Adult Enteral And Parenteral Nutrition Book 1f3s42

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 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 HANDBOOK TABLE OF CONTENTS ADULT NUTRITION SERVICES AT THE UVA HEALTH SCIENCES CENTER…….……1 Inpatient clinical nutrition services Nutrition teams SECTION 1. I

II III IV

V

SECTION 2.

NUTRITIONAL ASSESSMENT OF ADULT PATIENTS Introduction………………………………. ………………….…………2 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 Clinical information……….……………………………………………..4 Physical signs of nutritional deficiency (table)……….……………...5 Nutritional intake history…………………….…………………………6 Biochemical data Factors associated with nutritional status (table)….………………..7 Refeeding syndrome…………………….……………………..…..8-9 Subjective global assessment of nutritional status……….……….10 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 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 istration…………………….18 To order enteral nutrition…………………………………………….….18 Enteral nutrition delivery: Routes of istration (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 : Preventing complications ………………………...…………….……25 General guidelines for istering 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 ed 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 dietitian is on site on Sundays. Nutrition Teams: Medicine/Surgery: There are two nutrition teams for adult patients at UVA HS. 1.

Medicine Nutrition (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 or patients with complex GI disorders affecting nutritional intake. The team can be ed by paging PIC # 4264 and/or entering an order via EPIC. 2.

Surgery Nutrition (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 . The team can be ed 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 measures. The four basic components of nutritional assessment include (1): 1. 2. 3. 4. I.

Anthropometrics Clinical Information Nutrition Intake History Biochemical Data

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

2

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 s 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 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.

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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): % Total Body Weighta 1.8 6 15 18.5 1 3 5 6.5

Type of Amputation Foot Below Knee Amputation Above Knee Amputation Entire Lower Extremity Hand Below Elbow Above Elbow Entire Upper Extremity 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 Moderate Ascites Severe/tense Ascites

~ ~ ~

3 kg 7-8 kg 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 Petechiae, Ecchymosis Follicular hyperkeratosis

Vitamin A Vitamin C or K Vitamin A, Vitamin C, Essential Fatty Acid

Pellagrous dermatosis “Flaky Paint” dermatosis

Niacin, Tryptophan Protein

Hair

Dull, dry, thin and easily pluckable

Protein and Essential Fatty Acid

Eyes

Eyelid lining and whites pale Bitot’s spots Corners of eyes cracked, Red or inflamed eyelids Cornea dull, milky, hazy, or opaque

Anemia Vitamin A Riboflavin and Niacin

Mouth

General Appearance

Neurologic

Vitamin A

Magenta tongue, Tastebuds atrophied

Riboflavin

Glossitis

Niacin, Folate, Vitamin B12

Bleeding gums

Vitamin C

Cheilosis

Riboflavin, Pyridoxine

Angular stomatitis

Riboflavin, Niacin, Iron, Pyridoxine, Vitamin B12

Edema

Protein

Muscle wasting Decreased subcutaneous fat

Protein-Calorie Malnutrition

Disorientation

Thiamin, Niacin

Thiamin, Copper, B12 Neuropathy ____________________________________________________________________________________________

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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 

IV.

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 , education, etc.

(4)

Past or present need for enteral or parenteral nutrition

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

TOTAL URINARY NITROGEN ( TUN)* Measures the net changes in the body’s total protein mass**

Interpretation of Values

Potential causes for high values

Calculation of N2 balance**: 24 hr. protein intake – TUN (gm) + 2 gm] 6.25

Growth Pregnancy Recovery from illness Athletic training

Potential causes for low values______________________ Inadequate calorie or protein intake Increased catabolism Trauma 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 changes in the body’s total protein mass

Calculation of N2 balance**: 24 hr. protein intake –UUN (gm) + 4 gm] 6.25

Growth Pregnancy Recovery from illness Athletic training

Inadequate protein intake Increased catabolism Trauma 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 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 oxyhemoglobin. The degree of symptoms exhibited depends upon the extent of malnutrition, electrolyte supplementation prior to nutrition 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 itted 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 and replace any low levels promptly – however, do not withhold nutrition until serum levels are corrected, rather replete electrolytes concurrently with the nutrition provided. 3) Initiate nutrition , 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 ed 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 ister vitamins to malnourished patients, especially thiamin; consider a “loading dose” prior to initiation of nutrition . 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 A.

Features of Subjective Global Assessment (SGA) 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 10

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 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 *See page 8-9 Patients at risk for refeeding* 15-20 kcal/kg 20-30 kcal/kg Adults (18-65) Elderly (65+)  25 kcal/kg 15-20 kcal/kg AdjWt Obese or Super obese *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) Carbohydrate oxidation Mixed substrate oxidation (appropriate feeding) Protein oxidation Fat oxidation (underfeeding) Ketosis

1.00–1.20 1.00 0.85 0.82 0.71 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) Severe Obesity Severe stress, catabolic, burns Chronic renal failure, no dialysis Hemodialysis

1.5-2.0 g/kg 1.5 g / kg AdjWt – 2.0 g/kg IBW 2.0 –2.5 g/kg 0.8-1.3 g/kg *

Continuous Ambulatory Peritoneal Dialysis (CAPD)

*Protein needs may be higher if the patient is critically ill

12

1.2 1.4 g/kg 1.2 –1.5 g/kg

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

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

2.

Ex: 1800 calorie diet = 1800 calories x 1ml = 1800ml Calorie By body weight and age (37): Age 16-55 years 56-65 years > 65 years

Fluid requirements 35 ml/kg/day 30 ml/kg/day 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. 2. 3. 4. 5. 6. 7. 8.

9. 10. 11. 12.

13. 14. 15. 16.

Hooley RA. Clinical nutritional assessment; A perspective. JADA. 1980; 77:682-685. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic of Hospitalized Patients. WB Saunders Co; 1986. Hamwi GJ. Therapy: changing dietary concepts. In: Danowski TS, ed. Diabetes Mellitus: Diagnosis and Treatment. New York, NY:American Diabetes Association; 1964:73–78. Blackburn GL, Bistrian BR, Maini BS. Nutritional and metabolic assessment of the hospitalized patient. JPEN. 1977;1:11-22. Krenitsky J. Adjusted body weight, pro: evidence to the use of adjusted body weight in calculating calorie requirements. Nutr Clin Pract. 2005;20:468-73. Bray G. Pathophysiology of obesity. Am J Clin Nutr. 1992;55:488S-494S. Bray GA, Gray DS. Obesity: 1. Pathogenesis 2. Treatment. West J Med. 1988;149:429-555. 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. Grant A, DeHoog S. Nutritional Assessment and . Northgate Station, Seattle, WA: Grant and DeHoog; 1985. Williams SR. Nutrition and Diet Therapy. Times/Mirror, Mosby. 1985; 485-502. Rombeau J, Richter GC, Forlaw L. Practical aspects of nutritional assessment. Pract Gastroenterol. 1984;8:43. 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 McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical Gastroenterology. 2005;23:26-44. Zeman FJ. Clinical Nutrition and Dietetics. New York: MacMillan, 1991;80. Boylan H. Virginia Dietetic Association Meeting: Presentation on Refeeding Syndrome. 1998. Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr Rev 2003;61(9):320-323. 14

17. 18. 19. 20.

21. 22.

23.

24. 25. 26. 27.

28. 29.

30. 31. 32. 33. 34. 35.

36. 37. 38. 39.

Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001;17:632-637. Matz R. Precipitation of refeeding-associated electrolyte abnormalities with intravenous hydration. [Letter to editor] Am J Med 1999;107:302. Mallet M. Refeeding Syndrome. Age & Aging 2002;31:65-66. University of Virginia Health System Nutrition Traineeship Syllabus (Parrish CR, Krenitsky J, McCray S). University of Virginia Health System Nutrition Traineeship, 2003. Detsky AS et al. What is the subjective global assessment on nutritional status? JPEN. 1987;11:8-13. 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):64957. 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. 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 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. Streat SJ, Beddoe AH and Hill GL. Aggressive nutritional does not prevent protein loss despite fat gain in septic intensive care patients. J Trauma 1987;27(3):262-6. 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. Hester DD, Lawson K. Suggested guidelines for use by dietitians in the interpretation of indirect calorimetry data. JADA. 1989;89:100-101. 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. 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. Weinser RG et al. Handbook of Clinical Nutrition. St. Louis, MO:CV Mosby Co; 1989;130-179. Herndon D, Tompkins R. of the Metabolic Response to Burn Injury. Lancet. 2004;363:1895-1902. Lefton J. Specialized Nutrition for Adult Burn Patients. Line. 2003;25: 19-24. Dickerson, R. Estimating energy and protein requirements of thermally injured patients: Art or Science? Nutrition. 2002; 18:439-442. 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. Randall HT. Fluid electrolyte and acid base balance. Surg Clin North Amer. 1976;56:1019. Water requirements in enteral . Line. Dietitians in Nutrition : A Dietetic Practice Group of the ADA; 1989;11. American Dietetic Association Evidence Analysis Library. Available at www.adaevidencelibrary.com. Updated 1/4/11. Accessed 3/3/11. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition 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 Examples Oral intake is contraindicated Dysphagia, mechanical ventilation, mandibular fractures, head & neck surgery, neurological impairment, demyelinating diseases such as amyotrophic lateral sclerosis, muscular dystrophy, etc. Inability to meet markedly increased Burns, trauma, radiation therapy, nutritional needs with oral intake chemotherapy, sepsis/infection, closed head injury Inability to meet basic nutritional needs with Anorexia, cancer, head and neck tumors oral intake alone Need to by part of the GI tract to allow enteral nutrition

Pancreatitis, gastric outlet obstruction, esophageal cancer, gastroparesis

The need for supplemental nutrition due to decreased absorption

Short bowel syndrome, inflammatory bowel disease, fat malabsorption or other malabsorptive syndromes such as cystic fibrosis

16

TABLE 2.3

UVAHS Adult Formulary

Type of Formula Standard, high protein (Promote, Promote with Fiber*) Calorie dense (Jevity 1.5*, TwoCal HN*, Osmolite 1.5) Elemental /Semi-Elemental (Vivonex RTF, Perative*) Low-Electrolyte/Volume Restricted (Nepro*)

Kcal/mL

Protein

1 kcal/mL

High, intact

1.5 or 2.0 kcal/mL

Moderate, intact

1 kcal/mL, 1.3 kcal/mL

Peptides and Amino acids

1.8 kcal/mL

Low, intact

Special Considerations Used most frequently at UVAHS; high protein:calorie ratio Provides high amount of calories when reduced volume is desired Low fat, Low cholesterol Simple carbohydrate Lowest K, Magnesium, P formula, concentrated; 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 ISTRATION 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.

2.



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

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 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 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 istering 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 Team 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 ISTRATION (4-7) DELIVERY METHOD COMMON INDICATIONS PRECAUTIONS Tube must be secured Nasogastric (NGT)*/ Unable or unwilling to consume adequate nutrition via Orogastric oral route Use CO2 detection device when placing tube. e.g. patient intubated, sedated

Nasoduodenal/ Nasojejunal

Hypercatabolism in presence of at least partially functional GI tract Functional GI tract with a proximal obstruction

Document placement of tube with x-ray. Use CO2 detection device when placing tube, then confirm with x-ray.

Inadequate gastric motility Tube must be secured Esophageal reflux

Esophageal injury or obstruction

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 adequate oral calories

Should be avoided in patients with intractable vomiting

Anticipate that nutrition will be needed for >4 weeks

Caution: consider using an abdominal binder in agitated patients or those inclined to pull lines/tubes

After upper GI surgery

Gastrostomy

Jejunostomy

Functioning GI tract with an obstruction in the proximal jejunum (long term)

Stoma care required Potential bowel perforation Bacterial overgrowth

Upper GI stricture or fistula

Stoma care required

Inadequate gastric motility

Continuous feeding preferred due to high probability of dumping syndrome with bolus feeds.

Long-term transpyloric feeding desired

*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 Short term feeding

INTERMITTENT Not recommended for postpyloric feeding tubes

Intensive Care Unit (ICU) setting

Appropriate for long-term gastric feeding

May reduce risk of aspiration and/or gastric distension

Allows time for more mobility between feedings

NOCTURNAL 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

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  Delayed gastric emptying (Gastroparesis)

 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

 Tube dislodgment

 Discontinue tube feeding  Check tube placement  Replace tube, if necessary

 Gastroesophageal reflux

 Use small bore feeding tube  Keep head of bed elevated during and 1 hr after feeding  Regularly check tube placement

Nasopharyngeal irritation/breakdown

 Prolonged intubation with a large bore feeding tube.

Luminal obstruction (clogged tube)

 Thickened formula residue  Medication particles  Inadequate flushing

 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

Aspiration of formula

21

COMPLICATIONS II.

POSSIBLE CAUSE

POSSIBLE MANAGEMENT

Gastrointestinal

Diarrhea

 Medications (sorbitol elixirs, antibiotics, Shohl’s solution, magnesium-containing antacids, laxatives, cathartic agents, Lactulose)  C. difficile

 Review medications and eliminate causative agent, if possible.

 Bacterial contamination

 Refrigerate any opened cans of formula  Discard all unused formula within 24 hours  Ensure cleanliness during preparation and istration  Place  8 hours of formula at a time in the feeding set/bag  Change feeding bag and tubing every 24 hours

 Improper istration

 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

 Fat malabsorption

Constipation

 Lack of dietary fiber / too much fiber  Inadequate fluid

  C. difficile toxin

 Increase fluid intake

 Inactivity

 Encourage ambulation if possible

 GI obstruction

 May require decompression and surgical intervention  Address presumed cause

   

Colonic dysmotility Drug induced Post op Other

22

COMPLICATION

POSSIBLE CAUSE

Bloating

 Delayed gastric emptying

Vomiting/Nausea

 Rapid formula istration  Delayed gastric emptying

Persistantly High Gastric Residual (>500 ml)

III.



Delayed gastric emptying

POSSIBLE MANAGEMENT  Calorie dense formula  Prokinetic agent  Post pyloric tube  Initiate feedings at a lower rate and gradually advance  Consider post pyloric tube  Monitor residuals  correct tube placement  Prescribe anti-emetics/ antinauseants, prokinetics  Post pyloric tube  Slower infusion  Prokinetic agent  Consider change to a calorically dense formula to decrease volume  Post pyloric tube

Metabolic

Hyperglycemia

Hypoglycemia

Dehydration or Hypernatremia

 Diabetes  Hypercatabolism Stress/Trauma  Corticosteroids  Sepsis

 Monitor serum glucose  Give oral hypoglycemic agents or insulin  Avoid overfeeding

 Sudden cessation of tube feeding or parenteral nutrition (PN) in patients on oral Hypoglycemic agent or insulin

 Monitor serum glucose  If tube feeding or PN must must be stopped after after insulin given, hang D10 IV fluid.  Treat hypoglycemia with IV dextrose

 Inadequate fluid intake  Excessive protein intake  High urine output, excessive diarrhea, ostomy output, fistula output, or NGT output

 Monitor body weight  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 Hyponatremia

Hyperkalemia

Hypokalemia

POSSIBLE CAUSE                

Hyperphosphatemia

Hypophosphatemia

Fluid overload Hypotonic formula Excessive production of antidiuretic hormone (SIADH) Cerebral salt wasting Poor perfusion (CHF) Metabolic acidosis Excessive potassium intake Decreased excretion Renal insufficiency Potassium-sparing meds Refeeding syndrome Diuretics Excessive losses (i.e. from diarrhea or NG drainage) Insulin therapy Volume overload Metabolic alkalosis

 Renal insufficiency

   

Refeeding syndrome 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 PREVENTING COMPLICATIONS Continued monitoring of nutritional intake is particularly important for patients receiving enteral or parenteral nutrition in order to identify inadequacies before deficiencies develop. Recommendations for changing or supplementing nutritional are based on accurate and timely documentation of delivery. Patients on nutrition 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. 2. 3. 4. 5. 6. 7.

Hyperglycemia Lipogenesis Fluid and fat gain rather than lean body mass gain Fatty liver Immunosuppression (with excessive lipid and linoleic acid intake) Increased minute ventilation (VE) 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 istered 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 (bying 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 istering medications with tube feedings are as follows (Table 2.7):

25

TABLE 2.7 GENERAL GUIDELINES FOR ISTERING MEDICATIONS WITH ENTERAL FEEDINGS (13) 1.

Stop the tube feeding prior to istration 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 istered via feeding tubes.

UVAHS DRUG INFORMATION HELP LINE: 4-8034 References 1. University of Virginia Health System Nutrition Traineeship Syllabus. Parrish CR, Krenitsky J, McCray S. University of Virginia Health System Nutrition Traineeship, 2003. 2. Schwartz D. Enteral therapy. In: Lang CE, ed. Nutritional in Critical Care. Rockville, MD: ASPEN Publishers Inc; 1987. 3. Breach CL, Saldanha LG. Tube feeding complications. Part I: Gastrointestinal. Nutrition Services. 1988;8:15. 4. Gottschlich MM, ed. The A.S.P.E.N. Nutrition 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 of Hospitalized Patients. W.B. Saunders Company, 1986. 9. Breach CL, Saldanha LG. Tube feeding complications. Part II: Mechanical. Nutrition Services. 1988;8:28. 10. Breach CL, Saldanha LG. Tube feeding complications. Part III: Metabolic. Nutrition Services. 1988;8:16. 11. Lucarelli MR, Shirk MB, Julian MW, Cro 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) is used to nourish patients who either are already malnourished or have the potential for developing malnutrition and who are not candidates for enteral (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 istration 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 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

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 (N): Central Parenteral Nutrition is defined as delivery of nutrients via central venous access (1, 2). N 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 ed 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 710 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  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 istered into a central vein because of the high osmolarity. Consequences of excess CHO istration:     

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 istration. 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 istered over a 24 hour period. istering 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 istration:    

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 istered 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 istering the solution.  Optimal vitamin intakes for seriously ill and septic patients are unknown.

32

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

AMA Recommended Amount

FDA Recommended

Vitamin A

3300 IU

1 mg / 3300 units

Multi-Vitamins added to standard PN solution at UVA – (MVI-ADULT, 10 ml/day) 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 (B12) Pantothenic acid

5 mcg

5 mcg

5 mcg

15 mg

15 mg

15 mg

Biotin

60 mcg

60 mcg

60 mcg

Amount

2. TRACE ELEMENTS (13)  Trace elements are critical to 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 istration 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) Trace Element Zinc Copper Chromium Selenium Manganese

Previous Guidelines (AMA - 1979) 1

Recent Recommendations2 ( ASPEN-2004)

2.5-4 mg 0.5-1.5 mg 10-15 mcg No guideline 150-800 mcg

2.5-5 mg 0.3-0.5 mg 10-15 mcg 20-60 mcg 60-100 mcg

mg = milligrams

Concentrated Multitrace 5 (1mL) used at UVA 5 mg 1 mg 10 mcg 60 mcg 500 mcg

NonConcentrated MTE- 5 (2.5mL) 2.5 mg 1 mg 10 mcg 50 mcg 250 mcg

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) Daily

Electrolyte

Standard Additive at UVA

Recommendations or Requirements

Sodium

70 – 100 mEq/day

63 mEq/day

Chloride

70 – 100 mEq/day

Potassium

70 – 100 mEq/day

Varies per day, based on composition of other e’lytes in the PN solution. 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 Heparin Chromium Zinc Thiamin

Vitamin K Vitamin C Copper Selenium

Famotidine Vitamin B12 Manganese Iron dextran

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: N

Peripheral line: PPN

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

Provides: Macronutrients: 400 Dextrose calories/day 300 Protein calories/day 500 Fat calories/day (250 mL of 20% 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 protein: 75 g/day

Total calories: 1200/day Total protein: 75 g/day

The differences between standard N 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 Fatty liver



   

 

Cholestasis

Gastrointestinal mucosal atrophy

Possible Etiology Delivery of carbohydrate in excess of hepatic oxidative capacity Overfeeding of calories and/or fat Excess infusion of amino acids Essential fatty acid deficiency Carnitine deficiency

 

Impaired bile flow Lack of intraluminal nutrient stimulation of hepatic bile secretion  Overfeeding  Toxic tryptophan metabolites Atrophy of villi Colonic hypoplasia



Symptoms Elevation of liver enzymes within 1 to 3 weeks post PN initiation

   

 





Progressive  increases in serum  total bilirubin Elevated serum alkaline phosphatase

In vitro, presence of enteric bacteria in mesenteric lymph nodes Development of enteric bacteremia and sepsis without clear source

38



Treatment Reduce carbohydrate delivery Cyclic PN Rule out other causes Begin enteral nutrition if possible

   

Prevention Use mixed substrate solutions Avoid overfeeding Avoid glucose infusion > 5 – 7 mg/kg/minute Enteral nutrition as tolerated (trophic feedings)

Avoid overfeeding Rule out other causes



Early use of gastrointestinal tract

Transition to enteral/oral feedings as tolerated



Early use of gastrointestinal tract

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 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 Traineeship Syllabus (Parrish CR, Krenitsky J, McCray S). Parenteral Module. University of Virginia Health System Nutrition 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 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 therapy: Use of propofol in a patient receiving combined enteral and parenteral nutrition . 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 . April 20, 2000; 65:2120021201. 11. Fuhrman MP, Hammond KA, et.al. The Science And Practiceof Nutrition . 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 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. Lab Parameter

BUN

SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM* Normal Range

Elevated with:

7 – 18.7 mg/dl

Dehydration Renal disease Increased protein metabolism Starvation Stress Diabetes Fever Acute myocardial infarction G I bleed Congestive heart failure Urinary obstruction

Higher in elderly: 8.4 – 25.7 mg/dl

Creatinine

0.6 - 1.1 mg/dl

Large muscle mass Muscle disease Starvation Renal disease

CO2 (Bicarbonate)

22 – 29 mmol / L

Metabolic alkalosis Respiratory acidosis Emphysema Vomiting

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

41

Decreased with:

Liver failure Increased protein synthesis - Late pregnancy - Infancy Acromegaly Nephrotic syndrome Overhydration Malabsorption Low protein, high CHO diets

Metabolic acidosis Respiratory alkalosis Hyperventilation Fever Lack of oxygen

APPENDIX 1. Lab Parameter

SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (Cont)* Normal Range Elevated with: Decrease with:

Serum Osmolarity

275 – 295 mOsm/L

Osm = serum sodium x 2 +

Calculated values are generally lower than measured values

BUN + Glucose 2.8 18

Serum Glucose

74 – 99 mg/dl

* Elevated values may give falsely low serum sodium values. For every 100% elevation, serum sodium is decreased by 2 mEq/L

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

42

Inadequate fluid intake Diarrhea Diabetes mellitus Diabetes insipidus Renal disease Hyperlipidemia Hyperglycemia

Excess fluid intake Adrenal disease Inappropriate ADH secretion - Hypothyroidism - Cerebral disease Porphyria - Bronchogenic cancer

Diabetes mellitus Cushing’s syndrome Acromegaly Hemochromatosis Pheochromocytoma Burns, shock Acute pancreatitis Wernicke’s encephalopathy Dehydration Sepsis Overfeeding Corticosteroids Blood draw contaminated with PN (can confirm with a finger stick)

Liver disease Neoplasms Pancreatic disorders Adrenal insufficiency Hypothyroidism Fluid overload Severe sepsis

APPENDIX 1. Lab Parameter

Hematocrit (HCT)

SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)* Normal Range

Elevated with:

Women: 35 – 47% Men: 40 – 52%

Dehydration Polycythemia

Hemorrhage Anemia Fluid overload Advanced age Late Pregnancy

Women: 12 – 16 gm/dl Men: 14 – 18 gm/dl

Dehydration Polycythemia

Hemorrhage Iron deficiency anemia Malnutrition Advanced age Late pregnancy Renal failure Fluid overload

83 – 95 fL

Macrocytosis - Folate deficiency - Vitamin B 12 deficiency - Excess alcohol intake Hemochromatosis

Microcytosis - Advanced iron deficiency - Blood loss Iron malabsorption Lead poisoning

Often used to diagnose iron deficiency; not a conclusive measure Hemoglobin (Hgb) More direct measure of iron deficiency than HCT

Mean Corpuscular Volume (MCV)

Decreased with:

Indicates average size of the red blood cells. Calculated MCV = HCT x 10 RBC

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

43

APPENDIX 1. Lab Parameter

Sodium

SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)* Normal Range

Elevated with:

Decreased with:

136 – 145 mmol / L

Dehydration: Diabetes Insipidus Osmotic diuresis GI losses Renal disease Severe exercise

Adrenal insufficiency Extreme sweating Diuretics Diabetic acidosis Malabsorption Excessive GI losses ( diarrhea, vomiting, etc) SIADH

Potassium

3.4 – 4.4 mmol / L

Hemolysis Burns, shock Crush injuries Excess supplemental potassium Renal failure Diabetic ketoacidosis Dehydration Hyperglycemia Acidosis Blood draw contaminated with PN

Refeeding Syndrome Starvation Excessive GI losses (diarrhea, vomiting, etc) Hypomagnesemia Cushing’s syndrome Diuretics Amphotericin

Chloride

98 – 107 mmol / L

Dehydration Renal failure

Excessive GI losses (diarrhea, vomiting, etc) Excess urinary losses

Body content of sodium is not always reflected in serum levels

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

44

APPENDIX 1. Lab Parameter

Calcium

SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)* Normal Range

Elevated with:

Decreased with:

8.4 – 10.2 mg/dl

Cancer Renal disease Vitamin D intoxication Hyperparathyroidism Renal calculi Prolonged Immobilization

Hypoparathyroidism Renal disease Osteomalacia Steatorrhea Rickets Hypomagnesemia

Phosphorous

2.3 – 4.7 mg/dl

Hemolysis Renal disease Healing fractures Vitamin D deficiency Skeletal disease

Magnesium

1.6 – 2.6 mg/dl

Renal failure Diabetic acidosis Hypothyroidism Addison’s disease Dehydration Overuse of magnesium supplements or antacids Hemolysis

Rickets Insulin injections Malnutrition Malabsorption Refeeding syndrome Chronic diarrhea Alcoholism Pancreatitis Renal disease Hepatic cirrhosis Toxemia of pregnancy Hyperthyroidism Malabsorption Ulcerative colitis K- depleting diuretics Refeeding syndrome

Absorption decreased by phytates, oxalates, phosphates Check ionized calcium

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

45

APPENDIX 2.

ADULT MULTIVITAMIN SUPPLEMENTS AVAILABLE AT UVA Ca (mg)

Fe (mg)

*Others

60

-

-

-

0.4

90

40

-

1

0.3

60

-

-

-

200

-

-

-

-

60

-

9

2

5

0.6

200

-

-

3

1.5

12

0.2

60

-

-

4

10

10

6

0.8

60

-

-

5

10

10

12

1

100

250

60

6

Folate (mg)

C (mg)

6

0.4

6

12

-

1.05

4.5

100

21.4

4.1

5

-

1.7

20

10

2

6

6

3.6

40

15

6

150

1.2

1.3

10

10

-

-

1.5

1.7

20

400

30

3

3.4

20

Amt.

A (IU)

D (IU)

E (IU)

B1 (mg)

B2 (mg)

Niacin (mg)

B5 (mg)

B6 (mg)

B12 (mcg)

1 tablet

5000

400

30

1.5

1.7

20

10

2

1 tablet

5000

400

60

3

3.4

20

40

1 tablet

2500

400

15

1.05

1.2

13.5

Liquid multivitamin

5 ml

5000

400

-

10

10

Liquid high potency multivitamin with minerals MVI ADULT IV multivitamin ADEKs tablets

15 ml

1300

400

30

1.5

10ml

3300

200

10

1 tablet 1 tablet 1 tablet

4000

400

5000

Product/Form Therapeutic multivitamin tablet Therapeutic high potency vitamins with minerals Children’s Chewable Multivitamin

Nephro – vite for dialysis patients Materna Prenatal vitamin

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

Vitamin A

Capsule (as beta carotene) Drops

Composition

1 each

25,000 IU

1 ml

50,000 IU/ ml

Injection

2 ml

100,000 IU

Capsule

1 each

50,000 IU

Drops (“Drisdol”)

0.25 ml

2000 IU

Tablet

1 each

400 IU and 1000 IU

Vitamin D2 Ergocalciferol

Vitamin D3 Cholecalciferol

Capsule Calcitriol -active form (Calcijex or Rocaltrol)

0.25 mcg & 0.50 mcg

Liquid

0.25 mcg, 2 mcg

Injection

1 mcg/ml 1 mcg

Capsule

1 each

100 IU, 400 IU, & 1000 IU

Drops

0.3 ml

15 IU

Tablet

1 each

5 mg

Injection

0.5 ml 1 ml

1 mg 10 mg

Tablet

1 each

25 mg, 50 mg, & 100mg

Tablet

1 each

100 g

Injection

1 ml

1000 g

Tablet

1 each

500 mg

Syrup

5 ml

500 mg

Vitamin E (Aquasol E)

Vitamin K

Vitamin B6 Vitamin B12 (Cyanocobalamin) Vitamin C (Ascorbic acid)

47

Vitamin C (con’t.) Vitamin B Complex

Injection

1 ml

500 mg & 1000 mg

1 each

3 mg B1, 3 mg B2, 20 mg B3, 0.5 mg B6, 1 g B12, 5 mg Panthothenic acid, 60 mg Desiccated liver, 60 mg Debittered Brewer’s yeast 100 mg

Soft gel capsule

Thiamin

Tablet

1 each

Thiamine HCl Niacin

Injection Tablet

1 ml 1 each

100 mg 250 mg

Niacin ER (Niaspan)

Tablet

1 each

500 mg

Nicotinic Acid

Tablet

1 each

Folic Acid

Tablet

1 each

1 mg

Injection

1 mL

5 mg

APPENDIX 4.

Vitamin

50 mg & 100 mg

ADULT MINERAL SUPPLEMENTS AVAILABLE AT UVA

Form

Dose

Composition

Calcium Acetate

Capsule

1 each

667 mg

Calcium Carbonate

Liquid

2.5 ml 4 mL

625 mg 1g

Calcium Oyster Shell w/ Vit. D (Oscal 250)

Tablet

1 each

250 mg

Tablet

1 each

500 mg

Syrup (liquid)

5 mL

1.8 g

Calcium Oyster Shell 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

Powder

1 packet

P-250 mg/mol Na-160 mg K+-280 mg

Powder

1 packet

P-250 mg K+-556 mg

Tablet

1 each

500 mg

Liquid

5 mL

1000 mg

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, 22.5 mL

5, 10, 15, 30 mEq

Liquid

1 ml

1g

Phosphorus Phos-Nak (Na, Phos, K+) Neutrophos-K (K+, Phos) Magnesium Gluconate

Magnesium Oxide

Potassium Iodine

49

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. 50

APPENDIX 6 Body Fluid

Electrolyte Content and pH of Selected Body Fluids (mEq/L) Approx. amount HCO3 Na K H Cl

pH

secreted per day (mL)

Sweat Gastric Pancreas Ileostomy Bile Diarrhea Normal stool Urine Blood

750 2000 - 3000 2500 varies 500 - 750 varies

30-50 40-65 135-155 120-130 135-155 25-50

5 10 5 10 5 35-60

70-90 50-70 35-50 30-45

90 -

45-55 100-140 55-75 50-60 80-110 20-40

1.2-3 7-8 7 7 varies

200 varies n/a

5 30-80 138

10 30-80 4.5

25

-

10 50-100 103

varies 4.5-8 7.4

Used with permission from the University of Virginia Health System Nutrition 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 0 0 50 Hypotonic D5W 77 0 50 Hypotonic D5W 0.45 NS 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.

51

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

52

Appendix 11

Normal Lengths of Bowel

Section of Bowel Duodenum Jejunum Ileum Colon

Approximate Normal Length 10 inches (25 - 30 cm) 6 – 10 feet (200 – 300 cm) 10 – 13 feet (300 – 400 cm) 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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