Nutrition Services Sinai Hospital

1
Nutrition ServicesSinai Hospital

• Rachel Mutchler RD, LD-N, CNSD
• Clinical Nutrition Manager
• Sinai Hospital of Baltimore

2
Objectives

• Nutrition Services
• Room Service _at_ Sinai
• Enteral Nutrition
• Parenteral Nutrition

3
Clinical Dietitians

• Available For
• Consultation
• Professional Patient Education
• Outpatient Referral
• Weekend pager 8003
• Available by Vocera
• Formulary and other information available on
  BridgeNet

4
Nutrition Services

• All consults completed within 24 hours
• Patient Lists screened on daily basis
• Every NPO seen by day 3
• Every Clear Liquid seen by day 5
• Every patient seen by day 7
• Follow - up based on point system
• High Risk seen every 1-2 days
• Moderate Risk seen every 3-5 days
• Low Risk seen every 7 days

5
Room Service

• Rollout June 2006
• Automated Meal Ordering System-CBORD
• Interfaces directly with Cerner
• Menus available at bedside and adapted to
  patients dietary restrictions
• Order is processed in real time and delivered
  within 60 minutes

6
Room Service

• Patients call when they are ready to eat
  (2-FOOD)
• Call center staff takes orders using touch screen
  computers
• Fresh food delivered to patients
• Ideally, patients receive what they want, when
  they want it

7
Diets _at_ Sinai

• Regular
• Heart Healthly (Low Fat, Low Chol, 3-4 g Na)
• Carbohydrate Controlled Diabetic Diet (4 carb
  choices/meal)
• 2 g Sodium
• Renal-Predialysis (40-50 g Pro, 2 g K, 2 g Na)
• Renal-Dialysis (3 g K, 3 g Na)
• Low Residue-GI Soft

• Puree-Dysphagia Stage 1
• Mechanical Soft-Dysphagia Stage 2
• Dysphagia Advanced-Dysphagia Stage 3
• Full Liquid
• Clear Liquid
• Bariatric Surgery Puree
• Bariatric Surgery Clear Liquid

8
Medical Nutrition Therapy

• Enteral Nutrition

9
What is True About Enteral Nutritionwww.adaevide
ncelibrary.com

• Early Enteral Nutrition (within 24-48 hours of
  admit) is associated with reduced incidence of
  infectious complications and with reduced LOS
• A post-pyloric feeding tube is associated with
  reduced gastric residual volumes (GRV)
• Consider using a small bowel feeding tube when
  patient is in supine position or under heavy
  sedation/paralyzed.
• In adults GRV correlate very poorly with
  aspiration pneumonia

10
What is True About Enteral Nutritionwww.adaevide
ncelibrary.com

• Permissive underfeeding (70 of needs) during the
  first week of admission is associated with
  shortened LOS, decreased time on ventilator,
  with reduced infectious complications
• You can safely and effectively tube feed a
  patient with acute pancreatitis, a fistula, or
  gastroparesis (past the Ligament of Treitz, into
  the Jejunum)

11
Enteral Formulary

• Fibersource HN
• Diabetisource AC
• Traumacal
• Resource 2.0
• Novasource Renal
• Suplena
• Subdue Plus
• Impact w/ Glutamine
• Vivonex Plus

• Boost
• Boost Plus
• Boost Diabetic
• Resource Breeze
• Health Shake (NSA HS)
• Diabetishield
• Boost Pudding
• Optisource High Protein

12
Formulary Specifics
13
Formulary Specifics cont...
14
Formulary Specifics cont...
15
General Tube Feeding Guidelines

• Start TF at 20-30 mL/hour
• Increase by 10 mL q 4 hour to goal rate
• Check gastric residuals q 4 hours, hold TF for
  residuals gt250 mL on 2 consecutive draws
• When appropriate consider promotility agents
• Minimum of 50 mL water flush q 6 hours.
• Do Not check residuals with J tubes

16
Medical Nutrition Therapy

• Parenteral Nutrition

17
Definition ofParenteral Nutrition

• The administration of complete and balanced
  nutrition by intravenous infusion in order to
  support anabolism, body weight maintenance or
  gain, and nitrogen balance, when oral or enteral
  nutrition are not feasible or are inadequate
• You are the Metabolic Brain of Patients Receiving
  Parenteral Nutrition
• DO NOT TAKE IT CASUALLY

18
IF THE GUT WORKSUSE IT!!

• Enteral route is the preferred route for
  nutrition support
• EN is associated with reductions in septic
  morbidity, infectious complications cost when
  compared to PN
• Many benefits vs. TPN
• Preservation of intestinal function, decreased
  risk of bacterial translocation, pneumonia,
  mortality (1-5).

19
Indications forParenteral Nutrition

• NPO
• Well Nourished patients gt 7-10 days
• Moderately Malnourished patients gt 5 days
• Severely Malnourished patients 1-3 days
• Nonfunctional Gastrointestinal Tract
• High Output Fistula
• Failed Enteral Feeding

20
Indications forParenteral Nutrition

• Peripheral Parenteral Nutrition (PPN)
• Only appropriate/indicated for use in patients
  requiring nutritional supplementation (when
  oral/enteral intake cannot meet needs) for
  greater than 5 but less than 14 days
• Venous irritation limits the use of peripheral
  veins to about 14 days maximum

21
Indications for Parenteral Nutrition

• Total Parenteral Nutrition (TPN)
• Preferred mode of parenteral nutrition delivery
• ONLY indicated when used for greater than 7
  days!!!
• This is due to risk/benefit ratio of acquiring
  central access
• Literature does not show benefit to patients
  overall mortality/morbidity

22
Parenteral NutritionOveruse

• Reported Overuse
• Critically Ill Patients
• High mortality rate
• Perioperative Malnutrition
• Inappropriate due to use lt 7 days
• Oncology Patients
• Due to ease of ordering administration
• Ongoing n/v/d, mucositis, poor nutrition status

23
TPN vs. PPN

• TPN meets 100 of patients needs
• Need central access (cannot use peripheral vein)
• PPN cannot meet 100 of patients needs
• Uses peripheral vein
• Max 900 mOsm/L
• Studies do not support usage of PPN vs. TPN
• 2 weeks max usage
• Must use higher volume to infuse max nutrients

24
Initial TPN Rx

• Best Practice search supports use of a
  standard first-dose to avoid hyperglycemia and
  to assure fluid tolerance
• On First Day D15 AA6 _at_ 42ml / hr w/o lipids
  (150g CHO/60g PRO)
• Place Order For Nutrition Consult
• Always look for RD recommendations
• Remember all PN orders due by 100 pm

25
IV Lipid Emulsions

• At Sinai we have 3 different lipid solutions
• 20 Fat Emulsion (250 ml)/(500 kcal)/(50g fat)
• 20 Fat Emulsion (500 ml)/(1000 kcal)/(100g fat)
• 10 Fat Emulsion (500 ml)/(550 kcal)/(55g fat)
• A good energy source in times of stress
• Can be used 4-7 x week as calorie source
• Or 2-3 x week to prevent EFAD
• May help control hyperglycemia

26
IV Lipid Emulsions cont...

• Keep calories provided by fat to lt 30 of Total
  Calories
• All FDA approved IV lipid solutions are primarily
  omega-6 fatty acids (high in polyunsaturated
  fats)
• These can be immunosuppressive when given in
  excess
• Hold IV lipids when Triglycerides gt400 mg/dL
• If TG remain gt400 x 2 weeks give 50g lipid 2x
  week to prevent essential f.a. deficiency
• Hypertriglyceridemia induced pancreatitis only
  likely when TG gt1000

27
Electrolytes

• Phosphorous is usually 1st to decrease with
  initiation of enteral and parenteral nutrition
• If Phos lt 1.8 DO NOT INFUSE TPN (ASPEN)
• Consider 20-40 mEq if Phos lt2.5 mg/dL
• Always consider all additional sources
• Calculate Calcium Phos Ratio (mEq Ca/L x mEq
  Phos/L) Must be lt200
• Potassium is 2nd to fall
• Add extra in TPN to avoid numerous IV runs
• Max allowed due to compatibility is 80 mEq/L

28
Electrolytes continued

• Calcium
• Does not fall as quickly as Phos and Potassium
• Look at Ionized vs. Serum Ca
• Serum will fall as Albumin falls
• Correction factor (4 - alb) x (0.8) Ca
• Magnesium
• Replete as needed
• Can double standard dose

29
Electrolytes continued...

• If Chloride Low give NaCl or KCl
• If CO2 Low give NaAc or KAc
• Bicarbonate is insoluble in TPN admixture, so
  Acetate is used
• Acetate is converted to bicarbonate in the liver
• Use with caution in liver disease

30
Minimal Volume Calculation

• (G protein x 10)
• (CHO kcals / 2.38)
• 200 mL for electrolytes
• Example D20 AA6 _at_ 73mL / hr
• 350g CHO (1190 kcals), 105g protein
• 1750 minimal volume (73mL / hr)

31
Osmolarity Calculation

• Use for infusion of PPN
• Do not exceed 900 mOsm / L
• (G of Amino Acids / L x 10)
• (G of Dextrose / L x 5)
• Sum of mEq of electrolytes x 2

32
Cycling and Discontinuing TPN

• Cycling TPN
• Taper from 24-20, 20-16, 16-12 hour cycle
• May also use 24-18, 18-12 hour taper cycle (only
  if patient has stable, monitored BS levels)
• Helps to avoid extreme blood sugar fluctuations
• Discontinuing TPN
• Run at 1/2 goal rate for two hours then stop and
  discard

33
Hyperglycemia

• Can result from too many calories, specifically
  dextrose calories
• ASPEN Guidelines No more than 150-200g dextrose
  on 1st day of Parenteral Nutrition, (6).
• D25 at 42 ml / hr 250g dextrose
• D20 at 42 ml / hr 200g dextrose
• D15 at 42 ml / hr 150g dextrose
• Order Fingersticks Sliding Scale
• FS q 4-6 hours during first 3-5 days PN

34
Hyperglycemia cont...

• If patient is on insulin, an OHA or FS gt 200 mg /
  dL then...
• Provide only 100 g dextrose in first bag
• Goal BG to advance PN to goal lt 180mg/dL
• Goal BG during stable PN lt 150 mg / dL

35
Insulin and TPN

• Include a basal insulin amount for those who were
  previously on insulin or OHA
• Usually considered safe amount 0.1units insulin
  / g dextrose
• If BG gt 200 mg / dL, use 0.15 units / g dextrose
• If BG gt 300mg / dL, no PN until BG lt 200mg / dL

36
PN Insulin cont...

• If hyperglycemia persists when 0.3 units / g
  dextrose is in PN, patient may need separate
  insulin infusion
• If patient has unpredictable BG levels then
  separate insulin preferred, (ieICU) (6)
• Try to adjust PN insulin with what pt required
  from sliding scale
• Provide 2/3rds of previous days SSI in bag

37
Labs to check...whywhen

• Triglycerides
• Check on initiation of PN and then q week
• To monitor lipid and carbohydrate tolerance
• Goal decrease risk of acute pancreatitis (1)
• Hypertriglyceridemia induced pancreatitis usually
  only seen with TG gt 1000 mg / dL (1)
• ASPEN Guidelines continue IV lipids until TG are
  gt/ 400 mg / dL

38
Labs to Check Triglycerides

• High dextrose can elevate TG and lead to fatty
  liver (Hepatic Steatosis)
• If TG high (gt 400), hold IV lipids x 1 day and
  recheck TG before re-starting
• Need 1g/kg of lipid 2x week to prevent essential
  fatty-acid deficiency (EFAD)

39
Labs to CheckPre Albumin

• What is it? A negative acute-phase hepatic
  protein that binds Thyroxine and Retinol-Binding
  Protein. Decreased in times of stress and
  inflammation
• 1/2 life is 2-3 days
• Low levels lead to an increase in LOS, mortality
  rate and recovery time
• normal 16-36 mg/dL
• mild depletion 14-17
• moderate depletion 10-14
• severe depletion lt10

40
Pre Albumin continued

• Why order it? To monitor an increase in visceral
  protein status and/or improvements in pts
  clinical condition
• Pre Albumin will not increase (regardless of
  nutrition support provided) when patient is in a
  hypermetabolic, hypercatabolic state
• An increase should occur when the acute
  inflammation/stress resolves
• If there is no rise in pre albumin and the acute
  process is resolving there may be an inadequate
  provision of nutrients

41
Labs to Check C-Reactive Protein

• Positive acute-phase protein that can measure
  degree of inflammation/stress response
• normal level lt 11 mg / dL
• Very reflective of clinical condition
• Helps to determine whether nutritional labs
  (prealbumin) are indicative of nutritional status

42
Great Reference

• Fuhrman, M.P. et al. (10)
• Looks at Hepatic Proteins and Nutrition
  Assessment
• Is a solid review of the literature
• Focuses on albumin, pre albumin, transferrin and
  their role in nutrition assessment

43
Refeeding Syndrome

• What is it? Intracellular shift of Phos, K, and
  Mg in response to a rise in insulin due to influx
  of nutrients usually via TF/TPN
• Fat oxidation (used during fasting states for
  energy production) does not require Phosphorus
• Treatment If all 3 are low, replete before TPN
  (IV recommended)
• Administer volume and energy slowly
• Rationale for first dose TPN

44
Refeeding Syndrome Complications

• Sodium retention, expansion of cellular space
• Leads to weight gains and increased CV demands
• Arrhythmia, CHF
• Liver Dysfunction
• Confusion, Coma, Weakness
• Acute Respiratory Failure
• Constipation and Ileus

45
Those at Risk

• Patients with Anorexia, kwashiorkor or marasmus,
  chronic malnutrition, chronic alcoholism, morbid
  obesity with massive weight loss, significant
  stress and depletion, NPO 7 days.

46
Complications of Overfeeding

• Azotemia, hypercapnia, hypertonic dehydration,
  metabolic acidosis, and refeeding syndrome
• Excessive carbohydrate provision can lead to
  hyperglycemia, hypertriglyceridemia, hepatic
  steatosis
• Excessive lipid infusion can lead to
  hypertriglyceridemia

47
Summary

• If the gut works, use it!!
• Initial TPN order
• D15 AA6 _at_ 42 ml/hr w/o lipids
• Hyperglycemia is likely cause of many TPN induced
  complications
• Keep BG below 150mg/dL
• Order Fingersticks (q 4-6 h) Sliding Scale
  Insulin
• Consult Nutrition
• PN orders due to pharmacy by 100 PM
• Do Not Overfeed

48
Summary

• Monitor Phos and K
• Add extra Phos and K in anticipation of
  intracellular shift from TPN
• Hold Lipids if TG gt 400mg/dL
• Always monitor pre-albumin, triglycerides blood
  sugar (with finger sticks q 6 h)
• Order pre albumin and triglycerides upon
  initiation of parenteral nutrition and then
  weekly during course of parenteral nutrition

49
References

• 1. Gottschlich, MM, Fuhrman, MP, Hammond, KA,
  Holcombe, BJ, Seidner DL, The Science and
  Practice of Nutrition Support. A Cased-Based
  Curriculum. 2004.
• 2. Moore FA, Moore EE, Jones TN, et al. TEN
  versus TPN following major abdominal trauma
  Reduced septic morbidity. F Trauma.
  198929916-923.
• 3. Kudsk DA, Croce MA, Fabian TC, et al. Enteral
  versus parenteral feeding Effects on septic
  morbidity after blunt and penetrating abdominal
  trauma. Ann Surg. 1992215503-513.
• 4. Suchner U, Senftleben U, Eckart T, et al.
  Enteral versus parenteral nutrition Effects on
  gastrointestinal function and metabolism.
  Nutrition. 199612(1)13-22.
• 5. Roberts D, Thelen D, Weinstein S. Parenteral
  and enteral nutrition A cost-benefit audit. Minn
  Med. 198265707-710.
• 6. ASPEN Board of Directors. Safe Practices for
  Parenteral Nutrition. J Parenter Enteral Nutr.
  200428(6 suppl.) S39-69.
• 7. Mears E. Outcomes of continuous process
  improvement of a nutritional care program
  incorporating TTR measurement. Clin Chem Lab Med.
  2002 Dec40(12)1355-9.
• 8. Sulivan DH, Sun S, Walls RC. Protein-energy
  undernutrition among elderly hospitalized
  patients a prospective study. JAMA
  19992812013-9.
• 9. Garcia-de-Lorenzo A, Ortiz-Leyba C, Planas M,
  Montejo JC, Nunez R, Ordonez FJ, Aragon C,
  Jimenez FJ. Parenteral administration of
  different amounts of branch-chain amino acids in
  septic patients clinical and metabolic aspects.
  Crit Care Med. 1997 Mar25(3)418-24.
• 10. Fuhrman, MP, Charney, P, Mueller, CM.
  Hepatic Proteins and Nutrition Assessment J Am
  Diet Assn 2004104(8)1258-1264
• 11. Golden MHN. Oedematous malnutrition. Br Med
  Bull. 199854433-444.

50
References Continued

• 12. Kattelmann K., Hise M., et al. Preliminary
  Evidence for a Medical Nutrition Therapy
  Protocol Enteral Feedings for Critically Ill
  Patients. JADA 2006 vol 106 8 1226-1241.
• 13. Manary MJ, Leeuwenburgh C, Heinecke JW.
  Increased oxidative stress in kwashiorkor. J
  Pediatr. 2000137421-424.
• 14. ASPEN Board of Directors and The Clinical
  Guidelines Task Force. Guidelines for the use of
  parenteral and enteral nutrition in adult and
  pediatric patients. JPEN 200226(suppl)S1-S138.
• 15. American College of Chest Physicians/Society
  of Critical Care Medicine Consensus Conference
  Committee. American College of Chest
  Physicians/Society of Critical Care Medicine
  Consensus Conference Definitions for sepsis and
  organ failure and guidelines for the use of
  innovative therapies in sepsis. Crit Care Med.
  199220864-874.
• 16. Golden MH, Golden BE. Severe malnutrition.
  In Garrow JS, James WPT, Ralph A, eds. Human
  Nutrition and Dietetics. 10th ed. Edinburgh
  Churchhil Livingston 2000515-526.
• 17. McClave SA, Mitoraj TE, Thielmeier KA,
  Greenburg RA. Differentiating subtypes
  (hypoalbuminemic vs marasmic) of protein-calorie
  malnutrition Incidence and clinical significance
  in a university hospital setting. JPEN
  199216337-342

51
Discussion

• Rachel Mutchler RD, LD-N, CNSD
• Clinical Nutrition Manager
• Sinai Hospital of Baltimore
• 410.601.5727
• rmutchle_at_lifebridgehealth.org