication of major abdominal trauma bowel distension sepsis and shock Caused by increased intraabdominal pressure Casues hemodynamic instability and respiratory renal and neurologic consequences Reduced the size of the oral cavity Treatment emergent decompressive laparotomy to relieve intraabdominal pressure Abdominal trauma Surgery May include surgical wounds fistulas and abdominal distension Patients with an open abdomen have o Elevated nutritional and fluid needs due to increased metabolism and increased losses kcal ptns electrolytes vitamins and fluids o Enteral nutrition may be needs maybe TPN if GIT removed not functioning Well nourished patient tolerates surgery better obese patients have higher risk malnutrition associated with complications morbidity and death When possible replete before surgery Enerteal parenteral as needed Empty stomach at time of surgery NPO midnight before surgery 6hrs NPO before surgery Post operative nutrition if unable to meet nutrient needs orally for 7 10days Addition of omega 3 Fas Introduce solid foods when GI tract is ready advance quickly from liquids to solids o How is each type managed o Describe the MNT for each o What is Ebb phase Flow phase Ebb phase Immediately following injury hypovolemia shock tissue hypoxia Decreased cardiac output Decreased O2 consumption Lowered body temperature Insulin levels decrease because glucagon is elevated to increase hepatic glucose production Flow phase Follows fluid resuscitation and restoration of oxygen transport usually starts 2 3hrs after injury Increased cardiac output Increased body temperature Increased energy expenditure to maintain increased temp and cardiac output Total body catabolism starts Marked increased in glucose production FFA release circulating insulin catecholamines epinphine and nonepinphrine glucagon and cortisol o Know the hormonal and cell mediated response during MS Hormones cause protein catabolism Glucagon promotes gluconeogenesis amino acid uptake ureagenesis and protein catabolism Cortisol enhances skeletal muscle catabolism and promotes use of amino acids for gluconeogenesis glycogenolysis and actue phase protein synthesis BCAA to synthesis muscle glutamine and carbon skeletons used in the Mobilization of acute phase proteins cause rapid loss of LBM and glucose alanine cycle negative nitrogen balance Urinary loss of K P and Mg due to skeletal muscle breakdown Increased circulation of FFAs from increased lipolysis due to elevated cortisol catecholamines and glucagon Hypoglycemia caused by elevated gluconeogenesis and elevated levels of hormones eg epinephrine that decrease insulin release Na and water retention due to increased aldosterone and ADH Cytokines interleukin 1 IL 1 IL 6 and Tissue Necrosis Factor TNF cause hepatic amino acid uptake and protein synthesis increased muscle breakdown and induce gluconeogenesis Serum iron and zinc levels decreased due to sequestration and increased urinary zinc excretion o What are the differences between starvation and stress Metabolic stress and starvation have a different metabolic responses Starvation Decrease energy expenditure Use of alternative fuels Decreased protein wasting Late starvation Stored glycogen used in 24hrs and then muscle protein used for glucose production Fatty acids ketones and glycerol provide energy for all tissues except brain nervous system and RBCs Stress causes hypermetabolic state Accletated energy expenditure Glucose production Glucose cycling in liver and muscle Resting energy expenditure RQ Mediator activation Primary fuels Proteolysis ptn breakdown Branched chain oxidation Hepatic protein synthesis Ureagenesis Urinary nitrogen losses Gluconeogenesis Ketone body production Starvation Decreased 0 6 0 7 used more O2 more CO2 produced Fat Stress hypermetabolism Increased 0 8 0 9 Mixed faster Hyperglycemia can occur from either insulin resistance or excess glucose production via gluconeogenesis and cori cycle Muscle protein breakdown accelerated in stress o What is SIRS Describe the signs and pathophysiology of SIRS SIRS is the widespread inflammatory response that occurs in Infection Pancreatitis Ischemia Burns Multiple trauma Hemorrhagic shock Organ injury Inflammation present in areas away from the primary infection site Common complication MODS Begins with lung failure and leads to liver intestine kindey failure May be accompanied by hematologic myocardial or CNS failures Signs and symptoms of SIRS Low oxygen consumption often on ventilator Hypermetabolic High cardiac output increased BP increased blood volume High venous oxygen saturation Massive edema related to high cardiac output Decreased plasma protein concentrations due to increased fluid Lactic academia increase lactic acid in the body has been diluted Pathophysiology of SIRS Gut hypothesis Excessive production of pro inflammatory cytokines o Injury or disruption to gut barrier function o Translocation of enteric bacteria into the mesentery lymph nodes liver and other organs Shock causes gut hypoperfushion which increases pro inflammatory molecule production Causes ileus lack of peristalsis in stomach and small bowel Enteral feeding restores gut function by enhancing functional and structural integrity of the gut Enteral nutrition maintains tight