EN/PN/Critical Care MNT

french size

diameter of tube

indications of use for EN

functional GI tract

inadequate oral intake

advantages of EN

cost effective

less infections

reduced surgical interventions

maintenance of GI function and integrity

Nasogastric EN

3-4 weeks

can be kept longer but need to switch nostrils

Nasoduodenal/Nasojejunal

if nasogastric not tolerated

abdominal distinctions vomiting persistent diarrhea

EN placement for varices

nasogastric

Percutaneous endoscopic

PEG/PEJ

longer than 3-4 weeks

placed w/ minimally invasive techniqures

multi-lumen tubes

importance of osmolality and viscosity of EN

if osmol is too high —> dumping syndrome

if viscosity is too high —> clog tube

EN protein % and sources

6-37%

whey or soy isolate

EN carbs % and sources

30-85%

corn syrup and sucrose

sucrose not added if solely EN

EN lipid % and sources

1.5-55%

canola, soybean, safflower oil

EN % calories from linoleum and linolenic acid and why

2-4%

MCT do not provide these fatty acids

formula selection cascade

review medical history —> calc nutrient prescription —> determine primary medical and nutrition concerns —> select formula, feeding route, and administration pattern —> calc the volume and rate

polymeric formula

standard

intact macronutrients

requires normal digestive and absorptive capacity

lactose free

partially hydrolyzed or elemental/defined formulas

readily absorbed nutrients and low residue

disease specific formula

designed for specific nutrient needs cause by injury or disease

modular formula

consist of single nutrients that can be used to enhance a standard formula or multiple nutrients that can be combined to produce complete macronutrient formula

blenderized formula

traditionally home made but now commercialized options available

improved tolerance

more expensive

intact fiber —> better for microbiome

kcal/ml for EN formula

1-2 kcal/ml

what formulas have higher osmolality

concentrated formulas of >1.5 cal/ml

partially hydrolyzed

osmol of isotonic formula

290-300 most/kg

enteral formula osmolality range

300-700 most/kg

relative macronutrient content

percent of energy

absolute macronutrient content

gram amount

water content of formula concentrations

1 kcal/ml ~ 85% water

1.2-1.5 kcal/ml ~ 69%-82% water

1.5-2 kcal/ml ~ 69%-72% water

bolus feeding cycle

5-20 mins, 3-4 times/day

intermittent feeding cycle

pump or gravity drip

4-6 feedings

20-60 mins

continuous feeding cycle

18-24 hours

started at 50% of goal and increased every 8-12 hrs to final volume

determining nutrient prescription for EN

estimate energy needs

determine protein needs

calculate/consider fluid requirements

determine fat and carb needs

consider micronutrients - may need to supplement if full volume can’t be administered

closed system

large volume of set formula

open system

empty bag that can be filled w/ whatever

complications of EN

access problems

administration problems

gastrointestinal complications

metabolic complications

monitoring and evaluation of EN support

body weight

abdominal distention/discomfort

fluid balance

nutritional intake adequacy

electrolytes, substrates, other lab values

stool output/consistency

gastric residuals (higher residual is not an indication of intolerance)

nutrition focused physical exam

EN documentation

all information is embedded in nutrition care plan/documented in med record

volume of feeds and fluids received

tolerance

stool output

nutrition related labs

necessary adjustments, recommendations

indications for PN use

patient unable to meet nutritional needs orally or enterally

2-in-1 PN solutions

dextrose and amino acids

lipids infused separately

3-in-1 PN solutions

dextrose, amino acids, and lipids or a total nutrient admixture (TNA)

multi-chamber bag technology

central parenteral nutrition

short and long term access

CPN

peripheral parenteral nutrition

PPN

short term access

peripherally inserted central catheter

PICC

often at antecubital area of arm and tip goes subclavian vein

risk is high because of implantation not the nutrition itself

osmolality (EN) vs osmolarity (PN)

osmolality - mOsm/kg used for body fluids

osmolarity - mOsm/ml used to calc IV fluids

PN protein concentration

compounded from 3-20% solutions

final concentration typically 4-5% and provide ~ 15-20% energy

PN carb concentration

compounded from 5-70% solutions

in solution as dextrose monohydrate and provides 3.4kcal/g, maximal dose 5-6 mg/kg/min

PPN - dextrose final concentration does not exceed 10% of infused solution

CN - dextrose final concentrations does not exceed 35% of infused solution

PN lipid

10%/20%/30% intravenous lipid emulsions

ILE: 1.1, 2.0 and 2.9 kcal/ml, respectively

max lipid infusion is 1g/kg/24 not exceeding 2.5g/kg

EFA 2-4% total can be provided with 10%kcal/day from fat

intralipid

contains 100% soybean oil

primarily omega 6

SMOF lipids

a mixture of soybean oil, MCT

olive oil and fish oil

higher concentration of omega 3

potential benefits of SMOF lipids

reduced cholestasis

improved liver function

lower liver enzymes

is iron routinely provided in parenteral nutrition mixtures

no

iron overload is a concern

not compatible with lipids

impaired immune function/enhanced bacterial growth

adverse interactions with medications

trace elements in PN

chromium

copper

manganese

zinc

selenium

cyclic infusion

infuse for 8-12 hours, typically at night

often used for home TPN patient

PN/EN complications

mechanical - air embolism, catheter misplacement, hemothorax

infection/sepsis - catheter site, contaminations, long term catheter

metabolic - electrolyte imbalance, EFA deficiency (topical lipids can prevent deficiency), hyper/hyopglycemia, hyperlipidemia

gastrointestinal - gastrointestinal atrophy, hepatic abnormalities, cholestasis

monitoring and eval of PN

consider suggested freq for initial period vs later period

initial period - full dextrose infusion is being achieved

later period - characterized by stable metabolic state of patient

specifics of refeeding syndrome

severe electrolyte fluctuations

salt and water retention

rapid movement of K to intracellular space

who is high risk for refeeding syndrome

alcoholic cirrhotics

cancer patients

liver disease

inadequate eating for 1 month or longer

transitional feeding

one mode of feeding is discontinued once 75% of nutritional needs are being provided by alternative form of nutrition support

ebb phase

occurs immediately after injury and is associated with hypovolemic shock

decreased tissue perfusion

decreased metabolic rate

decreased oxygen consumption

drop in BP and temp

insulin levels drop, glucagon increases

flow phase

follows fluid resuscitation and restoration of oxygen transport and consists of an acute and an adaptive response

increased cardiac output

increases oxygen consumption

rise in body temp and total body protein catabolism

catabolism predominates acute response

anabolism predominated adaptive response

cortisol

enhances skeletal muscle catabolism

glucagon

promotes gluconeogenesis amino acid uptake by the liver, urea genesis, protein catabolism

acute phase proteins

mobilization associated loss of lean body mass and negative nitrogen balance

starvation

decreased energy expenditure

muscle mass loss much slower

glycogen depleted in 24 hours

glucose produced from protein breakdown

lipolysis after 1 week of fasting —> ketosis

energy needs during stress

energy expenditure is markedly increased

activated by hormonal and cell signaling

normal adaptive response

driven by glucose need and availability

intent to spare lean body mass

doe snot occur during starvation associated w/ injury/trauma

energy and protein needs in critically ill patients

may approach 2 times predicted energy expenditure

protein - 1.5-2.5 g/kg

micronutrients and antioxidants

respiratory quotient to better estimate energy needs

substrate utilization

RQ values reflect the relative contribution of fat protein and carbs

RQ >1.0

overfeeding

primarily carb metabolism is occurring

RQ <7

underfeeding

primarily fat metabolism is occurring

physiological RQ range

.67-1.3

sepsis

documented infection with identifiable organism

systematic infection

systemic inflammatory response syndrome (SIRS)

widespread

inflammation usually present in areas of remote from primary site of injury affecting otherwise healthy tissue

multi-organ dysfunction syndrome (MODS)

complication common to SIRS that typically starts with lung failure followed by failure of liver, intestines, kidney (in no particular order)

inflammation/infection in organs remote from original injury

nutrition support in hyper metabolism

minimize catabolism

meet energy requirement (do not overfeed)

non-obese - 25-30 kcal/kg

obese - 14-18 kcal/kg

meet protein and micronutrient needs

1.2-2g/kg (up to 2.5 g/kg)

establish and maintain fluid/electrolyte balance

custom MNT (PO, EN,PN)

consider pharmaconutriton

physical therapy

exercise

permissive underfeeding

used in obese patients

provides 40-60% of estimated energy expenditure

protein increased

pros of permissive under feeding

reduced risk of complications (hyperglycemia/hyperlipidemia)

decreased duration of mechanical ventilation

improved gastrointestinal function

lower mortality rates in some studies

cons of permissive underfeeding

potential for malnutrition and nutrient deficiencies

may delay recovery in some patients

requires careful monitoring and adjustment

pharmaconutrients

glutamine, omega-3, arginine

abdominal compartment syndrome

increased intraabdominal pressure (secondary to trauma or sepsis)

hemodynamic instability

respiratory, renal, neurologic abnormalities

fluid losses, metabolic alterations, protein losses, increased caloric needs

may require pressor support and large volume fluid rescussiation

management of abdominal compartment syndrome

emergent decompressive laparotomy

abdomen kept open

monitor drain output

increase protein provisions

increase kcal

EN is possible but only if hemodynaically stable and gut is functional

major burns

source of severe trauma

may result in 100% increase of REE

exaggerated protein catabolism, increased losses

typically requires mechanical ventilation

nausea, anorexia, dysphagia

MNT for major burns

fluid resuscitation

energy needs increases depending on size of wound and age of pt

goal is weight maintenance

high protein needs 1.5-2 g/kg in adults

supplementing selenium, copper, and zinc, and reduce infection risk

vitamin C for collagen synthesis

MNT goals for surgery

administration of correctly formulated nutrition

prevention of malnutrition and nutrition optimization

preemptive PN or EN support

pre surgery

carb rich intake

• enhances glycemic control

• decreases loss of protein/lean body/nitrogen

post surgery

early EN results in optimal outcomes

reduce infection

reduce hospitalization

place tube feed in surgery

pressure ulcers

impeded capillary blood flow to skin and underlying tissue

calories and protein to prevent pressure injuries

30-35 kcal

1.25-1.5 g protein

stage I and II PI protein

1-1.4 g

stage III and IV PI protein

1.5-2 g