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 Hydrolyzed-- $$
foods!!!!! $ Protein delivered as
small peptides/ AA for
Modular those with compromised
Contain a single nutrient digestive function.
(pro, CHO, lipid)
Combined to meet unique Often low in fat
needs of each pt
Used least often, $$$$$
 Nutrient Content of Enteral Formulas

Caloric Density
(kcal per ml or cc)

0.5 1.0 1.5 2.0

Normal formula

Energy Needs Met in

For pts with damaged or
atrophied GI tract. Smaller Volume:
• Kcal needs high
Dilute formulas allow for • Low appetite
recovery of GI function. • Volume Restricted
 Important Considerations: Physical Properties

Formula Osmolality (# of osmotic particles per Kg of solvent)

Hypotonic Isotonic Hypertonic

280-320 mmol/kg May cause

Osmolality of human gastric
plasma retention;
Example:
0.85 % sodium chloride in duodenum,
or “normal saline” may cause
fluid shift,
5% glucose solution diarrhea,
( 5 g per 100 ml) 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

Standard Procedure: use full-strength formula

but control flow rate!

Nasogastric Feedings:
start slow: 25-50 ml/ hour

increase 10-25 ml per 8-24 hrs.

Measuring Residuals: withdrawing formula left in stomach

using a syringe

if 100-150 ml remain, no add’t feeding.

 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 Maximum

(% of kcals) Units

Carbohydrate 40-60% < 5 mg/kg/day

Protein (CAA) 1-2 2-2.5 g/kg/day

gm/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 = 420 kcal

Total = 2970 kcal

 Types of Parenteral Feedings

Simple IV Solutions

Composition: Water, Dextrose, Electrolytes

Use: When pts are NPO after surgery,

trauma or illness.

Nutrients: 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?

1. Lack of functional GI tract.

2. Chronic GI disorder (Crohn’s Dz)

3. 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.
Mr. Rossi received three (3) liters of a solution
containing D50W and 10% amino acids.

D50W = 50 g dextrose per 100 mL

= 250 g dextrose per 500 mL bottle

kcal = 250 g x 3.4 kcal/gram = 850 kcal per

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, D70W, 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 UNDER-
or 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 D70W 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: 2235 kcal (25% lipid, 75%

dextrose)

Protein: 95 grams
Kcal: N ratio = 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.