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Nutritional considerations for ICU patients part 2 – ATOTW 545

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Quiz: Nutritional considerations for ICU patients part 2 – ATOTW 545

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Nutritional considerations for ICU patients part 2 – ATOTW 545

Mar 19, 2025

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1) What is the most frequent complication associated with both enteral and parenteral nutrition?

Overfeeding Underfeeding Hyperglycaemia Refeeding syndrome

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Hyperglycaemia is the most common metabolic complication in ICU patients receiving both enteral and parenteral nutrition. A glycaemic control target of 6-10mmol/l is recommended.

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2) A 60-year-old ICU patient has been receiving nutritional support but is not meeting his calculated energy requirements. Based on clinical guidelines, what is the definition of clinically significant underfeeding?

Providing less than 70% of intended nutritional intake Providing less than 50% of intended nutritional intake Caloric intake insufficient to meet metabolic demands Insufficient protein intake

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Underfeeding is defined as failing to meet at least 70% of the calculated energy needs in ICU patients. The aim of feeding is to progressively meet 70-80% of energy targets within 48-72hours while avoiding overfeeding

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3) Which of the following is a well-documented consequence of uncontrolled hyperglycaemia?

Hyperglycaemia has no impact on clinical outcomes Delayed wound healing Improved immune function Increased renal clearance

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Hyperglycaemia negatively affects wound healing by impairing collagen synthesis and neutrophil function, leading to an increased risk of surgical site infections.

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4) Which metabolic disturbance is the hallmark feature of refeeding syndrome?

Hypophosphatemia Hyperkalaemia Hypernatremia Hypercalcemia

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Refeeding syndrome occurs when nutrition is reintroduced too rapidly in a malnourished patient, leading to severe electrolyte shifts. Hypophosphatemia is the most critical abnormality and one of the earliest signs of the condition.

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5) Which one of these is a significant risk factor for developing refeeding syndrome?

Adequate nutritional intake for 5-10 days A history of bariatric surgery Patients above 65 years of age Unintentional weight loss >10-15% within the last 3-6 months

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Significant weight loss is a major marker of malnutrition, increasing the risk of refeeding syndrome.

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6) Refeeding syndrome can lead to serious complications that may be fatal. Which of the following is the deadliest?

Muscle weakness Renal failure Cardiac arrhythmias Respiratory failure

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Severe hypophosphatemia leads to multi-organ dysfunction; these include cardiac arrhythmia and instability and potential cardiac arrest.

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7) In a malnourished ICU patient, what is the safest initial step to nutritional approach to avoid refeeding complications?

Start feeds at a low rate of 10 kcal/kg/day and gradually increase Start feeding at full caloric requirement Provide only protein and fat, avoiding carbohydrates Avoid feeding for 72 hours

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Slow introduction of calories prevents metabolic stress and electrolyte shifts.

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8) The most common mechanical complications associated with PN include:

Air embolism Catheter dislodgement Catheter thrombosis Thoracic duct injury

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Catheter-related thrombosis is among the most prevalent mechanical complications of PN. Air embolism can occur during the placement or removal of the line. Malposition is typically identified early through imaging or by experiencing difficulty in aspirating or flushing. Injury to the thoracic duct is an extremely rare occurrence.

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9) Which of the following is the most common metabolic complication associated with PN:

Hypertriglyceridemia Hyperkalemia Hypoglycaemia Hypochloraemia

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Excessive lipid infusion in parenteral nutrition can lead to hypertriglyceridemia, raising the risk of pancreatitis and metabolic dysfunction.

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10) Which of the following is a well-recognised manifestation of Intestinal Failure-Associated Liver Disease (IFALD)?

Biliary cyst formation (choledochal cysts) Cholestasis Advanced hepatic cirrhosis None of the above

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IFALD is a significant complication in patients receiving prolonged PN, especially those with limited or absent enteral nutrition. Cholestasis is a defining characteristic, frequently manifesting with elevated bilirubin, abnormalities in liver enzymes, and progressive liver dysfunction.

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11) Which of the following is a recognised risk factor for parenteral nutrition-associated cholestasis (PNAC)?

High dietary fibre intake Frequent interruptions in PN administration Use of fish oil-based lipid emulsions Presence of a small bowel remnant <50cm

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PNAC occurs more frequently in patients with gut failure and short bowel syndrome because of impaired bile flow and prolonged use of PN.

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12) A 68-year-old ICU patient receiving enteral nutrition via a nasogastric tube has increasing gastric residual volumes, nausea, and abdominal discomfort. The medical team is concerned about enteral feeding intolerance (EFI). Which of the following is a common sign of EFI.

Gastric residual volumes (GRVs) > 500ml in 6 hours Persistent Vomiting Abdominal distension and discomfort All of the above

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EFI may present as delayed gastric emptying, high GRV, vomiting, and abdominal distension. GRV greater than 500ml in six hours is a common diagnostic threshold.

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13) Which of the following is NOT an appropriate management strategy for a patient in whom EFI is suspected?

Excluding a pathological cause Immediate switching from enteral to parenteral nutrition Using prokinetics such as erythromycin to improve gastric emptying Considering post-pyloric feeding (e.g. jejunal tube placement)

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Parenteral nutrition is only used when enteral nutrition is completely intolerable. First-line strategies for managing EFI include reducing EN rate, using prokinetics, and post-pyloric feeding.

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14) Which of the following is not a common cause of diarrhoea in patients receiving EN?

Broad-spectrum antibiotics Clostridioides difficile infection Fiber-enriched enteral formulas Hyperosmotic medications

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Diarrhoea is often caused by antibiotics, infections, and hyperosmolar formulas. Fibre can assist in reducing diarrhoea by improving stool consistency.

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15) A critically ill patient receiving enteral nutrition develops diarrhoea. What is the most appropriate first step in managing this complication?

Identifying and addressing the underlying cause Discontinue enteral feeding immediately Switch to parenteral nutrition Increasing the feeding rate to compensate for fluid losses

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Managing diarrhoea involves treating the underlying cause, modifying the nutritional formula, and reviewing and optimising medications, rather than completely ceasing enteral nutrition.

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16) An 18-year-old patient with severe asthma ICU patient has been transitioned from mechanical ventilation to extracorporeal membrane oxygenation (ECMO) due to respiratory failure and now requires nutritional support. What would be the preferred approach?

Prioritise EN whenever possible Immediate transition to parenteral nutrition Administer PN via the ECMO circuit Have energy needs determined by indirect calorimetry (IC)

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EN remains the preferred feeding route in ECMO patients whenever feasible. PN should not be delivered directly into the ECMO circuit. IC is inaccurate in these patients due to extracorporeal removal of carbon dioxide; predictive equations are thus preferred in this context.

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17) A 60-year-old male in the ICU with chronic kidney disease (CKD) is started on continuous renal replacement therapy (CRRT). How does CRRT influence nutritional requirements?

It allows unrestricted fluid intake Reduces protein requirements due to lower metabolic demand Increases losses of water-soluble vitamins and micronutrients Amino acids need separate supplementation

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CRRT significantly increases the loss of water-soluble vitamins (e.g., Vitamin B and C) and essential micronutrients (e.g., zinc, selenium and magnesium), requiring regular supplementation. Protein losses through CRRT are also substantial and are provided through standard ICU nutrition regimens rather than as separate amino acid infusions.

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18) According to the current guidelines, what is the recommended calorie intake for obese patients to optimise metabolic balance and avoid over/underfeeding?

11-14 kcal/kg ABW (for BMI 30-50) 22-25 kcal/kg ABW (for BMI >50) 30-35kcal/kg/day >35kcal/kg/day

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Critically ill obese patients require hypocaloric, high-protein feeding to preserve lean muscle mass while preventing complications related to overfeeding. For patients with a BMI of 30-50, the recommended energy intake is 11-14 kcal/kg of actual body weight (ABW), whereas for those with a BMI greater than 50, energy requirements are slightly higher, at 22-25 kcal/kg but using ideal body weight (IBW) instead of ABW.

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19) A 67-year-old survivor of the ICU is dealing with persistent fatigue, memory issues, and anxiety symptoms since being discharged. The differential diagnosis included post-intensive care syndrome (PICS). Which of the following is a recognized aspect of PICS?

Physical impairments Cognitive dysfunction Mental health disturbances All of the above

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Post-intensive care syndrome (PICS) is a well-recognised condition that affects ICU survivors, involving a combination of physical, cognitive, and mental health impairments.

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20) A 70-year-old ICU survivor is stepped down to the POST-ICU rehabilitation ward after a prolonged critical illness. To support recovery and prevent further muscle mass loss, what is the recommended calorie intake post-ICU discharge?

150% of predicted equations or IC 125% of predicted equations or IC 100% of predicted equations or IC 35 kcal/kg/day

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Energy requirements increase during the post-ICU and post-hospital phases due to ongoing metabolic stress, rehabilitation needs, and the recovery of functional muscle. In the post-ICU phase, calorie intake is gradually raised to 125% of the predicted energy requirements or indirect calorimetry measurements, and in the post-hospital phase, this should be escalated to 150%.

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