nutrition support

1. Nutrition Support

3. Enteral Nutrition By way of the GI tract Could be Oral Supplements Tube Feedings Nasogastric Nasoduodenal or nasojejunal Enterostomies Gastrostomies Percutaneous Endoscopic Gast.(PEG) Jejunostomies Multiple Lumen tubes

4. Selecting an Oral Supplement 1. Degree of inability to meet needs 2. Presence or absence of dysphagia 3. Taste preference or sensitivity 4. Availability of labor and resources for preparation 5. Tolerance to lactose or other components 6. Tolerance of osmotic load

5. Supplement Components Kcals: 250 kcal/ 240 ml portion is the norm Fat: Usually Long Chain Triglycerides Could be MCT if pt doesn�t tolerate fats Protein: 8 to 14 grams of intact protein CHO Form varies: Simple adds sweetness and osmotic load

6. Tube Feedings: Route of Access Several Factors: 1. Length of time required Short term: usually through nasopharynx Longer term through enterostomal routes 2. Risk of aspiration 3. Degree of digestion available 4. If there is a planned surgical intervention

7. Nasogastric Route Nasogastric Tube: simplest access Pt requires functional GI tract and normal gag reflex French = .33 mm Can be large bore tube (French #12+) Used for food, medications and gastric suctioning or Small bore, pliable tube (5 French) Greater comfort, but more easily clogged

8. Nasoduodenal or Nasojejunal Tube threads through stomach to duodenum or jejunum Migration from stomach to duodenum via peristaltic waves may take a few hours to days Radiologic verification is required Small bowel feedings require careful selection of enteral formula

9. Enterostomies Surgical Gastrostomy Catheter is placed through the abdominal wall into the stomach A balloon is inflated to hold the catheter in place in stomach Requires good gastric functioning Can be associated with skin erosion, leakage of gastric contents leading to peritonitis

10. Surgical Jejunostomy Needle jejunostomy(temporary) Catheter jejunostomy(more permanent) both reduce risk of pulmonary aspiration small lumen size of tube difficult to maintain so not often performed

11. Fluid requirements 1ml of water per kcal 35 ml/kg usual body weight Formulas contain 80 to 85% water may need to add water as an additional flush

12. Osmolality Intact formulas fall between 300 to 500 mOsmol/kg , approx the same as body fluids No real concerns with fluid shifts Hydrolyzed formulas are often higher up to 900 mOsmol/kg contributes to extra fluid and electrolyte loss diarrhea Proper administration is key

13. Administration of Enterals Continuous drip Intermittent drip Bolus feeding

14. Continuous Drip Estimated total kcal needs are made Rate per hour determined based on the kcal content of formula 2000 kcals needed per day Formula has 1kcal/cc 2000kcal/1kcal/cc= 2000 cc�s needed 2000cc/24 hrs=83cc�s/hr is set as the goal volume

15. Administration of Continuous Drip Caution when initiating tube feeding If the gut has not been used lately If the formula is hyperosmolar Feedings are typically started at 30 to 50 cc�s/hr Then advanced 25 to 30 cc�s/hr every 8 to 12 hours until the target rate is obtained Feedings of 300 to 500 mOsmol/kg can be started at full strength; hyper start slowly

16. Admin of Tube Feeding If intolerance: decrease to previous increment and advance as tolerated Don�t hang a bag for days Food born illness Don�t add new formula on top of old formula Bag should be changed daily

17. Administration of Tube Feedings If fed into stomach, stomach contents checked every 4 to 8 hours if residual volume exceeds 100 ml, stomach isn�t emptying quickly and volume admin should be reduced Risk of pulmonary aspiration

18. Intermittent or Bolus Feedings Quality of Life: A more normal lifestyle with intermittent feedings Frees pt to be mobile Figuring intermittent or bolus feedings similar to continuous Total Kcals determined Divided by number of hours feeding General: 4 to 6 feedings @ 20 to 60 min

19. Administration of Bolus or Intermittent Feeding Residuals checked more frequently: every 2 to 4 hours Few pts can tolerate more than 450 ml per feeding Pt needs to be monitored for several potential problems

20. Monitoring Tube Fed Pt Weight 3 x wk Signs of Edema daily Signs of dehydration daily Fluid In/Out daily Cal, Pro, fat, CHO, vit & min 2+/wk N balance (24-hour UUN) weekly Gastric residuals (2 to 4 hrs)

21. Monitoring Tube Fed pt Stool output and consistency (daily) Urine Glucose (every 6 hours until rate is established then daily for Db pt) Serum electrolytes, BUN, creatinine, blood count (2-3 x wk) Blood chemistry: total protein, albumin, pre-albumin, Ca, Mg, P, Liver Fxn weekly

22. Tube Feeding Problem Pulmonary Pt with 1800 kcal need No renal problems or fluid restrictions gastrostomy in place Tube feeder with Pulmocare Pro: casein; CHO: cornstarch and sucrose; Fat: mixed triglycerides 1.5 kcal/ml; 55.2 % kcal from Fat; 28.1 % kcal from CHO;62.5 g Pro/1000cc�s; 78.5% water ? How much Pulmocare?; how much fluid;Pro?

23. Use Nutrition Care Manual http://nutritioncaremanual.org

24. Pulmocare Problem Osmolality is 475 mOsmol/kg How would you administer this? What would you monitor to determine tolerance? What would you monitor to determine if needs were met?

25. Parenteral Nutrition If pt is unable to receive nutrients via the GI tract Then Parenteral Nutrition is Appropriate

26. Parenteral Access Peripheral Access: Arm (or leg) 900 mOsm/kg upper limit of acceptable Higher concentrations cause vein to become inflamed and collapse. PICC(Peripherally Inserted Central Catheter) Higher concentration is possible End of lumen is threaded to a larger vessel with greater dilution capacity

27. Parenteral Access Short Term Central Catheter Subclavian vein central catheter line inserted into Subclavian and threaded to the superior vena cava Provides maximum dilution of parenteral solution and no damage to the vein lumen Risk of infection

28. Parenteral Access Long-term Access When access is required for many months or longer, a permanent catheter is surgically placed A port is imbedded under the skin which is accessible

29. Terminology with Parenteral Solutions D Dextrose W Water NS Normal Saline (0.9%) NaCl solution 0.9 g NaCl/ 100 ml D5W 5% Dextrose solution in water (5 g Dextrose in 100 ml water) D51/2 NS 5% Dextrose in 1/2 Normal Saline (0.45 g NaCl in 100 ml Water)

30. Nutrients in Parenteral Soln Protein Combination of essential and non-essential aa�s Generally 15 to 20 % of total Kcal needs in most solutions Often a 10% amino acid solution is used 10 g / 100 ml which represents 100 grams/liter Final concentration often expressed as the con in the final volume after mix with CHO and Fat

31. Fat in Parenteral Soln Usually comes in 10% or 20% solutions 10 % represents 1.1 kcal/ml 20 % represents 2.0 kcal/ml Usually composed of safflower, soy oils with lecithin as an emulsifier to hold in solution Generally 20 to 30 % of Kcal Don�t exceed 60% (2.5 g/kg/d)

32. CHO in Parenteral Solution Dextrose monohydrate D Glucose Concentrations range from 5% to 70% Shouldn�t exceed 5 mg/kg/min Used to spare protein and provide kcals

33. Calculation of Osmolality Dextrose grams/l x 5 Protein grams x 10 Fat is isotonic so no osmotic force electrolytes further add to osmolarity 50 g of dextrose plus 30 grams of protein (50 x 5) + (30 x 10) = 550 mOsm/l

34. Indications for Peripheral Vein Feedings 1. Short term: enteral feeding again in 7 d 2. Transition with enteral feeding 3. Mild to mod malnutrition:supplemental nutrition needed 4. Normal or mild elevation of metabolic rate 5. No organ failure or fluid restriction

35. Indications for Central Vein Feeding 1.Unable to enteral feed for 7 + days 2. Mod to severely elevated metabolic rate 3. Moderate to severe malnutrition 4. Cardiac, renal, or hepatic failure or other conditions limiting fluid 5. Limited access to peripheral veins 6. Able to access central vein

36. Compounding Methods Two methods of prescription compounding: 1. All components except fat 2. All components including fat May be batch mixed to save money or may be individually prescribed and mixed Is done by pharmacist in aseptic conditions

37. Administration of TPN Continuous Infusion Initiate at 42 cc/hr or 1000 L/d increase incrementally until goal rate is reached over next two to three days If TPN is interrupted, infuse D10W or D20W until TPN can be restarted Guard against hypoglycemia

38. Cyclic Infusion To free individuals who are capable of mobility TPN for 12 to 18 hour infusion periods are possible. Allows pt to be mobile for 6 to 12 hours Cyclic administration is established incrementally

39. Monitoring and Problem Solving Actual intake of TPN is monitored Monitor Growth, weight Metabolic parameters Table 23-7 p549 serum lytes, BG, Hb, etc General Volume of infusate, oral intake, urinary output Infection Clin Observations: temp., WBC, cultures

40. Refeeding syndrome With intro of energy substrates following a period of no intake, may cause Refeeding Syndrome Shift of phosphorus, potassium from serum to intracellular sites for ATP production causes hypophosphatemia, hypokalemia Can be severe and life threatening Needs to be monitored and may require additional IV replacement of P and K

41. Transitional Feeding Parenteral to Enteral begin at 30 cc/hr increase 25-30 cc/hr every 8 to 24 hours Parenteral solution is reduced accordingly Parenteral to Oral Monitor oral intake; less predictable than above Reduce Parenteral accordingly Enteral to Oral Adjust to intermittent feeding first

42. Nutrition Support in Other Settings Long-term Care More happening in nursing facilities Home Care People are at home receiving nutrition support Concerns: motivation family�s ability to handle benefit of receiving nut support limitations such as physical

43. Ethical Issues End of life decisions Based on advance directives from patient What is the patient�s desire about end of life support? Standards and Guidelines American Society of Parenteral and Enteral Nutrition Guidelines for use of nutrition support

44. Problems 3 liters of D5W was given via peripheral IV over a 24 hour period. How many kcals did it provide? (1 gram Dextrose monohydrate= 3.4 kcals) (5 g/100ml) (1000ml/l)(3 l)(3.4 kcal/g)=510 kcal

45. Problem 2.5 l of 3.5% Dextrose (3.5 g/100ml)(1000ml/l)(2.5 l)(3.4 kcal/g)= 297.5 kcal

46. Problem 3 l of 25% Dextrose and 3.5% Amino Acids How many kcals and % kcal from each? (25g/100ml)(1000ml/l)(3 l)(3.4kcal/g)= 2550kcal from CHO (3.5g/100ml)(1000ml/l)(3 l)(4kcal/g)= 420 kcal from PRO Total = 2550 + 420 = 2970; 2550/2970=86% from CHO and 14% PRO

47. Problem 500 ml of 10% fat emulsion distributed in 2.5 l of TPN solution which has a final concentration of 20% Dextrose and 3.5 % Amino acids. How many total kcals and what % from each energy nutrient? (20 g/100ml)(1000ml/l)(2.5 l)(3.4 kcal/g) = 1700 from CHO (3.5 g/100ml)(1000ml/l)(2.5 l)(4 kcal/g) = 350 from PRO

48. Problem (cont) 10% fat emulsion = (1.1 kcal/ml) (500 ml)= 550 kcal from Fat Total = 1700 + 350 + 550 = 2600 kcal 1700/2600 = 65% from CHO 350/2600 = 13.4% from Pro 550/2600 = 21 % from Fat

49. Nut Assessment Pt requires 2200 kcal 60% kcal from CHO 25% kcal from fat 15% kcal from PRO How would you formulate this? Fat first: you need 2200 x .25 = 550 kcal 10 % fat emulsion @ 1.1 kcal/ml 550 kcal/ 1.1 kcal/ml = 500 ml 10% soln

50. Nut assessment Final volume of 2000 ml Fat contributes 500 ml 1500 ml for PRO and CHO 2200 kcal x .6 = 1320 kcal/3.4 kcal/g= 388 g CHO/1500 ml = 25 % Dextrose solution 2200 kcal x .15 = 330 kcal/4kcal/g = 82.5 g PRO/1500 = 5.5 % aa solution final concentration