Nutrition Support

Nutrition Support • Fluid and electrolyte requirements. • Calculate enteral and parenteral nutrition formulations.

Nutrition Support • Patient can’t meet nutritional needs by normal oral ingestion of food for greater than 5 - 7 days.

NS Methods • Add snack between meals • Add high kcal or protein supplements at meals • Enteral supplement via tube feeding

Two Types NS • Enteral – still use the gut

• Parenteral – DO NOT use the gut – veins

Dx and NS • Strong data for NS – Acute renal failure - ENS/PNS – Prolonged acute pancreatitis - ENS/PNS – Acute respiratory failure - ENS/PNS

Dx and NS • Strong data for NS – Acute Crohn’s disease - PNS – Short bowel syndrome - PNS/ENS – Severely malnourished - ENS – Entercutaneous fistulas - PNS

Dx and NS • Moderate data for NS – Acute alcoholic liver disease - ENS – Stable COPD and CF - ENS – Chronic Crohn’s - ENS – Acute ulcerative colitis - ENS/PNS

Selecting route of nutritional support

Questions? • What questions to ask to determine route of NS? • What happens if you don’t use the gut and it is functioning?

Enteral Nutrition Support Definition: liquid formulated foods designed to be used to supplement oral intakes or provide complete nutrition. Typically used in hospitalized pts, often in tube feedings.

Enteral Nutrition •Fluid and electrolyte requirements. •Calculate enteral and parenteral nutrition formulations. ENTERAL FEEDINGS SHOULD BE USED WHENEVER A CLIENT CAN DIGEST OR ABSORB NUTRIENTS VIA THE GI TRACT!!

“IF THE GUT WORKS, USE IT!”

ENS • Selecting the formula – Integrity of GI system – Type of protein, fat, CHO, fiber in formula – Kcal & protein density of formula

ENS • Selecting the formula – Ability of formula as taken to meet pt nutrient needs – Viscosity of formula and TF equipment – Cost of formula

ENS Components • Intact or polymeric formulas • Hydrolyzed or elemental formulas

ENS Components • Molality and molarity – number of free particles/unit wt or volume – the higher the number the more free particles – the higher the number more osmotic force – mOsm

ENS Components • Isotonic – 350 mOsm/kg or less

• Intact formulas – 300 - 500 mOsm/kg

• Hydrolyzed nutrient formulas hyperosmolar – 900 mOsm/kg

ENS Components • Density of formulas – more nutrients or kcal/ml the more dense – less free water

• Dense formulas used – restrict water – other source of water

ENS Components • Protein – polymeric formulas - intact HBV protein

• What if small intestine can’t digest protein?

ENS Components • CHO – starch hydrolysates – maltodextrins – sucrose – fructose – glucose

ENS Components • CHO – osmolality increases as mover towards simple sugars

ENS Components • Fat – corn, soy, safflower, canola – need 4% of total kcal as linoleic – some have MCT

ENS Components • Fluid – need to check free water – standard formulas - 80 - 85% – calorie dense - 60%

ENS Components • Fiber – soy polysaccaharide – fructooligosaccharides – 10 - 12 g/L

ENS • Things to consider when selecting – ability to digest – absorption – colonic residue – length of time on TF – risk of aspiration

Formula Types Standard, Intact, Blenderized For Pt able to digest/ Absorb nutrients May contain pureed foods!!!!! $ Modular Contain a single nutrient (pro, CHO, lipid) Combined to meet unique needs of each pt Used least often, $$$$$

Hydrolyzed-- $$ Protein delivered as small peptides/ AA for those with compromised digestive function. Often low in fat

Nutrient Content of Enteral Formulas

Caloric Density (kcal per ml or cc)

0.5

1.0

1.5

2.0

Normal formula For pts with damaged or atrophied GI tract. Dilute formulas allow for recovery of GI function.

Energy Needs Met in Smaller Volume: • Kcal needs high • Low appetite • Volume Restricted

Important Considerations: Physical Properties Formula Osmolality (# of osmotic particles per Kg of solvent) Hypotonic

Isotonic 280-320 mmol/kg Osmolality of human plasma Example: 0.85 % sodium chloride or “normal saline” 5% glucose solution ( 5 g per 100 ml)

Hypertonic May cause gastric retention; in duodenum, may cause fluid shift, diarrhea, dehydration

Other Important Physical Properties Renal Solute Load (RSL) Remember: Hyperosmolar solutions require increased water intake in order for renal excretion, particularly in the pediatric patient. Dehydration is a great risk-- hypernatremia azotemia (high serum N) oliguria fever weight loss

Tube Feeding protocols Frequency/ amount Bolus*= large volume delivered intermittently ex: 400 ml q 4 h (2,400 ml per 24 hours) Continuous= given over 16 to 24 hours ex: 75 ml per h for 24 hrs (1,800 ml per 24 hrs.) (final rate) Intermittent*= gravity drip using smaller volumes than bolus; more often *Often poorly tolerated; n/v/d, aspiration

Volume and Rate of Delivery

tandard Procedure: use full-strength formula but control flow rate!

asogastric Feedings: start slow: 25-50 ml/ hour increase 10-25 ml per 8-24 hrs.

Measuring Residuals: withdrawing formula left in sto using a syringe

if 100-150 ml remain, no add’t feedin

Methods of Delivery Due to risk of aspiration-Elevate upper body >30˚; remain at least 30 min. after feeding. Supplemental Water can be provided in the feeding tube. Functions to: • flush tube to prevent clogging • meet daily fluid requirements

•Chart showing narrowing the choice of formulas next

ENS Routes of Adminiatration • Nasogastric • Nasoduodenal or jasojejunal • Enterostomies – percutaneous endoscopic gastrostomy (PEG) – percutaneous endoscopic jejunostomy (PEJ)

ENS Admin • Bolus administration – maximum bolus - 400-450 ml – 4 - 6 times/day

• Check gastric residual • Contraindications? • Describe patient this might work?

ENS Admin • Continuous drip – infusion 18 - 24 hours – start 30 - 50 ml/hr – advance 8 - 12 hr as tolerate – flush with water

Question ? • What steps would you take in planning a tube feeding?

Starting ENS • 300 mOsm - full strength, full rate • >600 mOsm - full strength, low rate & as tolerated advance

Monitoring ENS • What would you monitor?

Monitoring ENS • Gastric residuals – >150-200 ml without feeding – maintain elevation – wait 30-60 min – check again

Monitoring ENS • Gastric residuals – if always 150-200 ml – find out why – if have this and greater with feeding stop feeding or slow rate

Complications ENS • Dehydration – why dehydrated – increase fluid – lower protein intake

Complications ENS • Signs of excessive protein – dehydration – inadequate fluid intake – hypernatremia – hypercholremia

Complications ENS • Signs of excessive protein – azotemia – pt appears confused

Complications ENS • Aspiration pneumonia – make sure correct tube and placement of end of tube – elevate head 30 degrees – continuous drip 22-24 hrs

Complications ENS • Diarrhea – lactose intolerance – bacterial contamination – hyperosmolar formula – low serum alb – medication

END ENS • Questions? • Calculations next

Parenteral NS • Fluid and electrolyte requirements. • Calculate enteral and parenteral formulations.

PNS Routes • Peripheral access • Short-term central access • Long-term central access

Peripheral Access • Veins in limbs • Cannot exceed 800-900 mOsm/kg • PICC - enter at peripheral but end of tube at subclavian vein

Central Access • • • • •

Figure 20-3 here Cephalic vein Subclavian vein Internal jugular vein Superior vena cava

Fig. 20-3. Central access

Central Access • Short-term – percutaneous technique

• Long-term – implanted vascular devices

PNS • Time frame for use of PNS – 5 days or less is short-term

• Total nutrients needed • Capacity of pt to handle fluid

PNS • Condition of peripheral veins • If can take adequate oral intake in 5 day - DO NOT do central line

PNS Components • Protein – crystalline amino acids – 3% to 15% solutions – 10% = 100g protein/L – 4 kcal/g protein – NPC non-protein calories

PNS Components • Carbohydrate – dextrose monohydrate – 5% to 70% solutions – D50W = 50% solution – 10% solution = 100g/L – 3.4 kcal/g dextrose

PNS Components • Lipid – soybean or safflower oil – 10%, 20% & 30% solutions – 10% = 1.1 kcal/ml – 20% = 2.0 kcal/ml – 30% = 3.0 kcal/ml

PNS Components • Lipid – 10% kcal/day every day will provide 4% of kcal need to prevent EFA deficiency – if have long chain fatty acids

PNS Components • Electrolytes, vitamins, minerals

PNS • PPN – less than 8.5% AA – 5-10% dextrose – lipid not more than 1g/kg/day

PNS • PPN – Rule of thumb for PPN – D5W or D10W with 8.5% AA – D20W with 5% AA and lipid at 125 ml/hr

PNS • Compounding methods – mix the dextrose and AA – ‘piggy’ back the lipid and filter before mix with dextrose and AA

PNS • Initiating TPN – start less than 50 ml/hr and 1 L/day – advance 12 - 24 hr intervals

PNS • Monitoring – amount receiving – Na –K – BUN – prealbumin

PNS • Monitoring – cholesterol – TG –I&O – body wt – blood glucose

McClaren 165. Essential fatty acid deficiency.

McClaren 166. Same pt. 165 after EFA supplementation.

Complications TPN • Catheter in wrong place • Sepsis • Deficiencies – EFA def – trace minerals - added routinely

Complications TPN • Metabolic complications – overloading – imbalances

Complications TPN • Overloading – solute or fluid - meas. Serum osmolality – CHO, fat, amino acids

Complications TPN • Imbalances – glucose intolerance – hypokalemia – reactive hypoglycemia – hypophosphatemia – hypo or hypermagnesemia

Refeeding Syndrome • Too aggressive administration after ‘starving’ • Hypokalemia • Hypophosphotemia

Transition Feeding • Parenteral to enteral – start enteral slow – keep TPN going & decrease as increase enteral – receive 75% from enteral before stop TPN

Transition Feeding • Parenteral to oral – start oral and slowly decrease TPN – be careful of hyperosmolality of common clear liquids – receive 75% of needs before stop TPN

Transition Feeding • Enteral to oral – ?? – mOsm/kg for different clear liquids be careful not too high

TPN END • Questions? • Now for calculations

Prior to 1968, many chronically/critically ill pts died of malnutrition; not 1˚ condition Parenteral nutrition, meeting all or part of pts nutritional needs via intravenous feeding, met a great medical need. Improperly managed, PEN has serious complications including liver dysfunction, bone diseases, kidney failure, and MANY nutrient deficiencies.

Ingredients to be considered in PN CHO Protein Lipids Vitamins Minerals Trace Elements FLUIDS

Composition of intravenous solutions Crystalline amino acids: 10 & 15% stock Sol’n Normal and special purpose formulations Available (renal= essential aa [ ], liver dz= High BCAA) 4.0 kcal/g Carbohydrate: Dextrose= 3.4 kcal/g Available in 2.5 to 70% sol’n

Lipid: Provides essential fa (linoleic, linolenic) 10% = 1.1 kcal/ml (500 ml bottle = 550 kcal) 20% = 2.0 kcal/ml (500 ml bottle = 1000 kcal) EFA Requirements can be met: 500 ml of 10% lipid emulsion 2 to 3 times/ week or 200 ml per day

Substrates in Parenteral Nutrition Substrate

Usual Amount (% of kcals)

Maximum Units

Carbohydrate

40-60%

< 5 mg/kg/day

Protein (CAA)

1-2 gm/kg/day

2-2.5 g/kg/day

Lipids

20-40%

2 g/kg/day < 1 g/kg/day in High Stress

Calculating the Nutrient Content of IV Solutions Example:

Pt receiving 3 liters consisting of: 1500 ml 50% dextrose (3.4 kcal/g) 1500 ml 7% CAA (4 kcal/g)

CHO:

50 g/100 ml = x g / 1500 ml x = 750 g dextrose x 3.4 kcal/g = 2550 kcal

Protein:

7 g/ 100 ml= x g / 1500 ml x = 150 g x 4.0 kcal/g =

Total

=

420 kcal 2970 kcal

Types of Parenteral Feedings Simple IV Solutions Composition: Use: Nutrients:

Water, Dextrose, Electrolytes

When pts are NPO after surgery, trauma or illness. 5% dextrose in normal saline (0.85% NaCl) often used. % means “grams per 100 mL” 3 liters delivers 150 g dextrose or ~500 kcal per day.

Types of Parenteral Feedings Peripheral Parenteral Nutrition (PPN) Use:

Short-term nutrition support for those with normal renal fxn and normal fluid/ electrolyte regulation. Can be used to supplement diet of those with limited oral intakes.

Composition:

Crystalline amino acids, dextrose, lipid emulsion, MVI, electrolytes, trace elements.

Types of Parenteral Feedings                                        PPN (con’t) Lipid Emulsion typically provides ~50% of kcals (Isotonicity of lipids helps peripheral veins tolerate  the hyperosmolar dextrose solutions) Prolonged IV lipids can cause hepatomegaly, enlarged spleen, dyslipidemia. Can deliver ~2500 kcal and ~ 150 g CAA via PPN.

Total Parenteral Nutrition by Central Vein Placed in large diameter central vein or threaded to central vein via catheter (PICC). Who are candidates? Paralytic ileus due to surgery, radiation trt, GI obstructions, etc. AIDS Unusable GI tract expected > 14 days (e.g. hypermetabolism, severe N/V) Severe pancreatitis Intractable diarrhea or vomiting High output enterocutaneous fistulas

Mr. Rossi, 37 yo mail carrier Admitted to hospital for deteriorating GI due to Crohn’s Appearance:

Emaciated, face appears drawn

Medical Prognosis:

Poor; recommend small bowel resection. Serum Albumin: 2.5 mg/dL

What Factors indicate need for Nutriton Support?

3.

1.

Lack of functional GI tract.

2.

Chronic GI disorder (Crohn’s Dz) Evidence of protein-energy malnutrition (e.g., physical signs, low serum albumin)

Mr. Rossi is placed on central TPN prior to surgery. WHY? Surgery in high risk PEM pts can exacerbate the condition

Because surgery produces catabolic stress that can further deplete somatic protein stores.

What are the goals of TPN? •

Stabilize nutritional status in in post-operative period.

•

weight restoration (improved nutritional status)

•

Increased strength and endurance.

Use the GI tract (begin enteral feeding) as soon as bowel function returns.

Rossi received three (3) liters of a solutio aining D50 W and 10% amino acids.

W = 50 g dextrose per 100 mL

=

250 g dextrose per 500 mL bottle =

250 g x 3.4 kcal/gram = 850 kca 500 mL bottle

Protein: 10% amino acid sol’n= 10 g / 100 mL or 50 g/500 mL bottle 50 g X 4.0 kcal/gram = 200 kcal per 500 mL bottle

Lipids: 1- 500 ml bottle 10% emulsion X 3 per week 500 mLs X 1.1 kcal/mL = ~500 kcal

How will Mr. Rossi be started on central TPN? Slowly!

Hyperosmolar solution!

Starting rate?

40 mL per hour for 24 hours

Increase one liter per day until desired volume per 24 hours is reached. MONITOR!

Blood glucose, electrolytes!

Transitioning Mr. Rossi to Enteral Diet When?

If >60% of kcals is being met by enteral formula, oral intake of solid food, or both TPN can be discontinued.

If solid foods are consumed BUT, after 3 days intakes are <50% of needs, START enteral feedings.

1.

Maintenance of the gut barrier.

2.

Improvement in immune function.

3.

Maintenance of digestive and absorptive function.

4.

Promotion of secretion of gut trophic hormones.

1.

Catheter-Related Problems: Sepsis: infection in bloodstream resulting from contaminated catheter or catheter site. Others: pneumothorax, air embolus, arterial puncture, et al.

2.

Metabolic Problems: Hyperglycemia, glycosuria, compromised respiratory function mineral and electrolyte abnormalities Elevation of hepatic enzymes (usually 2˚ to FATTY LIVER)

3.

GI Complications: GI Atrophy (Disuse Atrophy)

Sample TPN Calculation: 60 yo male with small bowel resection 5’10” (178 cm), 140# (63.6 kg) 1.

Estimate daily energy needs: 35 kcal/kg x 63.6 kg = 2230 kcal/day

2.

Estimate daily protein needs: 1.5 g/ kg x 63.6 kg = 95 kg or 95 g/ 6.25 = 15.3 g Nitrogen

3.

Estimate Fluid Needs: 30 mL fluid/ kg x 63.6 kg = 1910 mL

4.

Based on these data, assume a final volume of 2,000 mL or 2 L will be used. Assume <10% of total volume will be used for additives.

5.

Two more assumptions:

25% of kcal from fat

Standard solutions: 20% lipid, D70 W, 10% AA

Lipids Calculation: 2230 kcal/ day X 0.25 (25% of kcal) = 560 lipid kcals 560 lipid kcals X 1 mL/ 2 kcal (20% lipid emulsion) = 280 mL/ day or 140 mL in each liter

Calculate Amino Acids: 95 g protein/ day X 100 mL/ 10 g AA = 950 mL 10% AA or 475 mL per liter Options:

Can either count or NOT count protein kcals in total. In either case, must KNOW how much will be delivered to prevent UNDERor OVER-feeding.

If we assume we will NOT include protein kcals: 75% of kcals will be met from DEXTROSE. 2230 total kcals X 0.75 = 1675 kcals from dextrose 1675 dextrose kcals X 1 gram/ 3.4 kcal/gram = 495 grams dextrose/day

Volume of D70 W needed: 495 grams dextrose X 100 mL / 70 g = 710 mL 70% D/ day or 355 mL/ L of TPN solution Based on above: Each liter contains-140 mL 20% lipid emulsion 475 mL 10% AA solution 355 mL 70% dextrose 30-70 mL additives

Use this info to calculate FINAL [ ] of nutrients: Lipids: 140 mL/ liter X 20 g lipid/ 100 mL X 1 L/ 1000 mL = 0.028 g lipids/ mL X 100 mL = 2.8% lipids

Amino Acid [ ]: 475 mL / liter X 10 grams AA / 100 mL X 1 L / 1000 mL= 0.0475 g AA/ mL X 100 = 4.75% amino acids Dextrose [ ]: 355 mL/ liter X 70 g dextrose / 100 mL X 1 L / 1000 mL = 0.2485 g dextrose/ mL X 100 = 24.85 % AA

Summary and TPN Order Total Volume= 2,000 mL / 24 hrs; 83 ml/ hr. Nonprotein energy:

Protein: Kcal: N ratio =

2235 kcal (25% lipid, 75% dextrose)

95 grams 2235 nonprotein kcal/ 15.3 g N = 146: 1

Sample TPN Order: 2 L/ day of 25% dextrose, 2.8% lipid emulsion, and 4.75% amino acid solution with STD additives to run at 83 cc/hr.