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Nutrition Support

August 15, 2007

Maria Brown, RD, CNSD
Nutrition Support Dietitian
Mount Sinai Hospital

Objectives
† Participants will be able to:
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Estimate calorie and protein needs for preand posttransplant patients
State 4 questions which can assist in
enteral formula selection
List 3 possible etiologies of Parental
Nutrition Associated Liver Disease
(PNALD)

Overview
† How much?
† When?
† Where?
† What?
† And What now?

of Enteral and Parenteral Nutrition

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fluid ‡ Energy: maintenance 30kcals/kg ‡ Protein: maintenance 0.2 gms/kg „ „ „ „ „ 35-40kcals/kg for weight gain A deficit of 500 kcals/day for weight loss 1. dry weight Peritoneal dialysis: 1.Pretransplant goals & requirements „ Maintain or improve nutritional status Maintain normal electrolyte levels based upon organ failure „ Pretransplant needs „ ‡ Dietary restrictions of Na.2 to 1. with inadequate po intake for >5-7 days „ Following severe trauma or burns Patients with a functioning GI tract who are orally intubated Trophic effects/Gut integrity ‡ „ „ Contributing factors: poor appetite or dysphagia 2 . † Indications for enteral nutrition: „ Malnourished patient with a functioning GI tract.5gms/kg Posttransplant Requirements † Posttransplant Needs: Energy: 30-35kcals/kg or 1. K.5 gms/kg est.3-1.8 to 1.5-2 gms/kg immediate posttransplant (if renal function is normal) 1gm protein/kg chronic post-transplant „ I Indications for enteral nutrition † Enteral nutrition provides a more physiologic route of nutrient administration than parenteral nutrition.5 x basal energy expenditure „ Protein: 1.3 to 2 gms/kg for repletion Hemodialysis :1. PO4.

Polymeric – „ „ „ contains intact proteins Used for patients with normally functioning GI tracts.low CHO.Enteral Access Devices † NGT. necessity for this is controversial 3 .may be elevated in PUFAs. OGT. volume restricted Diabetic. May have additional protein added or be fluid concentrated † Semi-Elemental/Partially Hydrolyzed „ „ Contains Peptides and/or amino acids For use when function of the GI tract is questionable † Disease Specific „ „ Renal – Electrolyte restricted. Naso-enteric- short-term (4-6 weeks) † PEG – percutaneous endoscopic gastrostomy † PEG-J (may be for both gastric decompression and feeding) percutaneous endoscopic gastrostomy with jejunal extension † DPEJ- direct percutaneous endoscopic jejunostomy † Surgical gastrostomy and jejunostomy Enteral tube materials „ „ „ Polyurethane used for short-term tubes stiff give a larger inner diameter with thin wall Silicone for longevity and comfort for longtern use Rubber tubes (Foley) should not be used due to the rapid deterioration of the material and the lack of an external retaining device Types of Enteral Formulations † Standard.

an amino acid diet (Meguid et al) Comparable results found in primates (Albina et al) Protein Composition † Standard „ Intact whole proteins ‡ ‡ Examples: soy protein isolate Requires the most digestion † Semi-elemental „ Hydrolyzed whole proteins to 2.5 chained peptides ‡ ‡ ‡ Partially hydrolyzed whey Whey protein hydrolysate Hydrolyzed casein † Elemental „ Crystalline amino acids 4 .4 QUESTIONS WHEN CHOOSING AN ENTERAL FORMULA: † Is the functionality of the GI tract compromised? „ Is a semi-elemental formula needed? † Is there a need for a high protein formula? † Is there a need for a water restriction? † Is there a need for a low electrolyte formula? When GI functionality Is Impaired † Small peptides in the di & tri form may have better absorption than amino acids „ „ Improved nitrogen balance and absorption in patients fed a partially hydrolyzed protein diet vs.

absorbed without bile emulsification and lipase for micelle packaging bypass the lymphatic system † Hence. and water boluses would be necessary „ Osmolality often increases with concentration. to improved compromised absorption.69% allowing for varying fluid needs „ If the patient does not require a fluid restriction. MCTs may be beneficial in states of pancreatic insufficiency. „ Sometimes a more concentrated formula may exacerbate delayed gastric emptying. 5 .Fat Composition † Fat provided a calorie-dense energy source that serves as a vehicle for fat-soluble vitamins and provides essential fatty acids † Most semi-elemental formulas are lower in fat and high in mediumchained triglycerides (MCTs). likely the amount of water in the formula will be inadequate to meet needs. † Common sources of fat in enteral formulas: „ „ „ „ „ † Soybean oil Canola oil Safflower oil Corn and fish oils Lecithin Fat content may range from <10% to >50% of total calories in a formula Fat Composition † Many of the semi-elemental formulas contain MCTs † MCTs are: „ „ „ more water-soluble. chylous ascites. MCTs do not require lipoprotein lipase or carnitine for mitochondrial absorption „ (required by LCT for hydrolysis at the cell surface) Water Content † Water concentrations of formulas range from 85%. or biliary disorders † After absorption.

Slightly better glucose control (not statistically significant) has been exhibited with use of lower CHO formulas The American Diabetes Association suggests either a standard formula or a lower carbohydrate formula may be used Need to determine which formula is most beneficial for the patient.Specific Formulas † Renal Formulas † Diabetic Formulas Renal Formulas † Lower in electrolytes and volume concentrated „ Need to ensure this composition is consistent with other treatments Diabetic Formulas † Often lower in carbohydrate 34-40% of kcals. Recommended CHO content of diets for patients with diabetes or glucose intolerance is 45-65% total kcals. however.Disease. 6 . contain fiber and are higher in fat „ „ „ „ „ This may be detrimental in a patient with gastroparesis.

Managing Complications of Enteral Nutrition † Impaired Gastric Emptying † Diarrhea † Electrolyte Imbalances † Feeding Tube Occlusion Impaired Gastric Emptying † Possible causes: „ Sepsis. consider an anti-emetic medication „ Diagnostic work-up for distension. „ Infusion of very cold formulas (rare) Impaired Gastric Emptying † Treatment: „ Elevate HOB 30-45 degrees „ Provide prokinetic agents „ Review current medications (opiates. If low. „ High fat and fiber formulas could delay emptying. Propofol) „ Change to a lower fat and fiber-free formula „ Administer at room temp „ If distended or nauseated. hypotension „ Post-op state „ Medications such as opiate analgesics and anticholinergics „ Surgical vagotomies „ Diabetic gastroparesis. check gastric residuals every 4 hours during a continuous feeding. if abd girth increases by > 8-10cm with feeding initiation „ Consider feeding into the small bowel 7 .

would equal about 188ml/hr with 35-55% of gastric contents being emptied per hour. 1500ml of saliva. „ Frequently 2. 2002. rate of delivery opportunistic infections 8 . † A physical exam checking for bloating.” (McClave) More on Gastric Residuals † Average daily secretions. † Checking residuals from a small bowel feeding is inappropriate as the contents of the small bowel continuously move and do not pool. . Diarrhea has been defined as > 500ml every 8 hours or >3 stools per day for at least 2 consecutive days † Potential causes: „ „ „ „ „ „ „ medications GI disorders or dysfunction malabsorption fecal impaction malnutrition composition of feeding.McClave. Gastric residuals may be checked Diarrhea Normal stool content 250-500ml/day. there is reasonable doubt about the validity of this practice and the amount at which action should be taken. 3000ml gastric juices. however. nausea and vomiting may indicate patients with impaired gastric emptying. consistent episodes of a residual >200ml or 250ml is recommended before decreasing enteral feeding rate † " Little data exist to support a correlation of gastric residual volume with gastric emptying. † Gastric residual volumes do not correlate to regurgitation or aspiration and their use cannot be relied on to protect patients against aspiration pneumonia. volume of gastric contents or changes in infusion of enteral tube feeding. distension.Checking Gastric Residuals † Checking gastric residuals is usually recommended.

† Hypertonic feeding formula? „ „ Unless infused at a very high rate. the same diet but with dilution so that the osmolality increased over 4 days from 145-430 and a 296 mOsm/kg formula. Medical † † † † assessment to rule out inflammatory causes. decrease rate to the last tolerated level. hypertonicity usually does not cause diarrhea. etc. Originates from "home brew" diets with 1200mOsm/kg via 500ml boluses 118 hospitalized patients were randomized to receive either a 430 mOsm/kg enteral formula. including sorbitol-containing elixirs can induce diarrhea. Begin parenteral nutrition but continue enteral nutrition for gut stimulation 9 . antineoplastic agents Diarrhea † Malnutrition: „ decreased enzymatic secretion from the stomach. pancreas and brush border and decreased proliferation. or bolused into the SB. fecal impaction. Prokinetic agents. (Keohane et al) Treatment of Diarrhea † Check for C diff or other infectious causes. lactulose and laxatives. Add an antidiarrheal agent once C Diff has been ruled out If GI function is impaired due to disease state „ Change to a peptide-based or elemental formula „ A formula containing a large percentage of provided fat in the form of MCT in addition to pancreatic enzyme replacement may be needed with pancreatic insufficiency If fluid and electrolyte losses remain excessive.Diarrhea † Medication induced: „ „ „ Antibiotics can reduce the numbers of colonic bacteria resulting in less gases and shortchained fatty acids that normally aid in absorption of electrolytes and water. stool softeners. height and maturity of intestinal villi. Phos and Mg containing meds. but rather leads to suboptimal nutrient delivery. Change from elixir form. Reduce or change possible offending medications. if possible. Also associated with C diff Hyperosmolar liquid forms of medicines. ‡ Their conclusion: Diluting formulas does not improve tolerance.

Enteral Feeding Tube Occlusion † Potential causes: „ congealing or clumping of protein of formula w/ meds „ gastric secretions mixed with formula in the tube from withdrawal of residuals „ microbial growth and colonization of the tube † Prevention: „ flush whenever feeds are stopped „ before and after residuals „ before and after meds „ Overall.Cannulation of the subclavian vein -Mogil & others 1968 .Crystalline amino acids were synthesized from soybeans and replaced protein hydrolysates.AMA published recommendations for standard amounts of parenteral minerals 1983 . flush with enough water to clear the tube. clamp for 5 min and flush † Special declogging devices „ should only be used by someone who has been trained in its use † Never use soda or juices as they may result in dried residues that further clog the tube History of Parenteral Nutrition † History of TPN : „ „ „ „ „ „ „ „ 1967 . 1975 .Lipids were re-introduced in the US 1979 .Growth in beagle puppies receiving IV nutrition 1969 .An infant girl received parenteral nutrition 1970s . Treatment of an Enteral Feeding Tube Occlusion † Warm water flushing † Flush with a mixture of pancreatic enzymes and bicarbonate „ one table Viokase.FDA approved TNAs 10 . one 324mg tablet of sodium bicarb mixed with 5ml water.American Medical Association published recommendations for standard amounts of parenteral vitamins 1976 .

specifically: „ Short Bowel Syndrome „ Intestinal obstruction and Paralytic Ileus „ Mesenteric ischemia „ Diffuse peritonitis „ Massive GI Bleed „ Proven intolerance to Enteral Nutrition „ GI fistula. except when enteral access can be placed distally or volume of output is <250ml/day „ Cancer patients in whom treatment is expected to cause gastrointestinal disturbances > one week Components of Parenteral Nutrition † Dextrose † Amino Acids † Lipid † Electrolytes. trace elements Dextrose † The optimal amount is that which is adequate to spare protein from catabolism for energy.4kcals/g Available concentrations range from 2. without causing hyperglycemia „ „ Dextrose provides 3. vitamins.Indications for Parenteral Nutrition † Enteral nutrition is contraindicated or the GI tract has diminished function or is inaccessible.5%70% 11 .

however.Amino Acids † Amino acid concentrations yield 4 kcals/gm. peripheral parenteral nutrition is not recommended for patients requiring fluid restrictions † Maximum recommended time for peripheral parenteral nutrition is 12-14 days. depends upon patient tolerance and amount of nutritional needs being met 12 . † Available in 3%. therefore.20% concentrations Lipid † Lipid provides essential fatty acids and a calorically- dense nutrient source † Parenteral lipid emulsions provide 10 kcals/gm † Most commercial preparations are made of LCT from soybean oil or a mixture of soybean and safflower oils † Egg yolk phospholid is present as an emulsifier „ „ Patients with egg allergies may have a reaction Contains approximately 6mmol of phosphorus/L † At least 2% to 4% of total calories should be provided from linoleic acid to prevent EFAD PPN † A maximum of 900 mOsm/L is recommended for peripheral parenteral nutrition administration „ „ „ Amino acids are the major contributor to osmolarity Frequently calorie and protein provision is inadequate Osmolarity can be reduced with an increase in volume.

precise etiology unknown † Overfeeding of overall calories from all nutrient sources † Essential Fatty Acid. cyclosporine.Complications of Parenteral Nutrition †Catheter-related Complications †Hepatic Complications †Metabolic Bone Disease (Long term ) †Electrolyte abnormalities Hepatic Abnormalities. warfarin. choline or carnitine deficiency † Bacterial overgrowth (exhibited in rats) † Elevated Manganese levels † An absence of intraluminal nutrients to stimulate bile secretion (cholestasis) † Phytosterol components of lipid solutions? Metabolic Bone Disease † Abnormal bone metabolism.Theories of cause. associated with long-term TPN. phenytoin and tacrolimus Lack of exercise and smoking 13 . which may lead to osteoporosis or osteomalacia. „ Characterized by hypercalciuria and hypercalcemia † Possible causes of MBD „ Chronic hypercalciuria ‡ ‡ ‡ „ „ „ „ chronic acidosis Al toxicity due to contamination more common in patients with SBS and IBD Chronic diarrhea and Vit D malabsorption Inflammatory process and cytokine activity Medications: corticosteroids. heparin.

MD: ASPEN. Gottschlich.26(6):S43-48 Keohane PP. 7. BMJ (Clin Res Ed) 1984:288:67880 Raman M. JPEN 2002. Attrill H. Clinical Use of Gastric Residual Volume as a Monitor for Patients on Enteral Tube Feeding.: Relation Between Osmolality of Diet and Gastroiintestinal Side Effects in Enteral Nutrition. 33:324-30 McClave SA. MD:ASPEN. loss of height. 5. Silver Spring. Snider HA. Landel AM. Nutritional Consideration in the Intensive Care Unit. back pain „ Provide adequate amounts of Ca. Gottschlich MM. 30(6):492-6. A Case. before initiating enteral or parenteral nutrition References 1. 9(2):189-95 McClave SA. Martindale R. et al. IA: ASPEN. 4. CCM 2005. Metabolic Bone Disease in Patients Receiving Home Parenteral Nutrition: A Canadian Study and Review JPEN 2006. The ASPEN Nutrition Support Core Curriculum.Metabolic Bone Disease † Prevention/Treatment „ Evaluate all patients receiving TPN of >1 year for physical signs: bone pain. TerzJJ. 8. often correct with free water or water restriction. et al. Akrabawi SS. 2001 14 . S. MM. if nutritionally stable) „ Minimize acidosis treat with acetate in TPN „ Minimize steroid use „ Obtain DEXA scan if low bone mineral density „ Promote routine low-impact exercise „ Encourage cessation of smoking Electrolyte Abnormalities † Sodium „ „ „ Correction based upon etiology of high or low Na.5 gm/kg. Dubuque. J et al: Nitrogen Utilization from Elemental Diets. 2005 Meguid MM. Effect of Elemental Diet on Albumin and Urea Synthesis: Comparison with Partially Hydrolyzed Protein Diet. J Surg Res 1984.Based Approach. Poor Validity of Residual Volume as a Marker for Risk of Aspiration in Critically Ill Patients. Silver Spring. 2007 Shikora. Schwaitzberg S. 3. 2002 Merritt R. et al. 6. 10. 37 (1):16-24 Albina. MD: ASPEN. The ASPEN Nutrition Support Practice Manual. Assess volume and Na content of IV fluids Sodium needs 1-2 mEq/kg † Potassium „ „ Potassium needs 1-2 mEq/kg Increase or decrease based upon value and factors that may be contributing to the imbalance † Adjust Mg and PO4 as needed „ „ Remember low K and Ca can be refractory to a low Mg Replete low electrolytes to normal. Silver Sprong. JPEN 1985. A Core-Based Curriculm. The Science and Practice of Nutrition Support. 2nd ed. Love M. 2. Phos and Mg in TPN for bone remodeling „ Avoid excessive protein (>1. 9.