Nutrition in Cirrhosis: Dos and Don’ts
Screening:
• Patients at risk for RFH-Nutritional Prioritizing Tool
• Low BMI (<18.5)
• Advanced liver disease (Child-Pugh score C)
Assessment:
• Evaluation of nutritional status (Royal Free Hospital Global Assessment)
• Muscle mass (Anthropometry, CT scan, Dual Energy Exchange Absorptiometry, Biolectrical Impedance Analysis, muscle ultrasound)
• Muscle function (Handgrip test)
• Global physical performance (Time up and go, 6 min walk distance)
DOS:
• Take care of malnutrition as you do for other complications of chronic liver diseases.
• Get used to make an assessment of nutritional status with simple methods.
• Inform the patient about the importance of nutrition in chronic liver disease.
• Provide simple messages regarding dietary intake (in non-overweight individuals 30-35 kcal/body weight, 1.2-1.5 g of proteins/kg BW) and meal pattern (avoiding long fasting by having a late evening snack).
• Emphasize the importance of maintaining muscle mass and function by avoiding hypomobility.
• Introduce easy targets for physical activity.
DON’TS
• Approach malnutrition as inevitable consequence of the disease (”Nothing can be done”)
• Overload the patient with numerous unjustified dietary or lifestyle restrictions.
• Prescribe low protein diets to prevent or treat hepatic encephalopathy.
• Disregard the detrimental effect of long fasting periods.
• Overlook the relevance of muscle mass depletion on the prognosis in patients with liver cirrhosis.
#Nutrition #Cirrhosis #diet #management #hepatology #pathophysiology
Scurvy (Vitamin C Deficiency) - Diagnosis and Management
Vitamin C is required for hydroxylation of proline residues on procollagen molecules, which support the triple-helix structure of collagen that underpins the integrity of:
• Skin
• Vessels
• Mucous membranes
• Bone
Groups at risk for scurvy:
• Inadequate intake of fresh fruit and vegetables
• Persons with psychiatric illnesses
• Eating disorders
• Selective eating habits
• Infants who consume only pasteurized milk
• Children with autism spectrum disorder, persons with alcohol use disorder
• Isolated elderly persons with poor nutrition
Clinical Presentation:
• General malaise and lethargy
• Poor appetite and failure to thrive
• Ill temper
• Fever and tachypnea
As the condition progresses, shortness of breath, wasting, anemia, edema, mucocutaneous changes, ocular and musculoskeletal symptoms develop.
Psychiatric symptoms:
• Mood disturbances
• Depression
• Cognitive impairment
• Delusions
Ocular:
• Eye dryness and irritation
• Subconjunctival, periorbital, or orbital hemorrhage
Mouth:
• Gingival hemorrhages
• Loss of teeth
Anemia:
• Vitamin C deficiency can lead to iron and folate deficiencies
• Vit C contributes to red-cell cytoskeleton protein beta-spectrin, which is crucial to the structure and integrity of the cell. The loss of beta-spectrin can contribute to nonimmune hemolysis
MSK:
• Hemarthrosis
• Myalgias
• Weakness
• Muscle cramping
Skin:
• Petechia
• Purpura
• Perifollicular hemorrhages
• Corkscrew hairs
• Poor wound healing
• Follicular hyperkeratosis
DDX?
• Petechiae, purpura, and ecchymoses due to capillaritis, cutaneous vasculitis, thrombocytopenia, or any other cause
• Folliculitis
• Gingivitis and periodontitis
• ITP
• Henoch-Schonlein purpura
• DIC
• Rocky Mountain spotted fever
• Meningococcemia
• Hypersensitivity vasculitis
Treatment:
• Supplementation with 1 g/day of oral vitamin C for 2 weeks
#Scurvy #Pathophysiology #VitaminC #AscorbicAcid #Pathophysiology #Nutrition #Diagnosis #Management
Vitamin B12 (Cobalamin) Deficiency
Etiology:
• Vit B12 - aka cobalamin. Present in foods derived from animal products.
• Common Causes - decreased dietary intake (e.g. in vegans), malabsorption (d/t reduced gastric acidity, medications, pancreatic dysfunction, and/or disorders of small intestine), autoantibodies (pernicious anemia, PA - impaired absorption 2/2 ab to intrinsic factor, IF)
Clinical Presentation:
• Worsening macrocytic anemia, yellow skin, cognitive slowing, neuropathy, fatigue, wt loss
• If anemia is severe, may have sx attributable to tissue hypoxia and organ ischemia (e.g. CP, SOB, lightheadedness, palpitations), skin pallor
• GI - glossitis (pain, swelling, tenderness, loss of papillae of tongue), abd pain, diarrhea related to IBD, celiac disease, other malabsorptive state
• Neuropsych - symmetric parasthesias, gait problems (think of subacute combined degeneration of dorsal 8 lateral columns)
• Takes years to manifest its symptoms (in strict vegans who don't take B12 supplements) d/t large total body stores
Evaluation:
• History - Diet, previously dx'd associated conditions, surgeries (bariatric, gastric, intestinal), alcohol use, symptoms
• P/E - GI and derm findings, HSM, LN, peripheral neuropathy
• Labs:
- CBC, PBS - anemia, mild leukopenia and/or low pit, low retic count, hypersegmented neutrophils, macrocytosis
- Low Vit B12 level (< 200 pg/mL) - not specific, can have spuriously elevated or low levels
- Elevated MMA and homocysteine levels
- Check for IF ab
Treatment:
• Oral cobalamin 1000 - 2000 ug daily
• Adequate amount of this will be absorbed, even if IF is lacking or there is malabsorption
• If severe and need more rapid correction, can consider IM or IV
• Response - reticulocytosis in several days, Hb level increases by approx. lg per week
• If response is inadequate, consider other diagnosis e.g. leukemia
Dr. Joan Lee @taleanski
#Vitamin #B12 #Cobalamin #Deficiency #diagnosis #management #nutrition
Pediatric Trauma Primary Survey: C-ABCDE
C - Catastrophic Bleeding - Life-threatening hemorrhage
• Apply direct pressure/compression bandage
• Tourniquet for extremity bleeding (note time applied)
A - Airway Compromise - Position/patency, Need for protection
• Spinal motion restriction if indicated; expose neck to assess for neck injury/airway threat
• Jaw thrust to open; oral suction; oral airway (if obtunded)
• Early intubation with Manual In-Line Stabilization (MILS) if c-spine not cleared; plan for postintubation sedation needs
B - Respiratory Failure - Apnea/poor effort, Signs of tension pneumothorax (PTHX)
• Assist with BVM/prepare for drug-assisted intubation (See Drug Dosing Binder)
• Use POCUS to assess for PTX/HTX and/or pericardial tamponade
• Decompress chest: needle/finger thoracostomy, chest tube
• Consider chest tube insertion for any intubated patient with a pneumothorax
C - Hemorrhagic shock - Cool skin, ↑ HR, ↓ cap refill, ↓ BP is a late sign of shock
• Find bleeding source: Head/scalp, Chest/abdomen/pelvis, eFAST exam
• Bind pelvis if hemodynamically unstable/known or potential pelvic fracture
• NS/RL up to 40 mL/kq IV rapid bolus, then warmed PRBCs 10-20 mL/kg IV as rapidly as possible; repeat PRN. Move sooner to PRBCs if poor/no response to fluids.
• If active bleeding/hypotension, limit crystalloid and transfuse: uncrossmatched PRBCs (10-20 mL/kg, repeat PRN). IF ongoing need For blood, activate massive transfusion protocol if available, and transport STAT.
• Consider qivinq tranexamic acid (TXA) as a load 15-30 mq/kg/dose (MAX 1000-2000 mg) IV over 10-20 minutes, then 5-15 mg/kg/hr IV infusion (MAX 125 ma/hr) for the Tesser of 8 hours or until bleeding stops. Use higher end dosing range for more severe bleeds. Do NOT give TXA if greater than 3 hours since injury.
D - Severe head injury - GCS less than or equal to 8, Responds to pain only / Unresponsive (AVPU)
D - Impending herniation - Unilateral fixed and dilated pupil, Cushing's triad: ↓HR, ↑BP, irregular respirations
• ↑head of bed 30 degrees, head midline
• Drug assisted intubation with Manual In-Line Stabilization (MILS), maintain ETCO 35-40 mm Hg
• Analgesia/sedation plan (see ongoing care box below)
• Contact Neurosurgery; consider seizure prophylaxis
• If impending herniation:
- 3% NaCI 5 mL/kg/dose IV (MAX 250 mL/dose) over 10 minutes (repeat PRN) and/or mannitol I g/kg/dose (MAX 100g) over 15 min
- Initiate brief period of hyperventilation until responsive pupil, normalized vital signs
Neurogenic shock - ↓HR, ↓BP, Abnormal tone, ↓ power
• Vaspressor infusion IV/IO to maintain BP:
- NORepinephrine
- Phenylephrine
E - Exposure
• Maintain normothermia during assessment (warm blankets, forced-air warmer)
• Rectal examination only if concern for spinal cord injury
#Pediatrics #Trauma #Primary #Survey #CABCDE #management
#ICUCard
RENAL
GFR
90-131
mL/min
((140-age)*Wt)/(72*Cr)
Glomerular Filtration Rate (Cockcroft)
CI Cr
90-131
mL/min
(CrU * volume)/CrS
Creatinine Clearance
FENa
0.0-1.0
%
((U/P Na)/(U/P Cr))*100
Fractional Excretion of Na+
Na req
mEq
(125-Na)*0.6*Wt
Required Sodium
FE Urea 20-70
%
((UUN/BUN)(U/P Cr))*100
Fractional Excretion of Urea
RFI
0.0-1.0
%
(Na U(U/P Cr)
Renal Failure Index
BUN:CrS 13-20
%
BUN/Cr S
BUN / Creatinine (S) ratio
TTKG
4.0-6.0
%
(U/P K)/(U/P Osm)
Trans Tubular Potassium Gradient
Osm c
275-295
mOsm/kg
Osmolality, calculated
2"(Na + K))+(glucose/18)+(BUN/2.8)
OsmGap 0.0-10.0
mOsm/kg (Osm m)-(Osm calc)
Osmolar Gap
ACID-BASE
AG S
8-16
mEq/L
Na - (Cl + НСО3)
Anion Gap (Serum)
H_def
0
mEq
Acid Deficit
HCO3def O
mEq
Bicarbonate Deficit
Wt*0.5(HCO3m-HCO3d)
(m=measured. d=desired)
Wt*0.5(HCO3d-HCO3m)
Metabolic Acidosis
ІнСО3 → /PCO2
pCO2 = 1.5 (HCO3)+8 (+-2)|
Metabolic Alkalosis
ТНСО3 → TPCO2
pCO2 = 0.9 (HCO3)+9
Respiratory Acidosis
ТРСО2 → Тнсоз
acute: HCO3 T 1mEq/L for each 10 T in pCO2
chronic: HCO3 T 3.5mEq/L for each 10 1 in pCO2
Respiratory Alkalosis
IPCO2 → ІнСО3
acute: HCO3 + 2mEq/L for each 10 - in pCO2
chronic: HCO3 L 5mEq/L for each 10 J in pCO2
HHE
pk + log (HCO3/(PCO2*0.03))
Henderson - Hasselbalch Equation
КВЕ
(24*PaCO2)/HCO3
Acid base Equation
NUTRITION
IBW
110-220
Ib
Ideal Body Weight
BMI
18.5-25
kg*m2
(Ht^2)*23 (men)
(Ht^2)*21.5 (women)
Wt/Ht^2
Body Mass Index
BSA
1.3-2.5
m2
Body Surface Area
(Wt^0.425)*(Ht^0.725)*(0.007184)
NB
0
9
Nitrogen Balance
NB = protein int g/6.25 - (24h UUN(g) + 2.5g) |
BEE
Harris Benedict Equation
M= 66+ (13.7 x Wt kg) + (5 x Ht cm) - (6.8 x age)
F= 655+(9.6 x Wt kg) +(1.8 x Ht cm) - (4.7 x age)
EE
1200-2500 kcal/d
Energy Expenditure
СО*Hb*(((SaO2-SvO2)/100)*95) |
Perform computations online with:
> MediCalc® 7
Medical Calculator System™
VENTILATOR
INTUBATION CRITERIA* RR > 35-40/min
PaCO2 > 50mmHg (acute I pH).
Pa02 < 70 mmHg on 100% mask
A-a Gradient > 400 (100% FiO)
MIP < -25 cmH20
A from normal, Bronchopulmonary toilet,
A. Arturo Rodriguez, MD
ICU-card is a trademark of ScyMed 6th Ed, 2007. All rights reserved.
©2007 ScyMed. Inc
PO Box 20367 Houston TX 77225
Airway Protection, Inhalation injury (endoscopy/stridor). Head or spinal cord injury. Adult Resp. Distress Syndrome.
EXTUBATION CRITERIA*
Printed in USA
RR < 30/min
PaCO2 < 50 mmHg
Pa02 > 60mmHg on FIO2 < 50% pH normal (for the patient)
MIP > - 25 cm H20
PEEP < 5 cm H20
VT > 5mL/kg, VC > 10mL/kg
MV < 10L/min, Shunt < 20%
VD/VT < 0.6,
Patient awake, alert, cooperative
*Individual Patient assessment required
DRUGS
Adenosine: IVP: 6mg (1-3 sec) then 12mg
Aminophylline:
IV Infusion: 0.3-0.5mg/kg/h (500mg/500mL NS)
IV Infusion (smokers): 0.7 - 0.9mg/kg/h
Amrinone: IV: 0.75mg/kg (over 2 - 3 min) then, IV Inf: 5.0-15.0ug/kg/min (500mg/500mL NS)
Atenolol: IV: 5-10mg over 5 min.
Atropine SO4: IVP: 1.0mg (asystole, total 3mg)
IVP: 0.5-1.0mg (bradycardia, total 3mg)
Bicarbonate, Sodium:
IVP: 1.0mEq/kg then 0.5mEq/kg q10min
Bretylium Tosylate:
IVP: 5.0mg/kg in 1 min (total: 30-35mg/kg)
IV Infusion: 1.0-2.0mg/min (2g/500mL D5W)
Bumetanide: IV or IM: 0.5-1.0mg over 1-2min
Calcium chloride (10%):
IV: 2.0 - 4.0mg/kg q10min (as needed)
Digoxin:
IV/PO loading: 10-15ug/kg over 12-24hours (0.5mg IV over 5min -> 0.25mg q6h x2-4)
Diazepam: IV: 2-10mg (not to exceed 5mg/min)
Diltiazem:
IV: 20mg or 0.25mg/kg (then 0.35mg/kg)
IV Infusion: 5 - 15mg/h (250mg/500mL D5W-NS)
Dobutamine:
IV: 2 - 20ug/kg/min (250mg/500mL D5W-NS)
Dopamine: (400mg/250mL D5W= 1600ug/mL) dopaminergic: 1 - 3ug/kg/min IV b-adrenergic: 3 - 10ug/kg/min IV a-adrenergic: > 10ug/kg/min IV
Epinephrine: (1:1000) (1mg/250mL NS = 4ug/mL)
IVP: 1.0 mg q3-5min (then 5mg or 0.1mg/kg)
IV Infusion: 2 - 10ug/min
Flumazenil: IV: 0.2mg over 30 sec (max 3.0mg/h)
Furosemide: IV: 20-80mg over 1-2min
Heparin: (25,000units/500mL= 50u/mL) NS-D5W
IV Bolus: 5,000 units x1; IV Inf; 1000-1300 units/h
Insulin: 100units/250mL NS = 0.4 units/mL )
IVP: 0.1 units/kg
Isoproterenol: (1mg/250mL= 4ug/mL) NS-DsW
IV Infusion: 2 - 10ug/min
Labetalol: (200mg/200mL = 1 mg/mL) D5W-NS-RL
IV: 20mg over 2min, -->40-80mg (max 300mg)
Lidocaine: (2g/500mL = 4mg/mL) NS-D5W
IVP: 1.0 - 1.5mg/kg (x2 q5-10min)
IV Infusion: 2 - 4mg/min
Magnesium: IV Infusion: 1-2g/100mL D5W (2min)
Mannitol (20%): IV: 1.5 - 2.0g/kg over 30-60min
Metoprolol: IV: 5mg q5min x 3 (slow push)
Morphine SO4: IV: 1-3mg q5min (until response)
Naloxone: IV: 0.4 - 2.0mg q2min pr (up to 10mg)
Nifedipine: SL: 10mg (chew and swallow)
Nitroglycerin: (200mg/500mL) NS-DSW
IV Infusion: 10 - 300ug/min
Nitroprusside Na+: (100mg/500mL= 200ug/mL)
IV Infusion: 0.1 - 5.0ug/kg/min (use D5W only)
Norepinephrine: (4mg/250mL= 16ug/mL) D5W
IV Infusion: 0.5 - 1.0ug/min (up to 30ug/min)
Procainamide: (1g/250mL = 4mg/mL) D5W only
IV Infusion: 20mg/min (total: 17 mg/kg)
IV maintenance Infusion: 1 - 4mg/min
Streptokinase: IV: 1.5million units over 1h
TPA: IV: 100mg (15mg bolus, then 50mg in 1h, then 35mg in 1h)
IV: 2.5-5.0mg over 2 min (x4 q15-30min)
*IM=intramuscular. IV=intravenous.PO=oral. SL=sublingual.
DsW = dextrose 5% in water. NS = normal saline.
*Check drug packet inserts for doses & info.
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