Adult Enteral and Parenteral

Nutrition Handbook

Department of Nutrition Services

Adult Enteral and Parenteral Nutrition Handbook, 5th Ed.
Department of Nutrition Services
University of Virginia Health System
Charlottesville, Virginia

Contributors:
Ana Abad-Jorge, MS, RD, CNSD
Le Banh, MS, RD, CNSD
Cathleen Cumming, MS, RD, CNSD
Chitra Dadlani, RD
Pallavi Dharamsi, RD
Stacey Evans, RD
Lynda Fanning, MPH, RD
Theresa Fessler, MS, RD, CNSC
Tamara Karosanidze, MS, RD, CNSC
Joseph Krenitsky, MS, RD
Stacey McCray, RD
Carol Parrish, RD, MS
Kelly O’Donnell, MS, RD, CNSC
Wendy Phillips, MS, RD, CNSD
Kate Robertson, RD, CNSD
Sherrie Walker, RD, CNSD
Kate Willcutts, MS, RD, CNSC
Andrea Yoder, RD, CNSD

This handbook is intended to serve as a reference or guide in the area of enteral

and parenteral nutrition support for clinical dietitians, medical staff, nursing staff, dietetic
interns, medical students and nursing students.

Copyright 1998 University of Virginia Health System

Revised 2001, 2006, 2008, 2010; 2011
 ADULT NUTRITION SUPPORT HANDBOOK
TABLE OF CONTENTS

ADULT NUTRITION SERVICES AT THE UVA HEALTH SCIENCES CENTER…….……1

Inpatient clinical nutrition services
Nutrition support teams

SECTION 1. NUTRITIONAL ASSESSMENT OF ADULT PATIENTS

Introduction………………………………. ………………….…………2
I Anthropometrics
Estimating ideal or desirable weight for height
Height/Weight………………………….………………………………2
Weight…………………………………………………………………..2
 Adjusted body weight ……………..…………………………………3
 Body mass index (BMI) (Quetlet index)……….…………………...3
 Weight adjustment for amputation and ascites…….………..…….4
II Clinical information……….……………………………………………..4
Physical signs of nutritional deficiency (table)……….……………...5
III Nutritional intake history…………………….…………………………6
IV Biochemical data
Factors associated with nutritional status (table)….………………..7
Refeeding syndrome…………………….……………………..…..8-9
Subjective global assessment of nutritional status……….……….10
V Adult nutrition requirements………………………………………...11
Calorie requirements for hospitalized patients (table)………….…11
Metabolic cart
Respiratory quotient (table)….……………………………………12
Protein requirements (table)………………………………………...12
Energy and protein requirements for burn patients….……………13
Fluid requirements (tables)….………………………..……………...13
REFERENCES………………...………………….………………….14-15

SECTION 2. ENTERAL NUTRITION ……………………………….………………..16

Indications for initiation of enteral tube feedings (table)….………….16
Enteral formula selection guidelines (table)…………….…………….17
Supplemental food and drinks………….………………………………17
Increasing formula protein and fiber…….……………………………..17
Hospital protocol for tube feeding administration…………………….18
To order enteral nutrition…………………………………………….….18
Enteral nutrition delivery: Routes of administration (table)…….……19
Indications for continuous vs. intermittent vs. nocturnal
feedings (table)……………………………………………..…………20
Tube feeding progression......……………...…………………………20
Potential complications of tube feedings…………….…………….21-24
Monitoring of enteral nutrition support:
Preventing complications ………………………...…………….……25
General guidelines for administering medications with
Enteral feedings……………………………………….………………26
REFERENCES…………………………….……………………………..26
SECTION 3. ADULT PARENTERAL NUTRITION………….………………………27
Peripheral parenteral nutrition……….…………………………………27
Central parenteral nutrition……………….………………………….….28
Clinical indications for parenteral nutrition…….…………….………...29
Contraindications for parenteral nutrition…………..………………….29
Components of parenteral nutrition ……….…………………………. 30
Macronutrients………………….……………………………………..30
 Carbohydrate…………………………….………………………….30
 Protein……………………………………………………..…………30
 Fat……………………………..………………………..…………….31
Micronutrients……………………………………..…………………..32
 American Medical Association and FDA recommendations
for parenteral vitamin intake (table)……..……………………….33
 American Medical Association recommendations
for parenteral trace elements intake (table)..……………………34
 Electrolytes……………..…………………………………………..34
 Daily electrolyte recommendations (table)..……………………...35
Additives…..…………………………………………………………..…35
Parenteral nutrition schedules……………………….…………………35
Standard parenteral nutrition orders at UVA (table) ….……………..36
Parenteral nutrition calculations……………………………..…………36
Complications associated
with parenteral nutrition……………….……………………………37
Gastrointestinal complications associated
with parenteral nutrition (table) ……..……………………………..38
REFERENCES…………………………..……………………………….39

APPENDIX…………………….……………………………….………...40

Selected lab values at UVA………….………….……………….….41-45

Adult multivitamin supplements available at UVA…..…….………….46
Adult vitamin supplements available at UVA………..………………..47
Adult mineral supplements available at UVA…..…………………48-49
Nutrient conversion information………...………………………………50
Electrolyte/pH content of selected body fluids……...…………….…..51
Content of commonly used IV fluids…………….……………………..51
Recipe for normal saline………………………….……………………..52
Pancreatic enzyme replacement……………………...…………..……52
Common conversions (dextrose, kjoules)……………………………..52
Normal lengths of bowel………………………………………….……..53
ADULT NUTRITION SERVICES AT UVA HEALTH SYSTEM (UVA-HS)

DEPARTMENT OF NUTRITION SERVICES

Inpatient Clinical Nutrition Services:

The clinical dietitians provide the following at the University of Virginia (UVA) Medical Center:

 Assess nutritional status.

 Develop and implement a nutrition care plan tailored to the individual patient’s needs.

 Follow-up with revision of care plan as needed to improve nutritional status, as well as
nutrition counseling as needed.

Each patient unit has designated dietitians who can be contacted via EPIC, the Simon Paging
System, or by calling the Nutrition Services Office at 4-2286. The clinical dietitians are available
weekdays between 8:00 a.m. - 5:00 p.m. On weekends, a clinical dietitian is on site on Saturdays
for oral diet/education issues and a nutrition support dietitian is on site on Sundays.

Nutrition Support Teams: Medicine/Surgery: There are two nutrition support teams for adult
patients at UVA HS.

1. Medicine Nutrition Support (NST-M): NST-M is a multidisciplinary consult team

under the direction of the Division of Gastroenterology and Hepatology. The
team may be consulted for adult patients on any Medicine service requiring
enteral or parenteral nutrition support or patients with complex GI disorders
affecting nutritional intake. The team can be contacted by paging PIC # 4264
and/or entering an order via EPIC.

2. Surgery Nutrition Support (NST-S): NST-S is also a multidisciplinary consult

team that is available for consultation on the nutritional management of adult
patients on any surgery service requiring enteral or parenteral support. The team
can be contacted by paging PIC # 4253 and/or by entering an order via EPIC.

1
Section 1. NUTRITIONAL ASSESSMENT OF ADULT PATIENTS

INTRODUCTION
Nutritional assessment is evaluating nutritional status and determining the presence of, or
risk of developing malnutrition. Nutritional assessment does not stop with the first
evaluation, but is an ongoing process to monitor the adequacy and effectiveness of
nutritional support measures. The four basic components of nutritional assessment
include (1):

1. Anthropometrics
2. Clinical Information
3. Nutrition Intake History
4. Biochemical Data

I. ANTHROPOMETRICS
The most common anthropometrics used in the hospital setting are weight (wt), height (ht)
and weight/height (wt/ht) and their comparisons to standard values (2).

A. Estimating ideal body weight (IBW) or desirable wt/ht (Hamwi Method) (3):

Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%)

Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)

B. Height/Weight:
Body weight is used in nutrition assessment as an overall indicator of body fat and somatic
protein stores. Body weight is compared with usual body weight (UBW) and with IBW as
determined by the Hamwi method. It is important to use clinical judgment and avoid using
a weight that is based on a fluid overloaded state when calculating nutritional needs. In
these cases, the patient’s “euvolemic” or estimated euvolemic weight should be used.

1. Weight:
Weight is used to assess a patient’s degree of malnutrition including evaluation of
current weight as a percentage of IBW, current weight as percentage of usual
weight and recent weight change. The following formulas were devised by
Blackburn et al (4). Clinical judgment must also be used to consider frame size and
muscle mass and to adjust for any edema or excess fluid present.

A. Percentage of UBW = current weight  100

UBW
85-90% = mild malnutrition
75-84% = moderate malnutrition
<74% = severe malnutrition

B. Recent weight change = UBW – current weight  100

UBW

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 Evaluation of Weight Change
Time Significant Loss Severe Loss
1 week 1-2% >2%
1 month 5% >5%
3 months 7.5% >7.5%
6 months 10% >10%

2. Adjusted Body Weight (AdjBW) for Obese Patients:

The American Dietetic Association (ADA) and the American Society for Enteral and
Parenteral Nutrition (ASPEN) recommend basing caloric intake on actual body weight
rather than adjusted body weight and using a reduced calorie per kg level (38, 39).
However, clinicians at UVA have agreed to continue using AdjBW to determine energy
needs. The research for justification either way is limited, and the only research that
focused on patient outcomes used an adjusted body weight assuming 25% of the excess
weight was metabolically active (5). Therefore, for patients who are overweight at >130%
of their IBW, the nutritional requirements for calories should be based on an adjusted body
weight rather than their IBW or actual body weight. AdjBW can be calculated as follows
(5):

If patient is 130% or greater  AdjBW = (Actual Wt –IBW)  0.25 + IBW

3. Body Mass Index (BMI) (Quetlet Index):

The Body Mass Index or the Quetlet Index accounts for differences in body composition by
defining the level of adiposity according to the relationship of weight to height and
eliminates dependence on frame size (6, 7). However, it does not account for muscle
mass.

BMI = wt (in kilograms)/ ht (in meters)2 or wt (in pounds)/ ht (in inches)2  705

 A BMI of 18.5-24.9 is associated with the least risk of early death.

 A BMI of > 30 may indicate obesity and increased risk of developing health
problems.
 A BMI of <18.5 may indicate nutritional risk and increased risk of illness (8).

Table 1.1 Risk of Associated Disease According to BMI and Waist Size
Waist less than Waist greater
BMI* Category or equal to than
40 in. (men) or 40 in. (men) or
35 in. (women) 35 in. (women)
< 18.5 Underweight --- N/A
18.5 – 24.9 Normal --- N/A
25.0 – 29.9 Overweight Increased High
30.0 – 34.9 Obesity Class I High Very High
35.0 – 39.9 Obesity Class II Very High Very High
40 or greater Obesity Class III Extremely High Extremely High
*These values may underestimate the degree of malnutrition in some patients. An overweight or obese patient may be
malnourished if significant weight loss has occurred, but not fall into the category of malnutrition based on BMI alone.
Adapted from: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm. Accessed 3/3/11.

3
4. Weight Adjustment for Amputation

If a patient has loss of a body part or parts, IBW should be adjusted to reflect
amputation. Percentages for adjustments in body weight (2):

Type of Amputation % Total Body Weighta

Foot 1.8
Below Knee Amputation 6
Above Knee Amputation 15
Entire Lower Extremity 18.5
Hand 1
Below Elbow 3
Above Elbow 5
Entire Upper Extremity 6.5
a
Double if bilateral

5. Weight Adjustment for Ascites

To estimate euvolemic weight, determine degree of ascites and subtract the
following amount from actual weight.
Mild Ascites ~ 3 kg
Moderate Ascites ~ 7-8 kg
Severe/tense Ascites ~ 14-15 kg
These adjustments were approved by UVA hepatologists.

4
II. CLINICAL INFORMATION

Clinical variables can potentially influence all parameters of protein and calorie
status. Clinical information is derived from a variety of sources, some of which include:
 Medical record
 Physician and other health care professionals
 Patient or patient family interviews
 General observations of the patient’s physical appearance
 Evaluation of psychosocial background

This combined data provides further information for the nutrition assessment.
Some physical signs of nutritional deficiency are summarized in Table 1.2

TABLE 1.2 PHYSICALS SIGNS OF NUTRITIONAL DEFICIENCY (9, 10, 11)

Site Sign Possible Deficiency______________
Skin Dry and Scaling Vitamin A
Petechiae, Ecchymosis Vitamin C or K
Follicular hyperkeratosis Vitamin A, Vitamin C, Essential Fatty Acid

Pellagrous dermatosis Niacin, Tryptophan

“Flaky Paint” dermatosis Protein

Hair Dull, dry, thin and easily Protein and Essential Fatty Acid
pluckable

Eyes Eyelid lining and whites pale Anemia

Bitot’s spots Vitamin A
Corners of eyes cracked, Riboflavin and Niacin
Red or inflamed eyelids
Cornea dull, milky, hazy, or Vitamin A
opaque

Mouth Magenta tongue, Riboflavin

Tastebuds atrophied

Glossitis Niacin, Folate, Vitamin B12

Bleeding gums Vitamin C

Cheilosis Riboflavin, Pyridoxine

Angular stomatitis Riboflavin, Niacin, Iron,

Pyridoxine, Vitamin B12
General
Appearance Edema Protein

Muscle wasting Protein-Calorie

Decreased subcutaneous fat Malnutrition

Neurologic Disorientation Thiamin, Niacin

Neuropathy Thiamin, Copper, B12

____________________________________________________________________________________________

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III. NUTRITIONAL INTAKE HISTORY:

A history of food intake is usually obtained by one of the following:

 24 hour recall
 3 day food record

Data collection should include:

 Food habits
 Quality and quantity of ingested nutrients
 Appetite and changes in appetite
 Food intolerance and allergies
 Chewing or swallowing problems

Risk factors identified may include:

(1) Current anorexia or major changes in appetite within last 3 months
(2) Diet orders that are inadequate in meeting patient nutritional requirements

 NPO or clear liquid >5 days without enteral/parenteral nutrition

(3) Problems with chewing, swallowing, motor skills or mobility alert the dietitian
to investigate potential nutrient inadequacies. Nutritional intake (calorie
count or 24 hr recall) data may help the dietitian assess the need for nutrition
support, education, etc.

(4) Past or present need for enteral or parenteral nutrition

IV. BIOCHEMICAL DATA:

Table 1.3 summarizes selected lab values/tests that are most often used for
nutritional assessment of the adult patient at UVA. Although these lab values are helpful in
the assessment of nutritional status, they should be used in combination with other clinical
data, and no one value should be considered as a predictor of nutritional status.

6
TABLE 1.3 BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS* (3,9)
________________________________________________________________________________________________________
Lab Parameter Interpretation of Values Potential causes Potential causes for
for high values low values______________________

TOTAL URINARY
NITROGEN ( TUN)* Calculation of N2 balance**: Growth Inadequate calorie or protein intake
Measures the net Pregnancy Increased catabolism
changes in the body’s 24 hr. protein intake – TUN (gm) + 2 gm] Recovery from illness Trauma
total protein mass** 6.25 Athletic training Surgery
Poor quality protein intake
Critical Illness
+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to – 1: Net catabolism
__________________________________________________________________________________________________________________

URINARY UREA
NITROGEN (UUN)*
Measures the net Calculation of N2 balance**: Growth Inadequate protein intake
changes in the body’s Pregnancy Increased catabolism
total protein mass 24 hr. protein intake –UUN (gm) + 4 gm] Recovery from illness Trauma
6.25 Athletic training Surgery
Poor quality protein intake

+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to – 1: Net catabolism

*Both TUN and UUN are used at UVA, however, TUN is preferred. When UUN is used to estimate nitrogen balance, it does not take into account 2 g for the dermal
and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine). TUN measures all the protein in the urine,
so a factor of 2 grams can be used instead of 4. The above equation may not be appropriate in certain circumstances. For example, the unmeasured nitrogen
losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.

**Note: Do not do a Nitrogen Balance Study if unable to collect the full amount of urine, if the patient is anuric due to renal failure, or if the
nutrition provision has changed in the past 2-3 days.

7
Hepatic Proteins

Albumin, Prealbumin and Transferrin are not listed in the previous section as research
has shown that these hepatic proteins are not reliable indicators of nutritional status and are
negative acute phase reactants. Synthesis is impaired due to alterations in protein metabolism
that occurs during metabolic stress. Albumin, prealbumin, and transferrin should not be used as
indicators of nutritional status in hospitalized patients due to the effects of stress and
inflammation on these parameters (12).

REFEEDING SYNDROME:

Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and
mortality in the malnourished patient (13). Complications resulting from refeeding syndrome
include electrolyte abnormalities (low serum values of potassium, phosphorus, magnesium),
glucose and fluid shifts, cardiac dysfunction, and impaired release of oxygen from oxy-
hemoglobin. The degree of symptoms exhibited depends upon the extent of malnutrition,
electrolyte supplementation prior to nutrition support initiation, and calorie and fluid load initiated
(14, 15).

Table 1.4 Patients at Risk for Refeeding Syndrome (16-19)

 Anorexia nervosa
 Chronic alcoholism
 Oncology patients
 Post-operative patients
 Residents admitted from skilled nursing facilities or nursing homes
 Depression in the elderly
 Uncontrolled diabetes mellitus (diabetic ketoacidosis)
 Chronic malnutrition:
 Marasmus
 Kwashiorkor
 Prolonged hypocaloric feeding
 Morbid obesity with profound weight loss
 Prolonged fasting (including patients with non-nutritional IV fluids)
 High-stress patient not fed for >7 days
 Hunger strikers
 Victims of famine

8
Table 1.5 Summary Guidelines to Prevent Complications of the Refeeding Syndrome (20)
1) Anticipate patients at risk for refeeding syndrome.
2) Check baseline electrolytes before initiating nutrition support and replace
any low levels promptly – however, do not withhold nutrition support until
serum levels are corrected, rather replete electrolytes concurrently with
the nutrition support provided.
3) Initiate nutrition support, including total calories and fluids, slowly – this
does not mean that the enteral or parenteral nutrition has to progress
slowly to meet the “refeeding level” that has been predetermined.
Example: If a refeeding level of 20 kcal/kg is appropriate (which equates
to a continuous tube feeding rate of 45 ml/hour of a 1 kcal/ml product),
there is no need to also start enteral nutrition slower than this, as the
amount of refeeding calories the patient is to receive in 24 hours has
already been accounted for.
4) Consider additional sources of calories, such as dextrose in IV fluids,
glucose or lipid calories from medications, etc. and include these in total
calories.
5) Unless hemodynamically unstable, keep sodium-containing fluids to ~ 1
liter/day initially.
6) Monitor electrolytes daily for at least 3 days and replace any low levels as
needed. Be wary of the malnourished patient in renal failure with elevated
serum electrolytes secondary to decreased clearance, as they may be a
“late refeeder.”
7) Be prepared for accelerated refeeding and the need for aggressive
electrolyte replacement in the hyperglycemic patient while glucose control
is improved.
8) Routinely administer vitamins to malnourished patients, especially
thiamin; consider a “loading dose” prior to initiation of nutrition support.
9) Increase calories cautiously in a stepwise manner. Continue to monitor
electrolytes as calories are increased.
10) Outline a plan for nutrition advancement (especially if patient is to be
discharged) to prevent the patient from remaining on refeeding levels
longer than necessary, thereby delaying improvements in nutritional
status over time.

9
Subjective Global Assessment (SGA) of Nutritional Status

The nutritional status of hospitalized patients can be assessed by a variety of methods as discussed earlier.
The widely applied traditional methods rely on objective anthropometric measurements and laboratory test
results. Nutritional assessment can also be based on clinical criteria-that is findings of a routine history and
physical examination. Detsky et al (21) demonstrated a good correlation between the subjective and objective
measurements. Some of the advantages of SGA are:
 Quick, easily taught, inexpensive
 Adds structure to technical judgment
 Postoperative infections can be predicted to a degree that is equal to or better than with objective
measurements.
 Reproducible results

Table 1.6 Features of Subjective Global Assessment (SGA)

A. History
1. Weight Change
Overall loss in past 6 months: amount=______kg; %loss+______
(<5%= small loss, between 5 and 10%= potentially significant loss, >10% = definitely significant)
Change in past 2 weeks: ______increase
______ no change
______ decrease
(Pattern of weight loss: Patients who continue to lose weight are more likely to be malnourished,
than those who have recently gained some weight)

2. Dietary intake change (relative to normal)

_____ no change
_____ change _____duration #_____weeks
_____ type: _____suboptimal diet, _____full liquid diet
_____hypocaloric liquids _____starvation

3. Gastrointestinal symptoms (that persisted for > 2 weeks)

____none ____nausea ____vomiting ____diarrhea ____anorexia

4. Functional capacity
_____No dysfunction (e.g., full capacity)
_____Dysfunction ____duration = # ____weeks
____type ____working suboptimally
____ambulatory
____bedridden

5. Disease and its relation to nutritional requirements

Primary diagnosis (specify) _____
Metabolic demand (stress): _____ no stress, low stress
_____ moderate stress, high stress

B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)

# ______loss of subcutaneous fat (triceps, chest)
# ______muscle wasting (quadriceps, deltoids)
# ______ankle edema
# ______sacral edema
# ______ascites

With the information obtained in parts A and B, the clinician subjectively assesses nutritional
status. The most important factor is weight change over time.

C. SGA rating (select one)

_____A = Well nourished _____ B = Moderately (or suspected of being) malnourished
_____C = Severely malnourished

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V. ADULT NUTRITIONAL REQUIREMENTS:

Nutritional requirements for adults should be estimated on an individual basis. The

nutritional requirements of each patient will depend upon a number of factors including:

 Age
 Activity level
 Current nutritional status
 Current metabolic and disease states
 Individualized goals

The following section will provide a brief overview of the determination of nutritional
requirements including calories, protein and fluid for the hospitalized patient.

Calorie Requirements:
Estimating energy expenditure in hospitalized adult patients is challenging. If available,
indirect calorimetry can be used to measure energy expenditure using gas exchange (see
following section). Frequent measurements are required to appropriately identify a patient’s
energy expenditure (22). When indirect calorimetry is not possible, there are many possible
predictive equations (see ADA’s Evidence Analysis Library at www.adaevidencelibrary.com)
(38). Most of these predictive equations are based on a single indirect calorimetry study per
patient. The high degree of variability of an acutely ill patient’s energy needs from day to day
limits the ability to make strong conclusions regarding the superiority of any prediction equation
over another. More importantly, whichever method (indirect calorimetry or predictive equation) is
used, the optimal energy provision for hospitalized patients has yet to be determined (22).
Significantly underfeeding or overfeeding is harmful; (23, 24) however, there is no evidence that
feeding a patient the calories they are burning based on indirect calorimetry (or based on any
predictive equation) will improve outcome. Acutely ill patients remain catabolic despite meeting
or exceeding full calorie expenditure (25, 26). In fact, there is evidence that feeding critically ill
patients 100% of predicted energy needs may be harmful (27). For a discussion regarding
permissive underfeeding of obese patients, please refer to the guidelines published in 2009 for
the provision and assessment of nutrition support therapy by ASPEN and the Society for Critical
Care Medicine (SCCM) (39).
At UVAHS, the calories per kilogram method is most often used to estimate a patient’s
caloric needs to simplify calculations:

TABLE 1.7 CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

Patients at risk for refeeding* 15-20 kcal/kg *See page 8-9
Adults (18-65) 20-30 kcal/kg
Elderly (65+)  25 kcal/kg
Obese or Super obese 15-20 kcal/kg AdjWt

*Calorie requirements may vary based on degree of stress and need for
repletion

Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day

11
 Clinical judgment should be used to individualize each patient’s estimated needs, and
frequent monitoring and evaluation of nutrition interventions should occur to make adjustments
as needed based on patient response.

3. Metabolic cart (28, 29):

Indirect calorimetry using a “metabolic cart” measures actual energy expenditure
by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide
(VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated. The
RQ for carbohydrate, protein, and fat differs and reflects net substrate utilization at the time of
measurement.

Note: Patient has to be intubated for the test to be performed, FIO2  60%, no air leak or chest
tube leak.

TABLE 1.8 RESPIRATORY QUOTIENT INTERPRETATION

SUBSTRATE/MEASUREMENT CONDITION R.Q.
_______________________________________________________________________

Lipogenesis (overfeeding) 1.00–1.20

Carbohydrate oxidation 1.00
Mixed substrate oxidation (appropriate feeding) 0.85
Protein oxidation 0.82
Fat oxidation (underfeeding) 0.71
Ketosis 0.67–0.70

PROTEIN GUIDELINES (30, 31)

TABLE 1.9 SUGGESTED PROTEIN GUIDELINES IN ADULT HOSPITALIZED PATIENTS

Clinical condition Protein requirement
Mild stress 1.0 1.2 g/kg
Moderate stress (most ICU patients) 1.5-2.0 g/kg
Severe Obesity 1.5 g / kg AdjWt – 2.0 g/kg IBW
Severe stress, catabolic, burns 2.0 –2.5 g/kg
Chronic renal failure, no dialysis 0.8-1.3 g/kg *
Hemodialysis 1.2 1.4 g/kg
Continuous Ambulatory Peritoneal Dialysis (CAPD) 1.2 –1.5 g/kg
*Protein needs may be higher if the patient is critically ill

12
 4. Nutrition requirements for burn patients (32-35):

There are more than 30 predictive equations to estimate energy needs for burn
patients. At UVA, patients with >20% TBSA burn are provided kcals and protein based on the
guidelines below:
Energy Requirements = 30-35 kcal/kg

Protein requirements = 2.0-2.5g protein/kg

Note: once grafting has taken place, calorie and protein requirements will decrease

Additional Needs (35):

Vitamin C = 500 mg BID
Zinc Sulfate = 220 mg (limit to 2 – 3 weeks)
Beta Carotene = 25,000 IU x 5 days
Therapeutic Multivitamin/Mineral

IV selenium, copper and zinc - awaiting further research to determine

specific amounts.

FLUID REQUIREMENTS:

Fluid requirements will vary among patients and may increase or decrease from normal
needs under a number of conditions including the following:

TABLE 1.10 Potential Source of Fluid Excess or Loss in Hospitalized Patients (20)
Intake
 Maintenance IV fluids
 Medications given via IV drip
 Water flushes given with crushed
medications
 Water flushes to keep tubes
patent
 Water contained in tube feedings
or PN
Output
 Chest tubes
 Percutaneous drains
 Biliary /Pancreatic
 Wound drainage
 Ostomies/Stool/Urine
 Naso/oro gastric tube suction
 Excessive drooling/Sialorrhea
(cerebral palsy, Down’s syndrome,
undetermined neuromuscular
disorders or those following a head
injury or stroke
 Fistulas
 Insensible losses
 Increased insensible losses including:
 Burns
 Tracheostomies
 Fever
 Kinair beds

13
TABLE 1.11 ESTIMATING ADULT FLUID REQUIREMENTS
1. By caloric intake (36): 1ml/calorie

Ex: 1800 calorie diet = 1800 calories x 1ml = 1800ml

Calorie
2. By body weight and age (37):

Age Fluid requirements

16-55 years 35 ml/kg/day
56-65 years 30 ml/kg/day
> 65 years 25 ml/kg/day

Ex: 62 year old, weighs 58kg = 30ml x 58kg = 1740ml/day

When determining total fluid intake of the tube fed patient, the amount of free water in the
tube feeding formula and intravenous fluids needs to be considered. Intake and output records
should be monitored as well as weight. A rapid weight gain or loss of 1 kg may be the result of
a fluid gain or loss of 1 liter.

References

1. Hooley RA. Clinical nutritional assessment; A perspective. JADA. 1980; 77:682-685.

2. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized
Patients. WB Saunders Co; 1986.
3. Hamwi GJ. Therapy: changing dietary concepts. In: Danowski TS, ed. Diabetes Mellitus:
Diagnosis and Treatment. New York, NY:American Diabetes Association; 1964:73–78.
4. Blackburn GL, Bistrian BR, Maini BS. Nutritional and metabolic assessment of the hospitalized
patient. JPEN. 1977;1:11-22.
5. Krenitsky J. Adjusted body weight, pro: evidence to support the use of adjusted body weight in
calculating calorie requirements. Nutr Clin Pract. 2005;20:468-73.
6. Bray G. Pathophysiology of obesity. Am J Clin Nutr. 1992;55:488S-494S.
7. Bray GA, Gray DS. Obesity: 1. Pathogenesis 2. Treatment. West J Med. 1988;149:429-555.
8. WHO. Physical status: the use and interpretation of anthropometry. Report of the WHO Expert
Committee. WHO Technical Report Series 854. Geneva: World Health Organization, 1995.
Available at: http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf. Accessed 8/22/08.
9. Grant A, DeHoog S. Nutritional Assessment and Support. Northgate Station, Seattle, WA: Grant
and DeHoog; 1985.
10. Williams SR. Nutrition and Diet Therapy. Times/Mirror, Mosby. 1985; 485-502.
11. Rombeau J, Richter GC, Forlaw L. Practical aspects of nutritional
assessment. Pract Gastroenterol. 1984;8:43.
12. Banh L. Serum Proteins as a Marker of Nutrition: What Are We Treating? Practical
Gastroenterology 2006; XXX(10): 46-64. Available at:
http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm
13. McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical Gastroenterology.
2005;23:26-44.
14. Zeman FJ. Clinical Nutrition and Dietetics. New York: MacMillan, 1991;80.
15. Boylan H. Virginia Dietetic Association Meeting: Presentation on Refeeding Syndrome. 1998.
16. Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr Rev 2003;61(9):320-323.

14
17. Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition
2001;17:632-637.
18. Matz R. Precipitation of refeeding-associated electrolyte abnormalities with intravenous hydration.
[Letter to editor] Am J Med 1999;107:302.
19. Mallet M. Refeeding Syndrome. Age & Aging 2002;31:65-66.
20. University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR,
Krenitsky J, McCray S). University of Virginia Health System Nutrition Support Traineeship,
2003.
21. Detsky AS et al. What is the subjective global assessment on nutritional status? JPEN.
1987;11:8-13.
22. Reid CL. Poor agreement between continuous measurements. The use of energy expenditure
and routinely used prediction equations in intensive care unit patients. Clin Nutr. 2007;26(5):649-
57.
23. Talpers SS, Romberger DJ, Bunce SB and Pingleton SK. Nutritionally associated increased
carbon dioxide production. Excess total calories vs high proportion of carbohydrate calories.
Chest 1992;102(2):551-5.
24. Casper K, Matthews DE and Heymsfield SB. Overfeeding: cardiovascular and metabolic
response during continuous formula infusion in adult humans. Am J Clin Nutr 1990;52(4):602-9
25. Frankenfield DC, Smith JS and Cooney RN. Accelerated nitrogen loss after traumatic injury is not
attenuated by achievement of energy balance. JPEN J Parenter Enteral Nutr 1997;21(6):324-9.
26. Streat SJ, Beddoe AH and Hill GL. Aggressive nutritional support does not prevent protein loss
despite fat gain in septic intensive care patients. J Trauma 1987;27(3):262-6.
27. Krishnan JA, Parce PB, Martinez A, Diette GB, and Brower RG.
Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to
clinical outcomes. Chest. 2003;124: 297–305.
28. Hester DD, Lawson K. Suggested guidelines for use by dietitians in the interpretation of indirect
calorimetry data. JADA. 1989;89:100-101.
29. French SN. Nutritional assessment via indirect calorimetry. Tech Notes. Medical Graphics
Corporation; 1987;1-12.
Harris JS, Benedict FG. A Biometric Study of Basal Metabolism in Man. Carnegie Institute of
Washington, 1919.
30. Long CL, Schaeffel N, Geiger JW, et al. Metabolic response to injury and illness: Estimation of
energy and protein needs from indirect calorimetry and nitrogen balance. JPEN. 1979;3:452.
31. Weinser RG et al. Handbook of Clinical Nutrition. St. Louis, MO:CV Mosby Co; 1989;130-179.
32. Herndon D, Tompkins R. Support of the Metabolic Response to Burn Injury. Lancet.
2004;363:1895-1902.
33. Lefton J. Specialized Nutrition Support for Adult Burn Patients. Support Line. 2003;25: 19-24.
34. Dickerson, R. Estimating energy and protein requirements of thermally injured patients: Art or
Science? Nutrition. 2002; 18:439-442.
35. Berger, MM, et al. Trace element supplementation after major burns modulates antioxidant status
and clinical course by way of increased tissue trace element concentrations. Am J Clin Nutr
2007;85:1293-1300.
36. Randall HT. Fluid electrolyte and acid base balance. Surg Clin North Amer. 1976;56:1019.
37. Water requirements in enteral support. Support Line. Dietitians in Nutrition Support: A Dietetic
Practice Group of the ADA; 1989;11.
38. American Dietetic Association Evidence Analysis Library. Available at
www.adaevidencelibrary.com. Updated 1/4/11. Accessed 3/3/11.
39. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J
Parenter Enteral Nutr. 2009; 33: 277. Available at http://pen.sagepub.com/content/33/3.toc.
Accessed 3/3/11.

15
SECTION 2. ENTERAL NUTRITION (EN)

INTRODUCTION

The gastrointestinal tract (GI) is the most effective way to feed the patient. If the
patient has at least a partially functioning gut, but is unable to meet his nutritional needs via the
oral (po) route, then enteral nutrition therapy via tube feeding should be considered. Enteral
nutrition (EN) promotes the usual physiologic integrity of the GI tract, has less risk of harm (line
infections, sepsis) and is more economical than parenteral nutrition.

Table 2.1 Benefits of Enteral Nutrition (compared with Parenteral Nutrition) (1)
 Stimulates immune barrier function
 Physiologic presentation of nutrients
 Maintains gut mucosa
 Attenuates hypermetabolic response
 Simplifies fluid/electrolyte management
 More “complete” nutrition than parenteral nutrition
o iron, fiber, glutamine, phytochemicals, etc. are not provided.
 Less infectious complications (and costs associated with these complications)
 ? Stimulates return of bowel function
 Less expensive  

TABLE 2.2 INDICATIONS FOR INITIATION OF ENTERAL NUTRITION (1)

Indication
Oral intake is contraindicated
Inability to meet markedly increased
nutritional needs with oral intake
Inability to meet basic nutritional needs with Anorexia, cancer, head and neck tumors
oral intake alone
Examples
Dysphagia, mechanical ventilation,
mandibular fractures, head & neck surgery,
neurological impairment, demyelinating
diseases such as amyotrophic lateral
sclerosis, muscular dystrophy, etc.
Burns, trauma, radiation therapy,
chemotherapy, sepsis/infection, closed head
injury

Need to bypass part of the GI tract to allow Pancreatitis, gastric outlet obstruction,
enteral nutrition esophageal cancer, gastroparesis

The need for supplemental nutrition due to Short bowel syndrome, inflammatory bowel
decreased absorption disease, fat malabsorption or other
malabsorptive syndromes such as cystic
fibrosis

16
 TABLE 2.3 UVAHS Adult Formulary

Type of Formula Kcal/mL Protein Special Considerations

Standard, high protein Used most frequently at
(Promote, Promote with 1 kcal/mL High, intact UVAHS; high
Fiber*) protein:calorie ratio
Calorie dense (Jevity 1.5*, Provides high amount of
TwoCal HN*, Osmolite 1.5) 1.5 or 2.0 Moderate, intact calories when reduced
kcal/mL volume is desired
Elemental /Semi-Elemental Low fat, Low cholesterol
(Vivonex RTF, Perative*) 1 kcal/mL, Peptides and Simple carbohydrate
1.3 kcal/mL Amino acids
Low-Electrolyte/Volume Lowest K, Magnesium, P
Restricted 1.8 kcal/mL Low, intact formula, concentrated;
(Nepro*) appropriate when fluid or
electrolyte restriction is
needed
*contains fiber

Note: All formulas are gluten-free, lactose-free and low sodium. These formulas are listed on the adult
enteral formulary at UVA as of 9/2008. Subject to change.

Supplemental foods and drinks

If a patient is willing to consume them, oral supplements can be provided to help achieve
calorie and protein goals. These are available in a variety of drinks and puddings. Some
tube feeding products are flavored and can also be provided as oral supplements.
Patient acceptability may improve if these supplements are served chilled.

Please refer to adult enteral formulary card for a list of current enteral products
and supplements.

Increasing protein

Protein delivery can be increased using modular protein products. A packet of

Beneprotein provides ~25 kcal and 6 gms of protein.

Increasing fiber

Fiber delivery can be increased using fiber additive products. 2 teaspoons of Benefiber
provides ~15 kcals and 3 g soluble fiber. Fiber should not be the first choice for
treatment of diarrhea or constipation (see Table 2.7).

17
 HOSPITAL PROTOCOL FOR TUBE FEEDING ADMINISTRATION

When providing enteral nutrition, a number of factors need to be considered to provide

nourishment as safely and comfortably as possible. The following list can serve as a
guide (2-4).

1. Elevate head of bed to decrease the risk of aspiration:

a. Intermittent feeding: 30 - 45 degrees during and for 1 hour after feeding.

b. Continuous feeding: 30 - 45 degrees regardless of rate

2. Check for gastric residuals:

a. Intermittent feeding: Check prior to each feeding and if residuals are more
than 500 mL, hold tube feeding for 1 hour and contact house officer.

b. Continuous feeding: Check every 8 hours. If gastric residuals are more

than 500 mL, hold the tube feeding for 1 hour and contact the house officer.
There is no need to obtain residuals from nasoduodenal, nasojejunal
or jejunostomy tubes.

 Irrigate the feeding tube with at least 30 mL water before and after administering tube
feeds to ensure patency. Additional water to meet fluid needs is recommended on an
individual basis.

TO ORDER ENTERAL NUTRITION

1. Use EPIC for ordering all adult formulas.

2. If an additive is desired, see “TF Options”.

.
3. Following directions, select desired formula, method of delivery, strength and rate.

4. Enter water flushes and order gastric residual checks, if appropriate.

5. Nutrition Support Team members should be consulted to assist with nutrition

assessment, appropriate formula selection and provision, ongoing monitoring; and
to answer questions regarding each patient’s nutritional needs.

18
TABLE 2.4 ENTERAL NUTRITION DELIVERY: ROUTES OF ADMINISTRATION (4-7)
DELIVERY METHOD COMMON INDICATIONS PRECAUTIONS
Nasogastric (NGT)*/ Unable or unwilling to Tube must be secured
Orogastric consume adequate nutrition via
oral route Use CO2 detection device
e.g. patient intubated, sedated when placing tube.

Hypercatabolism in presence of Document placement of tube

at least partially functional GI
tract
Nasoduodenal/ Functional GI tract with a
Nasojejunal proximal obstruction
Inadequate gastric motility
Esophageal reflux
After upper GI surgery
Gastrostomy Esophageal injury or
obstruction
with x-ray.
Use CO2 detection device
when placing tube, then
confirm with x-ray.
Tube must be secured
Continuous feeding preferred
due to high probability of
dumping syndrome with bolus
feeds.
Caution in patients with
severe GE reflux

Inability to swallow or consume Should be avoided in patients

adequate oral calories with intractable vomiting

Anticipate that nutrition support Caution: consider using an

will be needed for >4 weeks abdominal binder in agitated
patients or those inclined to
pull lines/tubes

Stoma care required

Jejunostomy Functioning GI tract with an Potential bowel perforation
obstruction in the proximal
jejunum (long term) Bacterial overgrowth

Upper GI stricture or fistula Stoma care required

Inadequate gastric motility Continuous feeding preferred

due to high probability of
Long-term transpyloric feeding dumping syndrome with bolus
desired feeds.

*For patient comfort and to decrease the risk of sinusitis, nasal Salem sumps used for
feeding should be changed to a small-bore nasoenteric feeding tubes.

19
TABLE 2.5 INDICATIONS FOR CONTINUOUS VS INTERMITTENT FEEDINGS VS
NOCTURNAL FEEDINGS (5, 8)

CONTINUOUS INTERMITTENT NOCTURNAL

Short term feeding
Intensive Care Unit (ICU)
setting
Not recommended for post-
pyloric feeding tubes
Appropriate for long-term
gastric feeding
Long-term feeding for patients
who don’t tolerate intermittent
feedings, who have a small
bowel feeding tube, or to
supplement daytime po intake

Allows daytime mobility

May reduce risk of aspiration
and/or gastric distension
Allows time for more mobility
between feedings
Allows the patient to receive
nutrition at meal time and
socialize with others
Can be used during transition
from tube feedings to po diet
Recommend decreasing total
calorie provision if increased
appetite is desired.

TUBE FEEDING PROGRESSION (See EPIC Orders for Enteral Tube Feeding)

Initiation:
 Standard protocol for initiation of continuous feeds for non-surgical patients: Start full
strength formula at 50 ml/hour x 4 hours, advance by 15 ml/hour every 4 hours until goal
of _______ ml/hour is reached.
 Standard protocol for initiation of bolus feeding: Give 125 ml x 1 feed, increase by 125
ml/feed until goal of ______ ml/feed is reached. Allow at least 3 hours between feedings.
 Note: intermittent feeding is not for use with post-pyloric feeding tubes.

Residual Checks:
 Do not check residuals with post-pyloric feeding tubes.
 If not contraindicated, place patient on the right side before checking residuals.
 If residuals > 500 ml, hold feeds for 1 hour then recheck. If <300 ml at recheck, then
restart feeds using initial rate and progress per orders. If continues > 500 ml, notify the
physician.
 Notify physician if feedings held twice in 24 hours.
 Return up to 250 ml gastric residuals to the patient.

20
TABLE 2.6 POTENTIAL COMPLICATIONS OF TUBE FEEDINGS (2-4, 9, 10)
COMPLICATIONS POSSIBLE CAUSE POSSIBLE MANAGEMENT
I. Mechanical
Aspiration of  Delayed gastric emptying
formula (Gastroparesis)
 Tube dislodgment
 Gastroesophageal reflux
Nasopharyngeal  Prolonged intubation with a
irritation/breakdown large bore feeding tube.
Luminal obstruction  Thickened formula residue
(clogged tube)  Medication particles
 Inadequate flushing
21
 Elevate head of bed at least
30 during and 1 hour after
tube feeding stopped
 Reduce infusion rate by
using more calorically dense
formula
 Consider prokinetic med
 Discontinue tube feeding
 Check tube placement
 Replace tube, if necessary
 Use small bore feeding tube
 Keep head of bed elevated
during and 1 hr after feeding
 Regularly check tube
placement
 Use soft, small-bore feeding
tube
 Proper taping of tube to
prevent undue pressure on
nostril
 Consider G-tube, J-tube,
PEG or PEJ for long term
enteral feedings
 Flush tube with water every
3-4 hours
 Flush tube with water before
and after medications
 Use liquid or suspension
form of medication if
possible (caution: Liquid
meds may cause diarrhea)
 Flush tube each time feeding
is stopped
 Confirm appropriate
medication delivery route
with Pharm D
 Add ClogZapper
(BIN#91200) or use Enteral
Feeding Tube Declogger by
Bionix
COMPLICATIONS POSSIBLE CAUSE POSSIBLE MANAGEMENT

II. Gastrointestinal

Diarrhea  Medications (sorbitol  Review medications and

elixirs, antibiotics, Shohl’s
solution, magnesium-containing
antacids, laxatives, cathartic
agents, Lactulose)
 C. difficile
eliminate causative agent,
if possible.
  C. difficile toxin

 Bacterial contamination  Refrigerate any opened

 Improper administration
 Fat malabsorption
 Lack of dietary fiber / too
much fiber
Constipation  Inadequate fluid
cans of formula
 Discard all unused formula
within 24 hours
 Ensure cleanliness during
preparation and administration
 Place  8 hours of formula at
a time in the feeding set/bag
 Change feeding bag and
tubing every 24 hours
 Consider reduced rate
 Give by continuous drip
(not preferred in home
patients)
 Check location of feeding
tube tip
 Determine cause
 Try pancreatic enzymes
 Select lower fat or consider
changing the formula
 Consider formula change
 Increase fluid intake

 Inactivity  Encourage ambulation if

possible

 GI obstruction  May require decompression

and surgical intervention
 Colonic dysmotility  Address presumed cause
 Drug induced
 Post op
 Other

22
 COMPLICATION POSSIBLE CAUSE POSSIBLE MANAGEMENT

Bloating  Delayed gastric emptying  Calorie dense formula

 Prokinetic agent
 Post pyloric tube
 Rapid formula  Initiate feedings at a lower
Vomiting/Nausea administration rate and gradually advance
 Consider post pyloric tube

 Delayed gastric emptying  Monitor residuals

 Verify correct tube
placement
 Prescribe anti-emetics/
antinauseants, prokinetics
 Post pyloric tube
 Slower infusion
Persistantly High Gastric  Delayed gastric emptying  Prokinetic agent
Residual (>500 ml)  Consider change to a
calorically dense formula to
decrease volume
 Post pyloric tube
III. Metabolic

Hyperglycemia  Diabetes  Monitor serum glucose

 Hypercatabolism  Give oral hypoglycemic
Stress/Trauma agents or insulin
 Corticosteroids  Avoid overfeeding
 Sepsis

 Sudden cessation of tube  Monitor serum glucose

Hypoglycemia feeding or parenteral nutrition
(PN) in patients on oral
Hypoglycemic agent
or insulin
 If tube feeding or PN must
must be stopped after
after insulin given, hang D10
IV fluid.
 Treat hypoglycemia with IV
dextrose

Dehydration or  Inadequate fluid intake  Monitor body weight

Hypernatremia  Excessive protein intake
 High urine output,
excessive diarrhea,
ostomy output, fistula
output, or NGT output
 Monitor fluid intake and
output
 Monitor serum sodium,
serum osmolality, BUN,
creatinine (BUN-Cr ratio is
usually 10:1 in patients with
normal hydration)
 Provide additional water

23
 COMPLICATION POSSIBLE CAUSE
Hyponatremia  Fluid overload
 Hypotonic formula
 Excessive production of
antidiuretic hormone (SIADH)
 Cerebral salt wasting
Hyperkalemia  Poor perfusion (CHF)
 Metabolic acidosis
 Excessive potassium intake
 Decreased excretion
 Renal insufficiency
 Potassium-sparing meds
Hypokalemia  Refeeding syndrome
 Diuretics
 Excessive losses
(i.e. from diarrhea or NG
drainage)
 Insulin therapy
 Volume overload
 Metabolic alkalosis
 Renal insufficiency
Hyperphosphatemia
 Refeeding syndrome
Hypophosphatemia  Insulin therapy
 Phosphate binding antacids
 Calcium carbonate
supplements
24
POSSIBLE MANAGEMENT
 Restrict fluids (when sodium
is < 130)
 Provide adequate sodium
and/or supplement
 Give diuretics
 Treat cause for poor
perfusion
 Reduce potassium intake
 Monitor serum levels
 Give Kayexalate, glucose
and/or insulin
● Reduce kcals
 Provide adequate
potassium and/or
supplement
 Monitor serum levels
 Phosphate binder
 Reduce phosphorus intake
● Monitor propofol infusion
  for Phos-containing
meds (Fleet enemas contain
phos)
 Monitor serum levels
 Provide adequate
phosphorus and/or
supplement
MONITORING OF ENTERAL NUTRITION SUPPORT

PREVENTING COMPLICATIONS
Continued monitoring of nutritional intake is particularly important for patients receiving
enteral or parenteral nutrition support in order to identify inadequacies before deficiencies
develop. Recommendations for changing or supplementing nutritional support are based on
accurate and timely documentation of delivery.

Patients on nutrition support also need to be closely monitored to ensure that energy
needs are being met but not exceeded. Overfeeding can cause a number of complications
which may prevent clinical improvement.

Complications of overfeeding include (but not limited to):

1. Hyperglycemia
2. Lipogenesis
3. Fluid and fat gain rather than lean body mass gain
4. Fatty liver
5. Immunosuppression (with excessive lipid and linoleic acid intake)
6. Increased minute ventilation (VE)
7. Excessive CO2 production impairing pulmonary status/vent wean

Prolonged underfeeding may lead to loss of lean tissue, skin breakdown, inadequate
wound healing and immune dysfunction.

Use of Blue Dye (11)

In the past, blue dye or food coloring was sometimes added to tube feedings as an
indicator of aspiration. This practice has not been shown to be an effective method to monitor
for or prevent aspiration pneumonia. In addition, studies have shown that critically ill patients
may have increased gut permeability, making them susceptible to absorption of the dye into
systemic circulation. When absorbed, blue food dye can act as a mitochondrial toxin causing
unfavorable outcomes, up to and including death. Methylene blue can be used to help
diagnosis enterocutaneous fistulas or during bedside swallow evaluations.

DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS

Medications are often administered through enteral feeding tubes. Information
concerning drug-nutrient interactions during enteral feedings is limited, particularly regarding
bioavailability and absorption. Medications given by the enteral route (bypassing the usual
location of absorption) may cause what appears to be formula intolerance and/or result in less
than optimal drug absorption (12). General guidelines for administering medications with tube
feedings are as follows (Table 2.7):

25
 TABLE 2.7 GENERAL GUIDELINES FOR ADMINISTERING MEDICATIONS
WITH ENTERAL FEEDINGS (13)

1. Stop the tube feeding prior to administration of meds.

2. Flush the feeding tube with 20-30 ml of warm water or appropriate volume before and after
giving medication through the tube.

3. If more than one medication is being given at the same time, give each medication separately
and flush the tube with 5 ml of warm water between medications.

4. Use liquid preparation if possible (if patient does not have diarrhea).

5. If a tablet form must be used, be sure it is finely crushed and dispersed in warm water.

6. Do not crush enteric-coated, sublingual, or sustained-release tablets, if in doubt check with

PharmD.

7. Restart tube feeding when done giving medications.

8. Consider tube site placement. Drugs that depend on gastric secretions for
breakdown/absorption may need to be substituted or given by an alternate method if tube
placement is in the duodenum or jejunum.

9. Medications may be given via NG, OG, ND, PEG or J tubes. Do not give crushed medications
via small bore ( 12 French) NJ or J tube, if at all possible, to prevent clogging.

10. Check with the pharmacist if in doubt about availability of medication in liquid form or whether
tablets may be crushed and administered via feeding tubes.

UVAHS DRUG INFORMATION HELP LINE: 4-8034

References
1. University of Virginia Health System Nutrition Support Traineeship Syllabus. Parrish CR, Krenitsky J,
McCray S. University of Virginia Health System Nutrition Support Traineeship, 2003.
2. Schwartz D. Enteral therapy. In: Lang CE, ed. Nutritional Support in Critical Care. Rockville, MD: ASPEN
Publishers Inc; 1987.
3. Breach CL, Saldanha LG. Tube feeding complications. Part I: Gastrointestinal. Nutrition Support
Services. 1988;8:15.
4. Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case Based Approach—The
Adult Patient. American Society of Parenteral and Enteral Nutrition. Silver Spring, MD, 2007.
5. Weinsier, RL, Heimberger DC, Butterworth CE. Handbook of Clinical Nutrition. St Louis: CV Mosby Co;
1989.
6. McClusky KW, Fishel L, Stover MR. Nutrition policy system: A model for patient care. JADA. 1987;87:200.
7. Page C, Andrassy R, Sandler J. Techniques in delivery of liquid diets: Short term and long term. Nutrition
in Clinical Surgery. Baltimore: Williams & Williams; 1985;60-87.
8. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized Patients. W.B.
Saunders Company, 1986.
9. Breach CL, Saldanha LG. Tube feeding complications. Part II: Mechanical. Nutrition Support Services.
1988;8:28.
10. Breach CL, Saldanha LG. Tube feeding complications. Part III: Metabolic. Nutrition Support Services.
1988;8:16.
11. Lucarelli MR, Shirk MB, Julian MW, Crouser ED. Toxicity of Food Drug and Cosmetic Blue No. 1 dye in
critically ill patients. Chest. 2004 Feb;125(2):793-5.
12. Smith MC, Brown TR. Handbook of Institutional Pharmacy Practice. Williams and Wilkins Co; 1984-5,
288-310.
13. Enteral Nutrition Handbook, Ross Laboratories, Columbus, Ohio, 1989.
26
SECTION 3. PARENTERAL NUTRITION (PN)

Parenteral nutrition (PN) support is used to nourish patients who either are
already malnourished or have the potential for developing malnutrition and who
are not candidates for enteral support (1). Parenteral nutrition provides
intravenous carbohydrates in the form of dextrose, protein in the form of amino
acids, lipids in the form of triglycerides, and vitamins, minerals, trace elements
and fluid.

PERIPHERAL PARENTERAL NUTRITION (PPN):

Peripheral Parenteral Nutrition is defined as supplementation via a peripheral

vein and is a temporary route for the administration of dilute nutrient solutions.
Sensitivity of peripheral veins to hypertonic solutions limits the caloric density of
formulations that may be used. Solutions with an osmolality of greater than 900
mOsm generally require central access (1, 2).

PPN is used only for a short time (up to 2 weeks) because (1):

 The lack of peripheral venous sites that can withstand long-term high
osmolality infusion
 May not meet patient’s calorie and protein needs

Indications:

PPN may be used in the following conditions:

 Partial or total nutrition support for patients who are not able to ingest
adequate calories orally or enterally, and whose therapy is likely to be less
than 7 days.
 When central-vein parenteral nutrition is not feasible or desirable.

Contraindications:

Because of the lower concentration of nutrients, PPN is not the optimal choice for
feeding patients with the following conditions:

 Large nutrient or electrolyte needs

 Fluid restriction
 The need for prolonged intravenous nutrition support

Note: “Vein Protector” is available and consists of:

Hydrocortisone 15mg (added to the PPN bag)
Heparin 1500 units (added to the PPN bag)

This may increase the life of the peripheral line on average from 6 days to 15
days (3).

27
CENTRAL PARENTERAL NUTRITION (CPN):

Central Parenteral Nutrition is defined as delivery of nutrients via central

venous access (1, 2). CPN allows for the provision of nutrients in greater
concentrations and smaller fluid volumes than is possible with PPN.

Short Term Access:

 Short term PN may be provided centrally via the subclavian or internal

jugular vein.
 If PN is needed for a prolonged period, one of the central venous access
devices listed below is required:

Long-term Access:

 Peripherally Inserted Central Catheter Line (PICC line), which is passed via
the antecubital vein, and advanced into the central venous system (5).
 Long-term access may be obtained using a catheter that is tunneled into the
subclavian vein subcutaneously away from the insertion site.
 Long term catheters that are tunneled under the skin, may reduce the
incidence of infection. Access ports may also be inserted under the skin.
Examples: Groshong, Hickman, Port – a – cath.
 Placement of long term IV access may be surgical or non – surgical
depending upon the type of catheter used. Implantable devices are inserted
surgically, whereas percutaneous catheters do not require surgical
intervention.

28
CLINICAL INDICATIONS FOR PARENTERAL NUTRITION:

Table 3.1 Indications for Parenteral Nutrition (1, 4)

Parenteral nutrition is usually indicated in the following situations:
 Documented inability to absorb adequate nutrients via the gastrointestinal
tract; this may be due to:
Massive small-bowel resection / Short bowel syndrome (at least initially)
Radiation enteritis
Severe diarrhea
Steatorrhea
 Complete bowel obstruction, or intestinal pseudo-obstruction
 Severe catabolism with or without malnutrition when gastrointestinal tract is
not usable within 5-7 days
 Inability to obtain enteral access
 Inability to provide sufficient nutrients/fluids enterally
 Pancreatitis in the setting of intolerance to jejunal delivery of nutrients
 Persistent GI hemorrhage
 Acute abdomen/ileus
 Lengthy GI work-up requiring npo status for several days in a malnourished
patient
 High output enterocutaneous fistula and EN access cannot be obtained distal
to the site.
 Trauma requiring repeat surgical procedures / NPO status
Parenteral nutrition may be indicated in the following situations:
 Enterocutaneous fistula as above
 Inflammatory bowel disease unresponsive to medical therapy
 Hyperemesis gravidarum when nausea and vomiting persist longer than 5 -7
days and enteral nutrition is not possible
 Partial small bowel obstruction
 Intensive chemotherapy / severe mucositis
 Major surgery/stress when enteral nutrition not expected to resume within 7-
10 days
 Intractable vomiting and jejunal access is not possible
 Chylous ascites or chylothorax when EN (with a very low fat formula) does
not adequately decrease output
Contraindications for Parenteral Nutrition:
 Functioning gastrointestinal tract
 Treatment anticipated for less than 5 days in patients without severe
malnutrition
 Inability to obtain venous access
 A prognosis that does not warrant aggressive nutrition support
 When the risks of PN are judged to exceed the potential benefits

29
COMPONENTS OF PARENTERAL NUTRITION:

A. MACRONUTRIENTS:

1. CARBOHYDRATE (1,2,5,6)

 Dextrose contains 3.4 kcal/g (CHO is given as a dextrose

monohydrate)

Requirements:

Minimum: 1 mg/kg/minute  1440 mg/kg/24hrs

Maximum: 5 mg/kg/minute 7200mg/kg/24hrs OR 7 g/kg/day OR 24
dextrose kcal/kg/day.

*Note: Per minute calculations are based on 24 hour infusions; not on

nocturnal or cyclic infusions, where infusion rates are generally higher.

Solutions:

Commercially prepared dextrose solutions are available in concentrations

ranging from 5% - 70% (D70W – Used at UVA). Solutions with final
concentrations greater than 10% must be administered into a central vein
because of the high osmolarity.

Consequences of excess CHO administration:

 Hyperglycemia
 Glucosuria
 Synthesis and storage of fat
 Hepatic steatosis
 Increased carbon dioxide production impairing pulmonary status/vent
wean

2. PROTEIN (1, 2, 7)

 Amino acid = 4 kcal/g

 Protein calories should be included when calculating total caloric
requirements.

Requirements:

 Approximately 16% of protein or amino acids are nitrogen. The goal

should be to provide adequate protein to maintain a positive (2 to 4 g)

30
  Requirements range from 0.8 g/kg/day to 2.5 g/kg/day. For specifics,
see table 1.9.
 Generally 15 – 20% of the daily caloric intake should come from
protein.

Crystalline amino acids are currently the protein source for commercial
formulas. Amino acids are available in concentrations of 3 – 15%. Amino
acid solutions of 3% and 3.5% (without added electrolytes) are nearly
isotonic, making them acceptable for peripheral administration. Standard
amino acid solutions are usually comprised of 40 – 50% essential amino
acids and 50 – 60% non-essential amino acids.

At UVA: 10% Travasol amino acid solution is used and is customized

according to the protein needs of patients.

2. FAT (1, 8, 9)

IV lipids are also referred to as IV fat emulsions (IVFE)

 Exact fat requirements are unknown.

Minimum: To prevent essential fatty acid deficiency (EFAD), 2% to 4%

of the total caloric requirement should come from linoleic acid (25 to
100 mg/kg/day)
Maximum: Maximal fat dosage should not exceed 60% of calories OR
1.0 - 2.5 g/kg/day (8)

For critically ill patients, IVFE should not exceed 1.0

g/kg/day (8)

 Intralipid (Soybean oil) – 20% lipid (2 kcal/ml) is used at UVA.

 Has phospholipid as the emulsifier.
 Use with caution in patients allergic to eggs.
 Lipids should be used with caution in patients with serum triglycerides
(TG) > 400mg/dl.
 Lipids are generally administered over a 24 hour period.
Administering lipids over a 24 hour period may avoid
immunosuppression and improve clearance. However with cyclic PN
( 12 hours), most patients tolerate lipids delivered over this shorter
period. Guidelines for rate of infusion are < 0.11 g / kg / hr (8).
 Propofol is a lipid-based sedative (soybean oil-in-water emulsion) that
contains phosphorus and provides 1.1 kcal/ml. Because propofol has
rapid onset and quick recovery, it is becoming widely used in critical
care units. Infusion of propofol or any other lipid-based drug must be

31
 Propofol contains phosphorus-75 mEq (115mg or 37mm) / 1 L

Consequences of excess lipid administration:

 Fat overload syndrome with neurologic, cardiac, pulmonary, hepatic

and renal dysfunction
 Thrombocyte adhesiveness
 Accumulation of lipid in the reticuloendothelial system (RES), leading
to RES dysfunction
 Impaired immune response

B. MICRONUTRIENTS:

1. VITAMINS (2)

Parenteral vitamin requirements differ from enteral requirements

because of differences in efficiency of absorption and utilization of
nutrients administered via the parenteral route, and physiochemical
stability in the parenteral solutions.
 Because of instability when mixed with PN solutions, vitamins are
added just prior to administering the solution.
 Optimal vitamin intakes for seriously ill and septic patients are
unknown.

32
 TABLE 3.2 AMERICAN MEDICAL ASSOCIATION and FOOD AND DRUG
ADMINISTRATION RECOMMENDATIONS FOR PARENTERAL VITAMIN
INTAKE (10-12)

Vitamin AMA FDA Multi-Vitamins added to

Recommended Recommended standard PN solution at
Amount Amount UVA –
(MVI-ADULT, 10 ml/day)
Vitamin A 3300 IU 1 mg / 3300 units 3300 USP units

Vitamin D 200 IU 5 mcg / 200 units 200 USP units

Vitamin E 10 IU 10 mg / 10 units 10 USP units

Vitamin K - 150 mcg 150 mcg

Ascorbic acid 100 mg 200 mg 200 mg

Folic Acid 0.4 mg 600 mcg 600 mcg

Niacin 40 mg 40 mg 40 mg

Riboflavin (B2) 3.6 mg 3.6 mg 3.6 mg

Thiamin (B1) 3 mg 6 mg 6 mg

Pyridoxine (B6) 4 mg 6 mg 6 mg

Cyanocobalamin 5 mcg 5 mcg 5 mcg

(B12)
Pantothenic acid 15 mg 15 mg 15 mg

Biotin 60 mcg 60 mcg 60 mcg

2. TRACE ELEMENTS (13)

 Trace elements are critical to support proper function of metabolic
pathways.

 Additional zinc (5-10 mg daily) should be considered during periods of

excessive GI output (diarrhea, fistulas, or ostomies) or for severe
wounds / burns.

 Use of copper and manganese should be closely evaluated in the

setting of biliary obstruction and liver failure. Whole blood manganese
levels should be monitored for any patient receiving parenteral nutrition
for > 3 months. Use 0.3 mg copper per day for patients with
cholestasis, and recheck levels monthly (13, 14).

33
  Iron is not routinely added to parenteral nutrition solutions. Iron may be
added to 2:1 mixtures but not 3:1 mixtures. Parenteral iron therapy is
indicated in patients with iron deficiency anemia associated with
conditions that interfere with the ingestion or absorption of oral iron.
The overall incidence of adverse reactions associated with the
parenteral administration of iron is low, but the potential for an
anaphylactic reaction requires that an initial test dose be given followed
by careful observation (13).

 Concentrated Multitrace 5 is used at UVA. See table 3.3

TABLE 3.3 Daily Parenteral Trace Element Supplementation for Adults (13)
Previous Guidelines Recent Concentrated Non-
Trace (AMA - 1979) 1 Recommendations2 Multitrace 5 Concentrated
Element ( ASPEN-2004) (1mL) MTE- 5 (2.5mL)
used at UVA
Zinc 2.5-4 mg 2.5-5 mg 5 mg 2.5 mg
Copper 0.5-1.5 mg 0.3-0.5 mg 1 mg 1 mg
Chromium 10-15 mcg 10-15 mcg 10 mcg 10 mcg
Selenium No guideline 20-60 mcg 60 mcg 50 mcg
Manganese 150-800 mcg 60-100 mcg 500 mcg 250 mcg

mg = milligrams mcg = micrograms

3 ELECTROLYTES (2)

 Electrolyte requirements in PN can vary widely The table on the

following page provides a guideline of “standard”, maintenance levels
of electrolytes used at UVA for patients without significant metabolic
disarray..

 Calcium and phosphorus (Ca/P) compatibility in PN solution:

The combination of calcium and phosphorus salts in excessive
amounts may result in crystalline precipitate and possible catheter
occlusion, as well as adverse patient outcomes. The maximal amount
of calcium and phosphorus that may be added to a given volume of PN
is dependent on several factors including the volume of fluid, the pH of
the solution ( in pH results in  Ca/P solubility), and mixing
procedures. At UVA a maximal combined dose of calcium and
phosphorus does not exceed 52 mEq/L of PN.
 At UVA, all macro and micronutrients are ordered as “per day” or “per
bag” and not per L.

34
TABLE 3.4 DAILY ELECTROLYTE RECOMMENDATIONS (15, 16)

Electrolyte Daily Standard Additive at UVA

Recommendations or
Requirements
Sodium 70 – 100 mEq/day 63 mEq/day

Chloride 70 – 100 mEq/day Varies per day,

based on composition of
other e’lytes in the PN
solution.
Potassium 70 – 100 mEq/day 72 mEq/day

Calcium 10 – 20 mEq/day 8.1 mEq/day

Magnesium 15 – 20 mEq/day 18 mEq/day

Phosphorus 40-60 mEq/day 18 mMol/day

Acetate 0 – 60 mEq/day 53 mEq/day

Other Custom PN Additives available at UVA include:

Insulin, Human Regular Vitamin K Famotidine

Heparin Vitamin C Vitamin B12
Chromium Copper Manganese
Zinc Selenium Iron dextran
Thiamin

C. FLUIDS
Standard rate at UVA is 75 ml/hour. See section on PN calculations to calculate
minimum flow rates.

PN SCHEDULES:

 Continuous nutrient infusion

 Cyclic – usually 12 hour infusion overnight
 Improved quality of life
 In preparation for discharge home
 Run PN at half of the goal rate for the first and the last hour
 Monitor fluid status, blood glucose response

35
 TABLE 3.5 STANDARD PN ORDERS AT UVA

Central Line: CPN Peripheral line: PPN

Provides: Provides:
Macronutrients: Macronutrients:
750 Dextrose calories/day 400 Dextrose calories/day
300 Protein calories/day 300 Protein calories/day
500 Fat calories/day (250 mL of 20% 500 Fat calories/day (250 mL of 20%
lipid per day) lipid per day)

Electrolytes: See Standards on Table 3.4

Trace elements: 1mL/day (ATES-5)—see page 34
Multivitamin: 10 ml/day—see page 33

Total calories: 1550/day Total calories: 1200/day

Total protein: 75 g/day Total protein: 75 g/day

The differences between standard CPN and PPN are in the dextrose and total calories and have been
underlined.

PARENTERAL NUTRITION CALCULATIONS:

CUSTOM PN:

Step 1 – Determine protein and calorie needs

Step 2 – Subtract protein calories (grams protein x 4) from total calories
Step 3 – Subtract lipid calories* from remaining calories
Step 4 – remaining will be dextrose calories

IV lipids UVA are 20% or 2 calories / mL. To avoid wastage of lipid and to simplify orders,
order lipid by 250 ml or 500 ml bag per day. Decide whether 250 ml or 500 ml is more
appropriate based on the goal for % of kcals provided by fat or by maximal amount allowed
to avoid immunosuppression (~1 gm / kg body weight).

36
Minimum flow rates:
Dex/50 + g Pro/215 + 5 = minimum flow rate

Central:
[(Dextrose kcals X 0.42) + (grams of protein X 10)] ÷ 24 = minimum hourly flow rate. Add
5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.

Peripheral: [(Dextrose kcals x 0.15) + grams of protein] ÷ 2.1 = minimum hourly flow rate.
Add 5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.

COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION (1):

Parenteral Nutrition can be a life-saving therapy, but complications may arise.

Potential complications of PN include:

 Metabolic complications; hyperglycemia is the most common – tight blood glucose

control is optimal.
 Gastrointestinal complications: steatohepatitis, cholestasis (17,18)
 Pharmacological complications
 Manganese toxicity is possible with prolonged use of PN (14)
 Infection / sepsis
 Metabolic bone disease (19)

37
TABLE 3.6 GASTROINTESTINAL COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION (OR LACK OF
ENTERAL NUTRITION) (4)

Complication Possible Etiology Symptoms Treatment Prevention

Fatty liver  Delivery of  Elevation of liver  Reduce  Use mixed
carbohydrate in excess enzymes within 1 to carbohydrate substrate
of hepatic oxidative 3 weeks post PN delivery solutions
capacity initiation  Cyclic PN  Avoid
 Overfeeding of calories  Rule out other overfeeding
and/or fat causes  Avoid glucose
 Excess infusion of  Begin enteral infusion > 5 – 7
amino acids nutrition if possible mg/kg/minute
 Essential fatty acid  Enteral nutrition
deficiency as tolerated
 Carnitine deficiency (trophic feedings)

Cholestasis  Impaired bile flow  Progressive  Avoid overfeeding  Early use of

 Lack of intraluminal increases in serum  Rule out other gastrointestinal
nutrient stimulation total bilirubin causes tract
of hepatic bile  Elevated serum
secretion alkaline phosphatase
 Overfeeding
 Toxic tryptophan
metabolites
Gastrointestinal  Atrophy of villi  In vitro, presence of  Transition to  Early use of
mucosal atrophy  Colonic hypoplasia enteric bacteria in enteral/oral gastrointestinal
mesenteric lymph feedings as tract
nodes tolerated
 Development of
enteric bacteremia
and sepsis without
clear source

38
References
1. Madsen H, Frankel EH. The Hitchhiker’s Guide to Parenteral Nutrition Management for
Adult Patients. Practical Gastroenterology 2006; XXX(7):46-68.
2. Gottschlich, MM, ed. Nutrition Support Core Curriculum: A Case Based Approach. Silver
Spring, MD: American Society of Parenteral and Enteral Nutrition; 2007.
3. Tighe MJ, Wong C, Martin IG, et al: Do heparin, hydrocortisone, and glyceryl trinitrate
influence thrombophlebitis during full intravenous nutrition via a peripheral vein? JPEN
19:507-509, 1995.
4. University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR,
Krenitsky J, McCray S). Parenteral Module. University of Virginia Health System Nutrition
Support Traineeship Syllabus, 2003.
5. Baumgartner TG. Parenteral macronutrition. In: Baumgartner TG, ed.
Clinical Guide to Parenteral Micronutrition. Fujisawa USA, Inc; 1997: 41.
6. Evans N. The role of total parenteral nutrition in critical illness: Guidelines
and recommendations. AACN Clinical Issues. 1994;5:476-484.
7. Miles J, Klein J. Should protein be included in calorie calculations for a TPN
prescription? Nutrition in Clinical Practice. 1996;11:204-206.
8. Hise ME, Brown JC. Lipids. In: Gottschlich, MM, ed. Nutrition Support Core Curriculum:
A Case Based Approach. Silver Spring, MD: American Society of Parenteral and Enteral
Nutrition; 2007:54-57.
9. Lowrey T, Dunlap A, Brown R, Dickerson R, Kudsk K. Pharmacologic
influence on nutrition support therapy: Use of propofol in a patient receiving
combined enteral and parenteral nutrition support. Nutrition in Clinical
Practice. 1996;11:147-149.
10. Parenteral multivitamins products; drugs for human use; drug efficacy study
implementation; amendment (21 CFR 5.70). Federal Register. April 20, 2000; 65:21200-
21201.
11. Fuhrman MP, Hammond KA, et.al. The Science And Practiceof Nutrition
Support. Dubuque, Iowa: American Society of Parenteral and Enteral Nutrition; 2001: 94.
12. M.V.I. Adult UNIT VIAL, Manufacatured by: AstraZeneca, Westborough MA;
January 2004.
13. Fessler TA. Trace Element Monitoring and Therapy For Adult Patients Receiving Long
Term Total Parenteral Nutrition. Practical Gastroenterology. 2005;25:44-65.
14. O’Donnell K, Radigan, A. Hypermanganesemia in an Acute Care Setting.
Nutrition in Clinical Practices. 2003;18:374-376.
15. Skipper A, Marian MJ. Parenteral Nutrition. In: Gottschlich MM, ed. Nutrition Support
Dietetics Core Curriculum. 2nd Ed. Silver Spring, MD. American Society of Parenteral and
Enteral Nutrition, 1993:111.
16. Evans JN. The role of total parenteral nutrition in critical illness: guidelines and
recommendations. AACN Clincal Issues. 1994;5:476-484.
17. Lee V. Liver Dysfunction Associated with Long Term Parenteral Nutrition:
What are the options? Practical Gastroenterology 2006. XXX(12):49-68.\
18. Jeejeebhoy. Management of PN induced cholestasis. Practical Gastroenterology 2005;
XXIX(2):62-68.
19. Hamilton C, Seidner D. Metabolic Bone Disease in the Patient on Long-Term Parenteral
Nutrition. Practical Gastroenterology 2008; XXXII(1):18-32.

39
APPENDIX

40
APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM*

Lab Parameter Normal Range Elevated with: Decreased with:

BUN 7 – 18.7 mg/dl Dehydration Liver failure

Renal disease Increased protein synthesis
Higher in elderly: Increased protein metabolism - Late pregnancy
8.4 – 25.7 mg/dl Starvation - Infancy
Stress Acromegaly
Diabetes Nephrotic syndrome
Fever Overhydration
Acute myocardial infarction Malabsorption
G I bleed Low protein, high CHO diets
Congestive heart failure
Urinary obstruction

Creatinine 0.6 - 1.1 mg/dl Large muscle mass

Muscle disease
Starvation
Renal disease

CO2 (Bicarbonate) 22 – 29 mmol / L Metabolic alkalosis Metabolic acidosis

Respiratory acidosis Respiratory alkalosis
Emphysema Hyperventilation
Vomiting Fever
Lack of oxygen

*This list is not all inclusive. For example, drug effects not listed.

41
APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (Cont)*
Lab Parameter Normal Range Elevated with: Decrease with:

Serum Osmolarity 275 – 295 mOsm/L Inadequate fluid intake Excess fluid intake
Diarrhea Adrenal disease
Osm = serum sodium x 2 + Calculated values are Diabetes mellitus Inappropriate ADH secretion
generally lower than Diabetes insipidus - Hypothyroidism
BUN + Glucose
2.8 18
measured values Renal disease - Cerebral disease
Hyperlipidemia Porphyria
Hyperglycemia - Bronchogenic cancer

Serum Glucose 74 – 99 mg/dl Diabetes mellitus Liver disease

Cushing’s syndrome Neoplasms
* Elevated values may give Acromegaly Pancreatic disorders
falsely low serum sodium Hemochromatosis Adrenal insufficiency
values. For every 100% Pheochromocytoma Hypothyroidism
elevation, serum sodium is Burns, shock Fluid overload
decreased by 2 mEq/L Acute pancreatitis Severe sepsis
Wernicke’s encephalopathy
Dehydration
Sepsis
Overfeeding
Corticosteroids
Blood draw contaminated with
PN (can confirm with a finger
stick)
*This list is not all inclusive. For example, drug effects not listed.

42
APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Hematocrit (HCT) Women: 35 – 47% Dehydration Hemorrhage

Men: 40 – 52% Polycythemia Anemia
Often used to diagnose iron Fluid overload
deficiency; not a conclusive Advanced age
measure Late Pregnancy

Hemoglobin (Hgb) Women: 12 – 16 gm/dl Dehydration Hemorrhage

Men: 14 – 18 gm/dl Polycythemia Iron deficiency anemia
More direct measure of iron Malnutrition
deficiency than HCT Advanced age
Late pregnancy
Renal failure
Fluid overload

Mean Corpuscular Volume 83 – 95 fL Macrocytosis Microcytosis

(MCV) - Folate deficiency - Advanced iron deficiency
- Vitamin B 12 deficiency - Blood loss
Indicates average size of the - Excess alcohol intake Iron malabsorption
red blood cells. Hemochromatosis Lead poisoning

Calculated MCV = HCT x 10

RBC

**This list is not all inclusive. For example, drug effects not listed.

43
APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Sodium 136 – 145 mmol / L Dehydration: Adrenal insufficiency

Diabetes Insipidus Extreme sweating
Body content of sodium is not Osmotic diuresis Diuretics
always reflected in serum GI losses Diabetic acidosis
levels Renal disease Malabsorption
Severe exercise Excessive GI losses
( diarrhea, vomiting, etc)
SIADH

Potassium 3.4 – 4.4 mmol / L Hemolysis Refeeding Syndrome

Burns, shock Starvation
Crush injuries Excessive GI losses
Excess supplemental potassium (diarrhea, vomiting, etc)
Renal failure Hypomagnesemia
Diabetic ketoacidosis Cushing’s syndrome
Dehydration Diuretics
Hyperglycemia Amphotericin
Acidosis
Blood draw contaminated with PN

Chloride 98 – 107 mmol / L Dehydration Excessive GI losses

Renal failure (diarrhea, vomiting, etc)
Excess urinary losses

*This list is not all inclusive. For example, drug effects not listed.

44
APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Calcium 8.4 – 10.2 mg/dl Cancer Hypoparathyroidism

Renal disease Renal disease
Absorption decreased by Vitamin D intoxication Osteomalacia
phytates, oxalates, Hyperparathyroidism Steatorrhea
phosphates Renal calculi Rickets
Prolonged Immobilization Hypomagnesemia
Check ionized calcium

Phosphorous 2.3 – 4.7 mg/dl Hemolysis Rickets

Renal disease Insulin injections
Healing fractures Malnutrition
Vitamin D deficiency Malabsorption
Skeletal disease Refeeding syndrome
Chronic diarrhea
Magnesium 1.6 – 2.6 mg/dl Renal failure Alcoholism
Diabetic acidosis Pancreatitis
Hypothyroidism Renal disease
Addison’s disease Hepatic cirrhosis
Dehydration Toxemia of pregnancy
Overuse of magnesium Hyperthyroidism
supplements or antacids Malabsorption
Hemolysis Ulcerative colitis
K- depleting diuretics
Refeeding syndrome
*This list is not all inclusive. For example, drug effects not listed.

45
 APPENDIX 2. ADULT MULTIVITAMIN SUPPLEMENTS AVAILABLE AT UVA
Amt. A D E B1 B2 Niacin B5 B6 B12 Folate C Ca Fe *Others
Product/Form (IU) (IU) (IU) (mg) (mg) (mg) (mg) (mg) (mcg) (mg) (mg) (mg) (mg)
1 5000 400 30 1.5 1.7 20 10 2 6 0.4 60 - - -
Therapeutic tablet
multivitamin tablet
1 5000 400 60 3 3.4 20 40 6 12 0.4 90 40 - 1
Therapeutic high tablet
potency vitamins
with minerals
1 2500 400 15 1.05 1.2 13.5 - 1.05 4.5 0.3 60 - - -
Children’s tablet
Chewable
Multivitamin
Liquid multivitamin 5 ml 5000 400 - 10 10 100 21.4 4.1 5 - 200 - - -

Liquid high potency 15 ml 1300 400 30 1.5 1.7 20 10 2 6 - 60 - 9 2

multivitamin with
minerals
MVI ADULT 10ml 3300 200 10 6 3.6 40 15 6 5 0.6 200 - - 3
IV multivitamin
ADEKs tablets 1 4000 400 150 1.2 1.3 10 10 1.5 12 0.2 60 - - 4
tablet
Nephro – vite for 1 - - - 1.5 1.7 20 10 10 6 0.8 60 - - 5
dialysis patients tablet
Materna 1 5000 400 30 3 3.4 20 10 10 12 1 100 250 60 6
Prenatal vitamin tablet
The “others” category:
1. Vitamin K 28 mcg, Calcium 40 mg, Phosphorus 31 mg, Potassium Chloride 7.5mg, Iodine 0.15mg, Copper 2 mg,, Biotin 30 mcg, Manganese 2 mg, Magnesium
100 mg, Zinc 15 mg, Selenium 70 mcg, Chromium 50 mcg, Molybdenum 75 mcg, Boron 150 mcg, Tin 10 mcg, Vandium 10 mcg, Nickel 5 mcg, Silica 2 mg
2. Chromium 25 mcg, Iodine 0.15 mg, Molybdenum 25 mcg, Manganese 2 mg, Zinc 3 mg, Biotin 300 mcg, Iron 9 mg (78 mg Fe gluconate)
3. Biotin 60 mcg
4. Zinc 7.5 mg, Vitamin K 150 mcg, Biotin 50 mcg, Beta carotene 3 mg, Fructose
5. Biotin 300 mcg
6. Chromium 25 mcg, Iodine 0.15 mg, Copper 2 mg, Magnesium 25 mg, Molybdenum 25 mcg, Biotin 30
mcg, Zinc 25 mg, Manganese 5 mg

46
 APPENDIX 3. ADULT VITAMIN SUPPLEMENTS AVAILABLE AT UVA

Vitamin Form Dose Composition

Capsule (as beta 1 each 25,000 IU
Vitamin A carotene)
Drops 1 ml 50,000 IU/ ml

Injection 2 ml 100,000 IU

Capsule 1 each 50,000 IU

Vitamin D2 -
Ergocalciferol
Drops (“Drisdol”) 0.25 ml 2000 IU

Vitamin D3 - Tablet 1 each 400 IU and 1000 IU

Cholecalciferol
Capsule 0.25 mcg & 0.50 mcg
Calcitriol -active
form (Calcijex or Liquid 0.25 mcg, 1 mcg/ml
Rocaltrol) 2 mcg
Injection 1 mcg

Capsule 1 each 100 IU, 400 IU, &

Vitamin E 1000 IU
(Aquasol E)
Drops 0.3 ml 15 IU

Tablet 1 each 5 mg
Vitamin K
Injection 0.5 ml 1 mg
1 ml 10 mg

Tablet 1 each 25 mg, 50 mg, & 100mg

Vitamin B6
Tablet 1 each 100 g
Vitamin B12
(Cyanocobalamin) Injection 1 ml 1000 g

Tablet 1 each 500 mg

Vitamin C
(Ascorbic acid) Syrup 5 ml 500 mg

47
Vitamin C (con’t.) Injection 1 ml 500 mg & 1000 mg

1 each 3 mg B1, 3 mg B2,

Vitamin B Complex Soft gel capsule 20 mg B3, 0.5 mg B6,
1 g B12,
5 mg Panthothenic acid,
60 mg Desiccated liver,
60 mg Debittered
Brewer’s yeast
Thiamin Tablet 1 each 100 mg

Thiamine HCl Injection 1 ml 100 mg

Niacin Tablet 1 each 250 mg

Niacin ER (Niaspan) Tablet 1 each 500 mg

Nicotinic Acid Tablet 1 each 50 mg & 100 mg

Folic Acid Tablet 1 each 1 mg

Injection 1 mL 5 mg

APPENDIX 4. ADULT MINERAL SUPPLEMENTS AVAILABLE AT UVA

Vitamin Form Dose Composition

Calcium Acetate Capsule 1 each 667 mg

Calcium Carbonate Liquid 2.5 ml 625 mg

4 mL 1g
Calcium Oyster
Shell w/ Vit. D Tablet 1 each 250 mg
(Oscal 250)

Calcium Oyster Tablet 1 each 500 mg

Shell
Syrup (liquid) 5 mL 1.8 g
Calcium Glubionate

48
Vitamin Form Dose Composition
Ferrous sulfate Tablet 1 each 300 mg

Ferrous gluconate Tablet 1 each 300 mg

Iron dextran Injection 1 mL 50 mg

Zinc Sulfate Capsule 1 each 220 mg

Zinc trace elements Injection 1 mL 1 mg

Chromium Injection 10 mL 40 mcg

Phosphorus
Phos-Nak (Na, P-250 mg/mol
Phos, K+) Powder 1 packet Na-160 mg
K+-280 mg

Neutrophos-K (K+, Powder 1 packet P-250 mg

Phos) K+-556 mg

Magnesium Tablet 1 each 500 mg

Gluconate
Liquid 5 mL 1000 mg

Magnesium Oxide Capsule 1 each 140 mg

Tablet 1 each 400 mg

Magnesium Sulfate Injection 1 ml 1 gm

Potassium Acetate Injection 1 mL 2 mEq

Potassium Chloride Capsule 1 each 10 mEq

Powder 1 scoop 20 mEq

Liquid 3.75, 7.5, 11.25, 5, 10, 15, 30 mEq

22.5 mL

Potassium Iodine Liquid 1 ml 1g

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APPENDIX 5 CONVERSION INFORMATION

1. Converting from milliequivalents (mEq) to milligrams (mg) and vice versa:

mEq = mg
Conversion factor

Conversion Factors For Major Minerals

 1 mEq Na = 1 mmol Na = 23 mg Na
 1 g Na = 43 mEq Na = 43 mmol Na
 1 mEq K = 1 mmol K = 39 mg K
 1 g K = 26 mEq K = 26 mmol K
 1 mEq Ca = 0.5 mmol Ca = 20 mg Ca
 1 g Ca = 50 mEq Ca = 25 mmol Ca
 1 mEq Magnesium = 0.5 mmol Magnesium = 12 mg Magnesium
 1 g Magnesium = 82 mEq Magnesium = 41 mmol Magnesium
 1 mmol Phos = 2 mEq HPO3 = 31 mg Phos
 1 mEq Cl = 1 mmol Cl = 35 mg Cl
 1 g Cl = 29 mEq Cl = 29 mmol Cl

Major Mineral Content in Various Compounds and solutions

 1 g NaCl = 393 mg Na = 17 mEq Na

 1 g NaHCO3 = 273 mg Na = 12 mEq Na
 1000 ml saline = 9 g NaCl = 3.5 g Na = 154 mEq Na
 1000 ml lactated Ringer’s solution = 3 g Na = 130 mEq Na
 1 ampule (50 ml) 7.5% NaHCO3 = 1 g Na = 44 mEq Na
 1 g KCl = 524 mg k = 13 mEq K
 1 g CaCl2 2H2O = 273 mg Ca = 13.6 mEq Ca (when weighed in hydrated forms)
 1 g Ca gluconate = 93 mg Ca = 4.6 mEq Ca
 1 g MgSO4 7H2O = 99 mg Mg = 8.1 mEq Mg (when weighed in hydrated forms)
 1 mg Mg gluconate 2H2O = 54 mg Mg = 4.4 mEq Mg (when weighed in hydrated forms)
 1 g CaCO3 = 400 mg Ca = 20 mEq Ca
 1 g FeSO4 7H2O = 201mg Fe (when weighed in hydrated forms)
 1 g Fe gluconate 2H2O = 116 mg Fe (when weighed in hydrated forms)
 1 ml Fe dextran (Imferon) = 50 mg Fe

2. Converting sodium chloride to sodium:

NaCl (table salt) is 40% sodium and 60% chloride.

Therefore: 1gm sodium chloride = 400 mg sodium
400 mg sodium = 17 mEq sodium

3. Niacin equivalents:
1% available dietary protein = tryptophan
60 mg dietary tryptophan is equivalent to 1 mg niacin.
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APPENDIX 6 Electrolyte Content and pH of Selected Body Fluids (mEq/L)
Body Fluid Approx. amount Na K HCO3 H Cl pH
secreted per day
(mL)
Sweat 750 30-50 5 - - 45-55
Gastric 2000 - 3000 40-65 10 - 90 100-140 1.2-3
Pancreas 2500 135-155 5 70-90 - 55-75 7-8
Ileostomy varies 120-130 10 50-70 50-60 7
Bile 500 - 750 135-155 5 35-50 - 80-110 7
Diarrhea varies 25-50 35-60 30-45 - 20-40 varies
Normal stool 200 5 10 - - 10 varies
Urine varies 30-80 30-80 - - 50-100 4.5-8
Blood n/a 138 4.5 25 - 103 7.4

Used with permission from the University of Virginia Health System Nutrition Support Traineeship
Syllabus (Parrish CR, Krenitsky J, McCray SF). University of Virginia Health System Traineeship, 2003.

Adapted from:

Willcutts K, Scarano K, Eddins CW. Ostomies and Fistulas: A Collaborative Approach. Practical
Gastroenterology 2005; XXIX(11):63-79.

Frietag & Miller (eds) Manual of Medical Thrapeutics 23rd ed, Little Brown and Co 1982.

Grant JP. Handbook of Total Parenteral Nutrition. 2nd ed. Philadelphia: W.B. Saunders Co; 1992: 174.

Pemberton, LB; Pemberton DK, and Cuddy PG. Treatment of Water, Electrolyte and Acid-base Disorders
in the Surgical Patient. McGraw-Hill, Inc. Health Professions Division, 1994.

Appendix 7 Content of Commonly Used Intravenous (IV) Fluids

Fluid Na K Glucose(gm) Tonicity
(mEq)
0.9 normal saline (NS) 154 0 0 Slightly Hypertonic
0.45 NS 77 0 0 Hypotonic
0.25 NS 38 0 0 Hypotonic
Lactated Ringers (LR) 130 4 0 Isotonic
D5W 0 0 50 Hypotonic
D5W 0.45 NS 77 0 50 Hypotonic

Note: 1 liter of NS contains approximately 2 teaspoons of salt

Adapted from: Corbett EC. Intravenous Fluids: It’s More Than Just Fill ‘Er Up. Practical
Gastroenterology 2007; XXXI(7):44-60.

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Appendix 8 Recipe for Normal Saline equivalent mixture (enteral use only)

Mix 1.5 teaspoons of table salt in 1 liter of warm water

Appendix 9 Pancreatic Enzyme Replacement Therapy

Pancreatic enzyme activity is measured in lipase units. The number in the product name
indicates the amount of lipase. Pancreatic enzyme medications are available in varying
strengths.
Name of Product
Creon 6,000
Creon 12,000
Creon 24,000

Guidelines for Dosing:

1,000 – 2,000 units of lipase / kg / meal
OR
500 – 4,000 units of lipase / gram of dietary fat (Becker, JADA 2001)

Dose should not exceed 2,500 units of lipase / kg / meal (Borowitz Peds Gastro 2002)
or 10,000 units of lipase / kg / day (Pankrease info)

High doses have been associated with fibrosing colonopathy (FitzSimmons NEJM 97)

Appendix 10 Common Conversions

Dextrose

To convert mmol / L to mg / dL, multiply by 18

To convert mg / dL to mmol / L, divide by 18 OR multiply by 0.55

Energy

1 kilocalorie = 4.184 kilojoules

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Appendix 11 Normal Lengths of Bowel

Section of Bowel Approximate Normal Length

Duodenum 10 inches (25 - 30 cm)
Jejunum 6 – 10 feet (200 – 300 cm)
Ileum 10 – 13 feet (300 – 400 cm)
Colon 5 feet (160 cm)

Note: Short gut is defined as either:

 3-4 feet (100- 120 cm) of small intestine without colon, OR
 60 - 75% of small bowel resected, OR
 1.6 feet of small intestine with colon (preservation of at least half of the
colon is equivalent to retaining 50 cm of functional SB.)

Adapted from: Parrish CR. TheClinician'sGuidetoShortBowelSyndrome. Practical Gastroenterology

2005; XXIX(9):67-106.

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