1What is the purpose of a nutrition risk assessment in critically ill patients?
To identify patients most likely to benefit from early and aggressive nutrition support
2What two main domains are added in the NRS 2002 score?
Nutritional status and severity of disease
3What age adjustment is used in NRS 2002?
Add 1 point for age ≥70 years
4What NRS 2002 score generally triggers nutrition support?
An age-corrected score ≥3
5What are the variables in the original NUTRIC score?
Age, APACHE II, SOFA, comorbidities, days from hospital to ICU admission, and IL-6
6What NUTRIC score is considered high nutrition risk?
6–10 points
7What NUTRIC score is considered low nutrition risk?
0–5 points
8Why was the modified NUTRIC score developed?
IL-6 is not routinely available in clinical practice
9What does the modified NUTRIC score omit?
IL-6
10What modified NUTRIC score indicates high nutrition risk?
≥5
11What are ASPEN's three broad malnutrition categories?
Starvation-related, chronic disease-related, and acute disease or injury-related malnutrition
12What are the classic features of marasmus?
Loss of fat and muscle protein stores with relatively preserved serum proteins
13What are the classic features of kwashiorkor?
Relatively preserved fat with reduced muscle protein and serum proteins
14How many consensus malnutrition characteristics are needed for diagnosis?
At least 2
15What six characteristics are used in the ASPEN/Academy malnutrition framework?
Low energy intake, weight loss, muscle loss, subcutaneous fat loss, fluid accumulation, and reduced hand-grip strength
16Why are albumin and prealbumin poor markers of nutrition status in critical illness?
They are strongly affected by inflammation and illness rather than nutrition stores alone
17Should BMI be used alone to diagnose malnutrition?
No
18Why is BMI excluded from the consensus malnutrition classification?
Patients can become malnourished regardless of body habitus
19What BMI is classified as underweight?
<18.5 kg/m²
20What BMI is classified as normal?
18.5–24.9 kg/m²
21What BMI is classified as overweight?
25–29.9 kg/m²
22What BMI range defines class I obesity?
30–34.9 kg/m²
23What BMI range defines class II obesity?
35–39.9 kg/m²
24What BMI defines class III obesity?
>40 kg/m²
25About what percentage of body weight is represented by one foot?
1.5%
26About what percentage of body weight is represented by a calf plus foot?
5.9%
27About what percentage of body weight is represented by an entire leg from the hip?
16%
28About what percentage of body weight is represented by one hand?
0.7%
29About what percentage of body weight is represented by a hand plus forearm?
2.3%
30About what percentage of body weight is represented by an entire arm?
5%
31What is the gold standard for measuring energy expenditure in the ICU?
Indirect calorimetry
32What variables does indirect calorimetry use to estimate energy expenditure?
Oxygen consumption and carbon dioxide production
33What is the respiratory quotient formula?
RQ = VCO₂ / VO₂
34What RQ is associated with carbohydrate oxidation?
About 1.0
35What RQ is associated with fat oxidation?
About 0.7
36What RQ is associated with protein oxidation?
About 0.8
37What does an RQ >1 usually suggest?
Overfeeding with net fat synthesis
38What can an RQ <0.7 suggest?
Ketosis or measurement error
39What ICU factors can reduce the accuracy of indirect calorimetry?
Chest tubes, supplemental oxygen, high or changing FiO₂, PEEP, CRRT, anesthesia, and patient movement
40What general caloric range did SCCM/ASPEN 2016 recommend when indirect calorimetry is unavailable?
About 25–30 kcal/kg/day
41What energy target is recommended for obesity when measured by indirect calorimetry?
No more than about 65%–70% of target energy requirements
42What weight-based calorie target is suggested for BMI 30–50 kg/m²?
11–14 kcal/kg actual body weight/day
43What weight-based calorie target is suggested for BMI >50 kg/m²?
22–25 kcal/kg ideal body weight/day
44What caloric range does ASPEN 2022 list for the first 7–10 ICU days?
12–25 kcal/kg/day
45What caloric range does ESPEN 2023 suggest when measured REE is unavailable?
20–25 kcal/kg/day
46Which predictive equation is preferred for many nonventilated patients with obesity, AKI, CKD, or hepatic encephalopathy?
Mifflin–St Jeor
47What is the Mifflin–St Jeor equation for women?
REE = 10W + 6.25H − 5A − 161
48What is the Mifflin–St Jeor equation for men?
REE = 10W + 6.25H − 5A + 5
49Which equation is preferred for ventilated patients with obesity?
Penn State equation
50Which equation is preferred for ventilated patients with obesity who are age ≥60?
Modified Penn State equation
51Which energy equation is favored for small adults and older adults in the chapter?
Harris–Benedict
52What glucose infusion rate should generally not be exceeded in acute critical illness?
About 4–5 mg/kg/min
53What total caloric ceiling is suggested to reduce overfeeding risk?
Avoid exceeding about 1.3–1.5 × measured REE or 25–30 kcal/kg/day for most patients
54What soybean-oil lipid dose is commonly used as an upper practical limit in critically ill adults?
Around 1 g/kg/day or less
55How can overfeeding worsen hypercapnia?
Excess calories increase CO₂ production and ventilatory demand
56What should be considered when unexplained hypercapnia develops during nutrition support?
Empirically reduce total caloric intake, especially during ventilator weaning
57What dextrose infusion rate is associated with a higher risk of marked hyperglycemia?
>5 mg/kg/min
58Why is continuous PN generally preferred over cyclic PN during critical illness?
It avoids very high glucose infusion rates and large hourly fluid loads
59When can overfeeding-related hepatic steatosis or cholestasis begin to appear?
After roughly 1 week to 10 days of overfeeding
60What liver tests commonly rise with PN-associated cholestatic liver injury?
GGT, alkaline phosphatase, and eventually bilirubin
61What is the first step when PN-associated liver disease is suspected?
Make sure the patient is not being overfed
62What is the SCCM/ASPEN protein range for most critically ill adults?
1.2–2 g/kg/day
63How much protein may be needed during CRRT?
Up to about 2.5 g/kg/day
64How much extra protein is suggested for open-abdomen fluid losses?
An additional 15–30 g protein per liter of wound or negative-pressure output
65What protein target is suggested for obesity with BMI 30–39.9 kg/m²?
2 g/kg ideal body weight/day
66What protein target is suggested for obesity with BMI ≥40 kg/m²?
2.5 g/kg ideal body weight/day
67What protein range is listed for AKI?
1.2–2 g/kg/day
68What protein range is listed for adults older than 60 years?
2–2.5 g/kg/day
69What protein target does ESPEN 2023 list for ICU patients?
About 1.3 g/kg/day
70What did the EFFORT Protein trial find when comparing about 1.6 vs 0.9 g/kg/day?
No overall improvement in being alive at hospital discharge with the higher protein strategy
71Which EFFORT subgroup raised concern for harm from higher protein?
Patients with AKI
72When is enteral nutrition indicated?
When oral intake is inadequate to meet nutrition goals and the GI tract can be used
73Why has EN traditionally been preferred over PN?
It supports GI integrity, is less costly, and historically had fewer infectious complications
74What did ASPEN 2022 conclude about EN versus PN as the primary feeding route in the first ICU week?
Either can be acceptable when patient-specific factors and clinical judgment support the choice
75Is absence of bowel sounds a contraindication to EN?
No
76Is absence of flatus or bowel movement alone a contraindication to EN?
No
77What GI finding is a relative contraindication to EN?
Evidence of ileus such as dilated bowel loops
78What NG output may suggest delayed gastric emptying or intolerance?
Roughly >800 mL over 24 hours
79Is anorexia or refusal to eat an absolute contraindication to EN?
No
80What should be tried before tube feeding solely for poor oral intake when feasible?
Address food preferences and add high-calorie or high-protein oral supplements
81What is a typical standard tube-feeding formula concentration?
About 1–1.2 kcal/mL
82What is a typical standard tube-feeding protein density?
About 40–50 g/L
83What is a typical volume-restricted EN concentration?
About 2 kcal/mL
84What type of EN formula is useful for predialysis renal dysfunction with high electrolytes?
A calorie-dense low-protein formula with reduced electrolytes
85What type of renal EN formula is used for patients receiving hemodialysis?
A calorie-dense higher-protein renal formula
86What type of EN formula is useful for trauma, surgery, or burns with high protein needs?
A high-protein formula
87What type of EN formula is used for diabetes or hyperglycemia?
A lower-carbohydrate formula with fiber
88What nutrients characterize many immune-enhancing formulas?
Higher protein with arginine, glutamine, and fish oil
89What type of formula is useful for malabsorption or fat intolerance?
An elemental or peptide-based lower-fat formula
90How much protein is typical in a modular protein supplement serving?
About 10–15 g
91What is the general hold recommendation for EN around interacting oral medications in this chapter?
Hold EN for 1 hour before and 1 hour after the dose
92What should be done to the EN rate when feeds are held for medication administration?
Increase the rate as needed to make up lost feeding time
93Which drugs are highlighted for clinically important EN interactions?
Warfarin, phenytoin, levothyroxine, itraconazole, and fluoroquinolones
94What levothyroxine formulation may reduce the need to hold EN?
Liquid levothyroxine
95What alternative levothyroxine strategy is described when continuous EN cannot be held?
Increase levothyroxine by about 25 mcg/day with weekly thyroid testing and reduce when EN stops
96Why is empiric dose escalation discouraged for warfarin or phenytoin during continuous EN?
The patient can become toxic if EN is suddenly held or discontinued without reducing the dose
97How should EN generally be handled during uncontrolled shock?
Avoid or delay EN
98When can EN be started in a patient receiving vasopressors?
Once shock is stabilized and vasopressor doses are no longer escalating
99What hypocaloric regimen was used in NUTRIREA-3?
About 6 kcal/kg/day with 0.2–0.4 g/kg/day of protein
100What did NUTRIREA-3 suggest about hypocaloric early EN during vasopressor therapy?
It reduced ICU duration and GI adverse events without a significant mortality reduction
101When does ESPEN 2023 suggest starting PN if oral intake and EN are contraindicated?
Within about 3–7 days
102When can very early PN be considered when EN is contraindicated?
Within about 48 hours for patients who are severely malnourished or at high nutrition risk
103What did SCCM/ASPEN 2016 advise about PN in acute sepsis?
Avoid PN during the acute phase of sepsis
104What GI conditions are listed as possible indications for PN?
Intractable vomiting or diarrhea, obstruction, short bowel or severe malabsorption, high-output fistula, ischemic bowel, or bowel discontinuity
105What fistula output is considered high enough to support PN consideration?
>500 mL/day
106What is the osmolarity limit listed for peripheral PN?
<900 mOsm/L
107Why is peripheral PN often inadequate in critically ill patients?
Osmolarity limits force dilute high-volume formulas that may not meet protein or energy goals
108How long is peripheral PN often difficult to maintain because of phlebitis?
Beyond about 2–3 days
109Where should a central PN catheter tip terminate?
In a large central vein such as the distal superior vena cava near the right atrium
110Which PN route is generally preferred for critically ill patients who require PN?
Central PN
111How should PN macronutrients and electrolytes be prescribed?
As total amounts per day rather than as stock concentrations or compounding recipes
112Why should the amino acid and lipid product brands be specified in PN orders?
Different products have different ingredients, compatibility, and stability profiles
113What is the approximate obligatory daily glucose requirement for the CNS and other glucose-dependent tissues?
About 130 g/day
114How much glucose may be required for surgical wound healing?
About 80–150 g/day
115How many kilocalories are provided by 1 g of IV dextrose?
3.4 kcal
116What is the mean glucose oxidation rate cited for critically ill adults?
About 5 mg/kg/min
117What is the FDA maximum hang time for IV lipid emulsion administered separately from PN?
12 hours
118Does ASPEN 2022 recommend one IV lipid emulsion product over another in critical illness?
No
119What is the composition of SMOFlipid?
30% soybean oil, 30% MCT, 25% olive oil, and 15% fish oil
120How many kilocalories per mL are in a 10% lipid emulsion?
About 1.1 kcal/mL
121How many kilocalories per mL are in a 20% lipid emulsion?
About 2 kcal/mL
122How many kilocalories per mL are in a 30% lipid emulsion?
About 3 kcal/mL
123How much soybean-oil lipid per week is usually enough to prevent essential fatty acid deficiency?
About 100–150 g/week or 1–1.5 g/kg/week
124What is the FDA upper limit for IV lipid emulsion in adults?
2.5 g/kg/day
125What soybean-oil lipid dose is generally kept below in critically ill adults?
About 1 g/kg/day
126What SMOFlipid dose range is listed?
1–2 g/kg/day
127What olive-oil/soybean-oil lipid dose range is listed?
1–1.5 g/kg/day
128What laboratory ratio is the classic biochemical marker of essential fatty acid deficiency?
Triene-to-tetraene ratio >0.2
129How soon can biochemical EFAD develop during fat-free full-calorie PN?
It can begin within about 1 week
130When do clinical signs of EFAD usually appear in adults receiving fat-free PN?
Roughly 2 weeks after biochemical evidence, often around 3 weeks of fat-free full-calorie PN
131What are clinical signs of EFAD?
Dry scaly skin, hair loss, and poor wound healing
132How often should triglycerides be monitored during IV lipid therapy?
At least weekly and more often when clearance may be impaired
133At what triglyceride concentration should temporary lipid withholding be considered?
When triglycerides approach or exceed about 400 mg/dL
134How many kilocalories per mL does propofol contribute?
1.1 kcal/mL
135How many kilocalories per mL does clevidipine contribute?
2 kcal/mL
136What conditions can impair triglyceride clearance?
Pancreatitis, uncontrolled diabetes, liver or kidney failure, advanced sepsis, hyperlipidemia, obesity, HIV, and pregnancy
137What electrolyte pattern is classic for refeeding syndrome?
Hypophosphatemia, hypokalemia, and hypomagnesemia
138How should nutrition be initiated in a patient at high risk for refeeding syndrome?
Start hypocalorically and advance toward goal over about 1–3 days
139How should established refeeding syndrome be managed?
Slow the feeding rate and aggressively replace electrolytes
140How much multivitamin for infusion is generally included in each PN bag?
10 mL/day
141Which vitamins can often be added above basal amounts to replace ongoing losses?
Thiamine and folic acid
142Where should vitamin repletion doses for a known deficiency generally be given?
Separately from the PN admixture
143What is the usual baseline zinc requirement in PN?
About 3 mg/day
144What zinc dose is often used during critical illness?
About 5 mg/day
145How much additional zinc is often added for major diarrhea or fistula losses?
About 10 mg/day additional
146What are classic manifestations of zinc deficiency?
Hair loss, periorbital erythematous rash, and poor wound healing
147What is the classic name for severe zinc deficiency?
Acrodermatitis enteropathica
148What is the usual copper requirement in PN?
About 0.3–0.5 mg/day
149Which ICU therapy increases risk of copper deficiency after prolonged use?
CRRT lasting more than about 7–10 days
150What hematologic finding can suggest copper deficiency?
Microcytic anemia unresponsive to iron, often with pancytopenia
151What neurologic findings can occur with copper deficiency?
Neuropathy or myelopathy with numbness, weakness, gait problems, vision changes, or dysphagia
152Why can a low serum copper be convincing even when CRP is high?
Inflammation tends to raise copper, so a low value despite inflammation strongly supports deficiency
153What is the usual chromium requirement listed for PN?
About 10–12 mcg/day
154Why is routine extra chromium often unnecessary in PN?
Commercial PN components frequently contain chromium contamination
155What is the classic presentation of chromium deficiency?
Hyperglycemia
156What manganese requirement is listed in the chapter?
About 150–300 mcg/day, although newer multitrace products provide much less
157What neurologic syndrome can manganese toxicity resemble?
Parkinson disease
158What selenium dose is typically used in PN?
About 60 mcg/day
159How much selenium may be used with diarrhea or short bowel syndrome?
Up to about 120 mcg/day
160What are classic manifestations of selenium deficiency?
Severe muscle weakness and congestive cardiomyopathy
161What is selenium-deficiency cardiomyopathy called?
Keshan disease
162What does 1 mL of the newer 4-trace-element injection provide?
Zinc 3 mg, copper 0.3 mg, manganese 55 mcg, and selenium 60 mcg
163Does the newer 4-trace-element product contain chromium?
No
164What is the historical approach to trace elements in cholestatic liver disease?
Withhold copper and manganese and add zinc and selenium separately
165Why is routine withholding of copper and manganese in all hyperbilirubinemic patients now uncertain?
Newer products contain lower doses and micronutrient deficiencies are increasingly recognized
166When should supplemental PN generally not be started according to ASPEN 2022?
Before ICU day 7
167What did the EPaNIC trial suggest about early supplemental PN?
More infections and slower ICU discharge with early supplemental PN
168What did the Heidegger trial suggest about supplemental PN after poor EN delivery by day 3?
Fewer infections with supplemental PN in selected patients
169What did the 2022 Gao trial suggest in high-risk postoperative patients with poor EN tolerance?
Day-3 supplemental PN increased energy delivery and reduced nosocomial infections compared with day 8
170What is the practical approach to supplemental PN in high-risk or severely malnourished patients?
Use case-by-case judgment while balancing underfeeding against overfeeding and refeeding risk
171When should early EN generally begin in a hemodynamically stable critically ill adult?
Within 24–48 hours
172How early is EN suggested after major burn injury when feasible?
Within about 4–6 hours
173What does ESPEN 2023 recommend when oral intake is not possible and EN is not contraindicated?
Start EN within 48 hours rather than delaying or starting PN
174What is a practical upper limit for delaying EN in most ICU patients?
No later than about 72 hours
175Which ICU populations have shown the most consistent benefit from early EN?
Surgical, trauma, and thermal-injury patients
176What BG range is commonly targeted in mixed medical-surgical ICU patients?
140–180 mg/dL
177At what persistent BG does SCCM 2024 recommend initiating a hyperglycemia management protocol?
>180 mg/dL
178What route of insulin is preferred for acute ICU hyperglycemia according to SCCM 2024?
Continuous IV insulin
179How often should BG be checked while a patient is receiving IV insulin according to SCCM 2024?
At least every 1 hour
180What BG threshold defines hypoglycemia in most ICU guidelines?
<70 mg/dL
181What BG range is commonly considered mild to moderate hypoglycemia?
About 40–60 mg/dL
182What BG level is considered severe life-threatening hypoglycemia?
<40 mg/dL
183What is a major nutrition-related cause of severe hypoglycemia during insulin therapy?
Abruptly stopping EN or PN without reducing insulin
184What medication change can precipitate hypoglycemia during insulin therapy?
Reducing a corticosteroid dose without adjusting insulin
185What organ failures increase hypoglycemia risk during insulin therapy?
Hepatic failure and renal failure
186What other ICU factors increase hypoglycemia risk?
Advanced age, sepsis, vasopressors or inotropes, and octreotide with insulin
187Which stable diabetic patients on IV insulin should generally transition to basal-bolus before stopping the infusion?
Those requiring >0.5 unit/hour
188Which stable patients with stress hyperglycemia should generally transition to basal-bolus before stopping IV insulin?
Those requiring >1 unit/hour
189What conditions should be met before transition from IV insulin to basal-bolus therapy?
No expected nutrition interruptions, peripheral edema resolved, and all vasopressors discontinued
190What proportion of the prior IV insulin daily requirement is commonly used for initial basal insulin?
About 60%–80%
191How long before stopping IV insulin should the first basal insulin dose be given?
About 2–4 hours
192How often can correction insulin be given during continuous EN or PN?
About every 4–6 hours
193What intermediate-acting insulin has been used for basal coverage during continuous EN?
NPH insulin
194What general nutrition principles were emphasized for critically ill patients with COVID-19?
Use standard critical-care nutrition principles while minimizing staff exposure and clustering care
195What EN delivery method was preferred in COVID-19 guidance?
Continuous EN rather than bolus feeding
196Is prone positioning a contraindication to EN?
No
197How should EN be started while a patient is prone?
Begin with trophic feeding, advance as tolerated, and elevate the head of bed about 10–25 degrees
198When may PN be considered earlier in patients with COVID-19?
When practical or clinical barriers prevent adequate EN
199What lipid-related laboratory requires close monitoring during PN in severe COVID-19?
Serum triglycerides