Answers to Self-Assessment Questions - ACCP

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3. Sundaram A, Koukia P, Apovian CM. Nutritional management of short bowel syndrome in adults. J Clin Gastroenterol 2002;34:207–20. 38. Answer: A R.C. is at high risk of developing a zinc deficiency (Answer A) because of the fact that zinc will be lost in high concentrations from the high-output jejunostomy; thus Answer A is correct. Zinc concentrations in small bowel output can be as high as 12 mg/L; thus, R.C. may be losing as much as 18 mg of zinc per day in the jejunostomy fluid. Vitamin B 12 (Answer B), folic acid (Answer C), and copper (Answer D) are not substantially eliminated in the stool; thus R.C.’s risk of zinc deficiency is substantially higher than the risk of vitamin B 12 , folic acid, or copper deficiencies, making Answer B, Answer C, and Answer D incorrect. 1. Parrish CR, Krenitsky J, Willcutts K, Radigan AE. Gastrointestinal disease. In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based Approach – The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, 508–39. 2. Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003;124:1111–34. 3. Sundaram A, Koukia P, Apovian CM. Nutritional management of short bowel syndrome in adults. J Clin Gastroenterol 2002;34:207–20. 39. Answer: C T.C. has developed hypoglycemia (blood glucose concentration less than 60 mg/dL. The most appropriate response to hypoglycemia after discontinuing the PN when cycling in a young infant is to increase the ramp-down time; therefore, Answer C (continue to ramp up over 1 hour; increase the ramp-down time to 2 hours) is the correct answer. Answer A (do nothing) is not correct. A blood glucose concentration less than 60 mg/dL can be associated with complications, including changes in neurodevelopment; therefore, allowing T.C.’s blood glucose concentration to fall to 45 mg/dL after discontinuing PN is not appropriate. Answer B (increase the ramp-up time to 2 hours; continue to ramp down over 1 hour) is incorrect because the serum glucose concentration at the maximum PN infusion rate is acceptable (90 mg/dL), so no change in the ramp-up time is needed; also, this option does not address the low glucose after discontinuing the PN. Answer D (increase both the ramp-up and ramp-down times to 2 hours) could be done; however, it is not the best answer because the ramp-up time does not need to be changed. 1. Kumpf VJ, Gervasio J. Complications of parenteral nutrition. In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based Approach – The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, 323–39. 2. Bendorf K, Friesen CA, Roberts CC. Glucose response to discontinuation of parenteral nutrition in patients less than 3 years of age. JPEN: J Parenteral Enteral Nutr 1996;20:120–2. 40. Answer: C T.C. has been receiving a standard multivitamin preparation in her PN formulation, but only zinc and chromium, because the standard trace element preparation was removed from her PN when her direct bilirubin was elevated to 4 mg/dL. She is receiving about 40% of her nutrition by the enteral route. Her direct bilirubin in clinic today is 2.1 mg/dL, and she has a microcytic anemia. The most appropriate response would be to draw a serum iron panel and ferritin and copper concentrations (Answer C). Deficiency of both iron and copper can cause microcytic anemia. T.C. is receiving neither iron nor copper in her PN formulation; thus she is at risk for deficiency of both. Therefore, Answer C is correct. Answer A (add standard pediatric trace elements to the PN formulation daily) is incorrect because T.C.’s direct bilirubin is still elevated, indicating cholestasis; thus, copper and manganese excretion may be compromised. The trace element preparation should not be added unless a deficiency of both copper and manganese is documented. Answer B (draw a serum iron panel and ferritin, vitamin B 12 , folate, and copper concentrations) is incorrect because T.C. has been receiving both vitamin B 12 and folate daily in her PN formulation, and these nutrients are associated with macrocytic anemia, not microcytic anemia. Answer D (start ferrous sulfate drops orally) is not appropriate at this time because the cause of the microcytic anemia has not been determined. 1. Chessman KH, Kumpf VJ. Assessment of nutrition status and nutrition requirements. In: Dipiro JT, Talber RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach, 7 th edition. New York: McGraw Hill Medical, 2008, 2349–66. 2. Btaiche IF, Khalidi N. Parenteral nutrition-associated liver complications in children. Pharmacotherapy 2002;22:188–211. 3. Btaiche IF, Khalidi N. Metabolic complications of parenteral nutrition in adults, part 2. Am J Health Syst Pharm 2004;61:2050–9. Immunonutrition 41. Answer: D The best EN intervention for J.B. immediately upon admission is actually no enteral feeding (Answer D) because J.B. is hemodynamically unstable and has been incompletely resuscitated; thus Answer D is correct. However, hemodynamic instability is a relative contraindication to EN, and some institutions might begin EN in a patient such as J.B. The immune-enhancing EN formulation with omega-3 polyunsaturated fatty acids (PUFAs) 8.6 g/L and antioxidants (Answer B) would be the best response only if J.B. was hemodynamically stable so that feedings could be initiated safely, so Answer B is incorrect. Answer A (immune-enhancing EN formulation with arginine 10 g/L and omega-3 PUFAs 3.6 g/L) and Answer C (immuneenhancing EN formulation with arginine 16.3 g/L, glutamine 15 g/L, nucleotides 1.6 g/L, and omega-3 PUFAs 1.7 g/L) are not correct choices because each contains arginine, which has been associated with potential harm in patients with sepsis. Gastroenterology and Nutrition Answers 44 Pharmacotherapy Self-Assessment Program, 6th Edition
1. Consensus recommendations from the U.S. Summit on immune-enhancing enteral therapy. JPEN J Parenter Enteral Nutr 2001;25:S61–S63. 2. Kudsk KA. Immunonutrition in surgery and critical care. Annu Rev Nutr 2006;26:463–79. 42. Answer: B In patients like J.B. with ARDS and acute lung injury (ALI), immune-enhancing EN formulations supplemented with the omega-3 PUFAs (eicosapentaenoic acid [EPA] and g-linolenic acid [GLA]) and antioxidants have been associated with decreased mortality and improved oxygenation. The immune-enhancing EN formulation with omega-3 PUFAs 8.6 g/L and antioxidants (Answer B) contains these nutrients and is therefore the best choice. The standard EN formulation with enteral glutamine supplementation (Answer C) is not the best option because it does not contain omega-3 PUFAs or antioxidants. Neither Answer A (immune-enhancing EN formulation with arginine, nucleotides, and omega-3 PUFAs) nor Answer D (immune-enhancing EN formulation with arginine and omega-3 PUFAs) is best for J.B. at this time because each contains arginine, which has been associated with potential harm in patients with sepsis. 1. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 2006;34:2325– 33. 2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;25:210–23. 43. Answer: C Once J.B. is started on an immune-enhancing EN formulation, the duration of therapy will have to be decided. Clinical studies indicate that the greatest benefit from these formulations in patients with ARDS is obtained when therapy is continued until the patient has been extubated (Answer C); thus, Answer C is the best answer. Patients are unlikely to benefit from any immunonutrition therapy administered for only 2 days (Answer A) or 4 days (Answer B), and there is no clinical evidence that patients with ARDS derive any further improvement in outcome if immune-enhancing diets are used after they have recovered sufficiently to be extubated. Because hospital discharge will generally occur days to weeks after extubation, discontinuing the product on discharge (Answer D) is not appropriate for the duration of J.B.’s immunonutrition therapy. 1. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med 2006;34:2325– 33. 2. Consensus recommendations from the U.S. Summit on immune-enhancing enteral therapy. JPEN J Parenter Enteral Nutr 2001;25:S61–S63. 44. Answer: C If a patient with ARDS receiving an immune-enhancing EN formulation was evaluated for immunologic and inflammatory markers, the result likely would reflect the increased use of omega-3 PUFAs, which is associated with a decrease in inflammatory mediators and markers. Thus, the concentrations of prostaglandin E 2 (Answer D) and interleukin 6 (IL-6) (Answer B) would be expected to decrease, not increase, making Answer B and Answer D incorrect. Tumor necrosis factor alpha concentrations (Answer C) decrease with the addition of PUFAs to the diet; thus, Answer C is correct. Although these immuneenhancing EN formulations may alter T lymphocyte function, total lymphocyte count would not be expected to decrease (Answer A); thus Answer A is incorrect. 1. Suchner U, Kuhn KS, Furst P. The scientific basis of immunonutrition. Proc Nutr Soc 2000;59:553–63. 2. Pacht ER, DeMichele SJ, Nelson JL, Hart J, Wennberg AK, Gadek JE. Enteral nutrition with eicosapentaenoic acid, gammalinolenic acid, and antioxidants reduces alveolar inflammatory mediators and protein influx in patients with acute respiratory distress syndrome. Crit Care Med 2003;31:491–500. 45. Answer: D The use of immune-enhancing EN formulations containing arginine, omega-3 PUFAs, and nucleotides has been shown to improve outcomes in patients after trauma. The potential benefit is greatest in patients with an injury severity score (ISS) greater than 20 or an abdominal trauma index (ATI) greater than 25. The 47-year-old woman injured in a fall with an ISS of 22 (Answer D) is the patient most likely to derive additional benefit from the use of immunonutrition. The 32-year-old man with an ISS of 12 (Answer A), the 29-year-old woman injured in an industrial accident with a ATI of 22 (Answer C), and the 55-year-old woman injured in an automobile accident with an ATI score of 11 (Answer B) do not have markers of injury severity in the range where a benefit of immunonutrition has been shown; thus Answer A, Answer B, and Answer C are incorrect. However, use of these products would not be expected to increase complications. 1. Kudsk KA, Minard G, Croce MA, Brown RO, Lowrey TS, Pritchard FE, et al. A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications. Ann Surg 1996;224:531–40; discussion 540–3. 2. Consensus recommendations from the U.S. Summit on immune-enhancing enteral therapy. JPEN J Parenter Enteral Nutr 2001;25:S61–S63. 46. Answer: B Improved outcomes have been demonstrated when patients with burn injuries like R.R. are given a standard EN formulation and enteral glutamine supplementation, so Answer B (begin feeding with a standard EN formulation with enteral glutamine supplementation) is the correct answer. Withholding enteral feeding for the first 48 hours after a thermal injury (Answer D) decreases the likelihood that EN will be tolerated once started; thus, Answer D is incorrect. Feeding should begin as soon as the patient is hemodynamically stable after thermal injury. Immuneenhancing EN formulations supplemented with arginine 12.5, omega-3 PUFAs, and nucleotides (Answer A) or arginine (Answer C) are not associated with harm in patients with burns, but they are not recommended for routine use Pharmacotherapy Self-Assessment Program, 6th Edition 45 Gastroenterology and Nutrition Answers
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