Week 3 Nutrition

Malnutrition → Starvation Related

• Prolonged duration of inadequate intake or feeding intolerance

• Chronic process with unintentional weight loss

  • Inadequate food supply

  • anorexia nervosa, other eating disorders

  • depression

  • feeding aversion

Malnutrition → Disease Related

• Disease associated with inflammatory state which results in increased energy or protein needs

• Chronic

  • > 3 months

  • IBS, Cancer, Organ failure, CF, malabsorption

• Acute

  • < 3 months

    • burns, trauma, brain injury, major surgery, infection

Malnutrition Screening Questions

1. Has there been recent weight loss of at least 5-10% within 6 months?

2. Has there been inadequate intake for at least 1-2 weeks?

• Yes to either → referred for full nutritional assessment

AdjBW Equation

• For 40% Adjusted weight:

AdjBW = IBW + 0.4(TBW-IBW)

BMI Equation

BMI = weight (kg) / height (m)²

BMI = weight (lbs) / height (in)² x 703

Normal to Class 3 Obesity BMI’s

Normal → 18.5 - 25 (ABW is 90-120% IBW)

Overweight → 25 - 30 (ABW is 120-150% IBW)

Class 1 + 2 Obesity → 30 - 40 (ABW is 150-200% IBW)

Class 3 obesity → >40 (ABW is >200% IBW)

Underweight BMI’s

Underweight → < 18.5 (ABW is <90% IBW)

• Mild → 17-18.5 (ABW is 80-90% IBW)

• Moderate → 17 - 16 (ABW is 70-80% IBW)

• Severe → < 16 (ABW is <70% IBW)

Diagnosis for Malnutrition

• Insufficient intake of calories

  • <75% of daily needs for at least 1-2 weeks

• Unintentional weight loss

  • 10% BW in 6 months, 5% in 1 month

Estimated Patient Energy Goals (kcal) → Neonates

• 80-120 kcal / kg / day

Estimated Patient Energy Goals (kcal) → Pediatric

• Child → 60-90 kcal / kg / day

• Adolescent → 40-55 kcal / kg / day

Estimated Patient Energy Goals (kcal) → Adult

• 20-30 kcal / kg / day

• Obese (IBW) → 22-25 kcal / kg / day

Fluid Requirements → Neonates

• 60-80 mL / kg / day titrated to → 120-150 mL / kg / day

Fluid Requirements → Pediatrics

• 4-2-1 Method

  • first 10 kg → 4mL / kg / hour

  • next 10-20 kg → 2mL / kg / hour

  • >20kg → 1 mL / kg / hour

Fluid Requirements → Adults

• 30-40 mL / kg /day

Enteral Nutrition Initiation Timing

• High-risk, malnourished, ICU → 24-48 hours

• Low risk, well nourished, expected to resume oral intake within 5-7 days of admission → delay in initiation (up to 5-7 days)

Parenteral Nutrition Initiation Timing → Adults

• Well-nourished, unable to achieve EN goal → 7 days

• Nutritional at-risk → 3-5 days

• Severe malnutrition → Initiate ASAP

Parenteral Nutrition Initiation Timing → Pediatrics

• Infants (1-12 months) → initiate 1-3 days (if unable to tolerate EN)

• Children/Adolescents (1-18 years) → initiate within 4-5 days (if unable to tolerate EN)

Parenteral Nutrition Initiation Timing → Neonates

• Pre-term, very low birth weight neonates → initiate promptly after birth

  • Only case where PN nutrition is an “emergency”

Refeeding Syndrome

• Occurance of electrolyte abnormalities in severely malnourished patients during rapid initiation of nutrition

• Insulin release results in rapid intracellular shift of—

  • Potassium

  • Magnesium

  • Phosphate

• Start slow, and ramp up over 5-7 days

Reasons to use EN over PN

• Decreased risk of complications such as infection

• Improves wound healing and immune function

• promotes physiologic function (endocrine, pancreas, biliary)

• preserves gut integrity

Gastric vs. Small Intestine EN Route

• Gastric tube

  • most utilized and physiologic

  • risk for aspiration with delayed gastric emptying

• Duodenal & Jejunal tubes

  • safer for patients with aspiration risks

  • more difficult to insert

  • smaller tube → can only do continuous feeds

EN Routes

• Nasal → temporary use, manually at beside

• Abdominal Wall → chronic use, surgical placement

• NG or OG → nose or mouth, feeds into stomach

• NJ or ND → nose, feeds into jejunum or duodenum (small intestines)

• G Tube → abdominal wall, feeds into stomach

• J Tube → abdominal wall, feeds into jejunum (small intestines)

Bolus & Continuous Feeds

• Bolus

  • Only for use with gastric tubes

  • Most physiologic

  • 240 - 500 mL’s per feed

  • cramping, N/V/D, aspiration

• Continuous

  • J-tubes

  • Well tolerated

  • 20-50mL / hour

Enteral Tubes + Medications

• Each med should be crushed / opened

  • mix with 15-30 mL water

  • rinse with 5-15mL water

• Liquid dosage forms can be utilized

• Certain meds need to be held for 1-2 hours before and after EN administration

  • Phenytoin

  • Fluoroquinolones & Tetracyclines

  • Levothyroxine

  • Warfarin

EN Formulas

• Standard Polymeric → meets needs of majority of patients

• High protein → patients with higher requirements

• High caloric density → patients with fluid or electrolyte restrictions

  • less electrolytes per calorie

  • less fluids

Gastrointestinal Tolerance of EN

Diarrhea (>3 liquid stools per day)

• Reduce rate of feed

• discontinue pro-kinetic med

• lower osmolality, add fiber

Bloating, Abdominal distension

• add pro-kinetic drug

• consider post-pyloric site of administration

• switch to continuous feed instead of bolus

• reduce volume of bolus

• slow the rate of administration

EN Bolus Rates

• Initiation → 120mL every 4 hours

• Increase by → 30-60 mL every 8-12 hours

• Max → 240-500mL every 4-6 hours

EN Continuous Feeds Rates

• Initiation → 20-50 mL/hour

• Increase by → 10-25mL/hour every 4-8 hours

• Max → 50-125 mL/hour

Complications of PN Therapy

• Metabolic

  • Hyper/hypoglycemia

  • Electrolyte imbalances

  • Hypertriglyceridemia (fat directly introduce to blood steam)

  • Liver function (acute LFT elevation, chronic alkaline phos/bilirubin)

• Mechanical

  • Thrombus (clot)

  • Phlebitis

• Infection → central line

Peripheral Line PN

• Pros

  • short term duration, bedside insertion

• Cons

  • Increased risk of phlebitis

  • 900 mOsm/L max osmolality

  • Not suitable for long term use

Peripherally Inserted Central Line PN

• Pros

  • Beside insertion with tip in superior vena cava

  • Short - medium duration

• Cons

  • May require radiologist guided placement

  • Increase risk of DVT

  • limits patient activity, easily infected

Central Line PN

• Pros

  • long term duration

  • minimal restrictions

  • Easier hidden and self care

• Cons

  • surgical placement

3 in 1 PN

• Contains all 3 macronutrients in 1 bag

• Increased risk of cracking / oiling out

• Adult use

2 in 1 PN

• Only has A.A. and dextrose, lipids in separate bag

• Pediatric use

Amino Acid Information

• 4 Kcal / g

• 100 mOsm per % of a.a.

Nitrogen Balance

• Goal → achieve positive nitrogen balance (anabolic state)

• Nitrogen In → grams of protein / 6.25

• Nitrogen Out → Urine Urea Nitrogen + 4 (insensible loss)

• Equation = Nitrogen In - (Nitrogen out +4)

  • negative value = catabolic state, need to increase protein intake

Dextrose Information

• 3.4 kcal / gram

• 50 mOsm per % of dextrose

• D70W (70%) used for compounding

Lipid Emulsion Information

• Intralipid / Nutralipid 20%

  • 2 kcal / mL

  • Soy bean based

• SMOF-lipid 20%

  • 2 kcal / mL

  • soybean, fish oil

• Omegaven 10%

  • 1.1 kcal / mL

  • Fish oil

• All have egg allergy concern

• Must have 1.2 um (micron) filter

• maximum hang time of 12 hours for one bag

Calcium-Phosphate Precipitation

• When compounding:

  • phosphate first

  • calcium last

• Factors that affect solubility

  • concentration

  • high pH

  • high temp

  • long hang time

Anion Balance

• All positive cations must associate with negative anion

  • chloride

  • acetate (bicarb)

• Ordered as ratios or mins/maximums

  • 1:1, 2:1, 1:2, maximum acetate, etc..

• Considerations

  • Metabolic ACIDOSIS → maximum acetate, decrease chloride

  • Metabolic ALKALOSIS → maximum chloride, decrease acetate

Compatibility (3n1 Solutions)

• Creaming → safe to use, reversible with gentle agitation

• Cracking → unsafe, irreversible separation

• Minimum for Stability

  • AA 4%, Dextrose 10%, Lipids 2%