Nutrition Support

1
Nutrition Support
2
Selecting a method

• If the gut works, use it
• When a person is unable to ingest enough food to
  meet their nutritional needs
• nutrition support is needed
• could be enteral if the gut works
• could be parenteral if the gut doesnt work

3
Complete the following statement. If the gut
works, ________.

• Forget it
• Sell it
• Use it
• Buy it
• Select an alternate form of feeding the patient
  other than the GI tract

4
Enteral Nutrition

• By way of the GI tract
• Could be
• Oral Supplements
• Tube Feedings
• Nasogastric
• Nasoduodenal or nasojejunal
• Enterostomies
• Gastrostomies Percutaneous Endoscopic Gast.(PEG)
• Jejunostomies Multiple Lumen tubes

5
Selecting an Oral Supplement

• 1. Degree of inability to meet needs
• 2. Presence or absence of dysphagia
• 3. Taste preference or sensitivity
• 4. Availability of labor and resources for
  preparation
• 5. Tolerance to lactose or other components
• 6. Tolerance of osmotic load

6
Supplement Components

• Kcals 250 kcal/ 240 ml portion is the norm
• Fat
• Usually Long Chain Triglycerides
• Could be MCT if pt doesnt tolerate fats
• Protein
• 8 to 14 grams of intact protein
• CHO
• Form varies Simple adds sweetness and osmotic
  load

7
Tube Feedings Route of Access

• Several Factors
• 1. Length of time required
• Short term usually through nasopharynx
• Longer term through enterostomal routes
• 2. Risk of aspiration
• 3. Degree of digestion available
• 4. If there is a planned surgical intervention

8
Nasogastric Route

• Nasogastric Tube simplest access
• Pt requires functional GI tract and normal gag
  reflex
• French .33 mm
• Can be large bore tube (French 12)
• Used for food, medications and gastric suctioning
  or
• Small bore, pliable tube (5 French)
• Greater comfort, but more easily clogged

9
Nasoduodenal or Nasojejunal

• Tube threads through stomach to duodenum or
  jejunum
• Migration from stomach to duodenum via
  peristaltic waves may take a few hours to days
• Radiologic verification is required
• Small bowel feedings require careful selection of
  enteral formula

10
If you had a 12 French tube, what would the
diameter be?

• 3.96 m
• 3.96 cm
• 3.96 mm
• 39.6 mm
• .33 mm

11
Enterostomies

• Surgical Gastrostomy
• Catheter is placed through the abdominal wall
  into the stomach
• A balloon is inflated to hold the catheter in
  place in stomach
• Requires good gastric functioning
• Can be associated with skin erosion, leakage of
  gastric contents leading to peritonitis

12
Surgical Jejunostomy

• Needle jejunostomy(temporary)
• Catheter jejunostomy(more permanent)
• both reduce risk of pulmonary aspiration
• small lumen size of tube difficult to maintain so
  not often performed

13
If you had a jejunostomy in place which of the
following formulas would you not use?

• Intact proteins as protein source
• Glucose as CHO source
• Free fatty acids as Fat source
• Pepperoni pizza
• 1 and 4

14
Fluid requirements

• 1ml of water per kcal
• 35 ml/kg usual body weight
• Formulas contain 80 to 85 water
• may need to add water as an additional flush

15
Osmolality

• Intact formulas fall between 300 to 500 mOsmol/kg
  , approx the same as body fluids
• No real concerns with fluid shifts
• Hydrolyzed formulas are often higher
• up to 900 mOsmol/kg
• contributes to extra fluid and electrolyte loss
• diarrhea
• Proper administration is key

16
Administration of Enterals

• Continuous drip
• Intermittent drip
• Bolus feeding

17
Continuous Drip

• Estimated total kcal needs are made
• Rate per hour determined based on the kcal
  content of formula
• 2000 kcals needed per day
• Formula has 1kcal/cc
• 2000kcal/1kcal/cc 2000 ccs needed
• 2000cc/24 hrs83ccs/hr is set as the goal volume

18
Administration of Continuous Drip

• Caution when initiating tube feeding
• If the gut has not been used lately
• If the formula is hyperosmolar
• Feedings are typically started at 30 to 50
  ccs/hr
• Then advanced 25 to 30 ccs/hr every 8 to 12
  hours until the target rate is obtained
• Feedings of 300 to 500 mOsmol/kg can be started
  at full strength hyper start slowly

19
If a pt needs 2200 kcal per day and you are
administering a formula with 1.5 kcal/cc, how
many ccs would you need per day.

• 1800
• 1667
• 1467
• 2200
• None of the above

20
For the pt on the previous slide, what would be
the goal hourly rate of enteral feeding?

• 100 cc/hr
• 88 cc/hr
• 61 cc/hr
• 42 cc/hr
• 25 cc/hr

21
Admin of Tube Feeding

• If intolerance decrease to previous increment
  and advance as tolerated
• Dont hang a bag for days
• Food born illness
• Bag should be changed daily
• Dont add new formula on top of old formula

22
Administration of Tube Feedings

• If fed into stomach, stomach contents checked
  every 4 to 8 hours
• if residual volume exceeds 100 ml, stomach isnt
  emptying quickly and volume admin should be
  reduced
• Risk of pulmonary aspiration

23
Intermittent or Bolus Feedings

• Quality of Life A more normal lifestyle with
  intermittent feedings
• Frees pt to be mobile
• Figuring intermittent or bolus feedings similar
  to continuous
• Total Kcals determined
• Divided by number of hours feeding
• General 4 to 6 feedings _at_ 20 to 60 min

24
Administration of Bolus or Intermittent Feeding

• Residuals checked more frequently every 2 to 4
  hours
• Few pts can tolerate more than 450 ml per feeding
• Pt needs to be monitored for several potential
  problems

25
Monitoring Tube Fed Pt

• Weight 3 x wk
• Signs of Edema daily
• Signs of dehydration daily
• Fluid In/Out daily
• Cal, Pro, fat, CHO, vit min 2/wk
• N balance (24-hour UUN) weekly
• Gastric residuals (2 to 4 hrs)

26
Monitoring Tube Fed pt

• Stool output and consistency (daily)
• Urine Glucose (every 6 hours until rate is
  established then daily for Db pt)
• Serum electrolytes, BUN, creatinine, blood count
  (2-3 x wk)
• Blood chemistry total protein, albumin,
  pre-albumin, Ca, Mg, P, Liver Fxn weekly

27
If you are initiating a tube feeding, which of
the following would you monitor?

• Gastric residuals
• Fluid in and out
• weight
• Blood values such as albumin and pre-albumin
• All of the above

28
Tube Feeding Problem

• Pulmonary Pt with 1800 kcal need
• No renal problems or fluid restrictions
• gastrostomy in place
• Tube feeder with Pulmocare
• Pro casein CHO cornstarch and sucrose Fat
  mixed triglycerides
• 1.5 kcal/ml 55.2 kcal from Fat 28.1 kcal
  from CHO62.5 g Pro/1000ccs 78.5 water
• ? How much Pulmocare? how much fluidPro?

29
Use Nutrition Care Manual

• http//nutritioncaremanual.org

30
Pulmocare Problem

• Osmolality is 475 mOsmol/kg
• How would you administer this?
• What would you monitor to determine tolerance?
• What would you monitor to determine if needs were
  met?

31
Parenteral Nutrition

• If pt is unable to receive nutrients via the GI
  tract
• Then Parenteral Nutrition is Appropriate

32
Parenteral Access

• Peripheral Access
• Arm (or leg)
• 900 mOsm/kg upper limit of acceptable
• Higher concentrations cause vein to become
  inflamed and collapse.
• PICC(Peripherally Inserted Central Catheter)
• Higher concentration is possible
• End of lumen is threaded to a larger vessel with
  greater dilution capacity

33
Parenteral Access

• Short Term Central Catheter
• Subclavian vein central catheter
• line inserted into Subclavian and threaded to the
  superior vena cava
• Provides maximum dilution of parenteral solution
  and no damage to the vein lumen
• Risk of infection

34
Parenteral Access

• Long-term Access
• When access is required for many months or
  longer, a permanent catheter is surgically placed
• A port is imbedded at the skin level or under the
  skin which is accessible
• Tunneled central venous catheter(Hickman,
  Broviac, Groshong) Tunneled under skin with
  external device for access on chest wall
• Implanted port silicone catheter with titanium
  disk placed under the skin

35
When only peripheral access is available but you
need to provide total nutrition without the use
of the GI tract, you would select which of the
following options?

• Enteral Nutrition
• A nasogastric tube
• A Hickman catheter at the chest to the subclavian
  vein
• PICC
• A needle jejunostomy

36
Terminology with Parenteral Solutions

• D Dextrose
• W Water
• NS Normal Saline (0.9) NaCl solution 0.9 g
  NaCl/ 100 ml
• D5W 5 Dextrose solution in water
• (5 g Dextrose in 100 ml water)
• D51/2 NS 5 Dextrose in 1/2 Normal Saline (0.45 g
  NaCl in 100 ml Water)

37
Nutrients in Parenteral Soln

• Protein
• Combination of essential and non-essential aas
• Generally 15 to 20 of total Kcal needs in most
  solutions
• Often a 10 amino acid solution is used
• 10 g / 100 ml which represents 100 grams/liter
• Final concentration often expressed as the
  concentration in the final volume after mix with
  CHO and Fat

38
Fat in Parenteral Soln

• Usually comes in 10 or 20 solutions
• 10 represents 1.1 kcal/ml(eg 0.9 cal/ml from
  soy oil, 0.2 cal/ml from glycerol and
  phospholipids(egg yolk))
• 20 represents 2.0 kcal/ml(1.8 cal/ml from soy
  oil, 0.2 kcal/ml from glycerol and phospholipids)
• Usually composed of safflower, soy oils with
  lecithin as an emulsifier to hold in solution
• Generally 20 to 30 of Kcal
• Dont exceed 60 (2.5 g/kg/d)

39
CHO in Parenteral Solution

• Dextrose monohydrate
• D Glucose with a water attached
• Concentrations range from 5 to 70
• Shouldnt exceed 5 mg/kg/min
• Used to spare protein and provide kcals

40
Calculation of Osmolality

• Dextrose grams/l x 5
• Protein grams x 10
• Fat is isotonic so no osmotic force
• electrolytes further add to osmolarity
• 50 g of dextrose plus 30 grams of protein
• (50 x 5) (30 x 10) 550 mOsm/l

41
Indications for Peripheral Vein Feedings

• 1. Short term enteral feeding again in 7 d
• 2. Transition with enteral feeding
• 3. Mild to mod malnutritionsupplemental
  nutrition needed
• 4. Normal or mild elevation of metabolic rate
• 5. No organ failure or fluid restriction

42
Indications for Central Vein Feeding

• 1.Unable to enteral feed for 7 days
• 2. Mod to severely elevated metabolic rate
• 3. Moderate to severe malnutrition
• 4. Cardiac, renal, or hepatic failure or other
  conditions limiting fluid
• 5. Limited access to peripheral veins
• 6. Able to access central vein

43
Compounding Methods

• Two methods of prescription compounding
• 1. All components except fat
• 2. All components including fat
• May be batch mixed to save money
• or may be individually prescribed and mixed
• Is done by pharmacist in aseptic conditions

44
If a person had extensive damage to their GI
tract because of a motor cycle accident which
required resection of the duodenum and much of
the jejunum, which of the following would be
appropriate methods of providing calories

• Oral intake only
• Nasogastric tube only
• Peripheral Parenteral nutrition only
• Total Parenteral Nutrition
• None of the above

45
Administration of TPN

• Continuous Infusion
• Initiate at 42 cc/hr or 1000 L/d
• increase incrementally until goal rate is reached
  over next two to three days
• If TPN is interrupted, infuse D10W or D20W until
  TPN can be restarted
• Guard against hypoglycemia

46
Cyclic Infusion

• To free individuals who are capable of mobility
• TPN for 12 to 18 hour infusion periods are
  possible. Allows pt to be mobile for 6 to 12
  hours
• Cyclic administration is established incrementally

47
Monitoring and Problem Solving

• Actual intake of TPN is monitored
• Monitor Growth, weight
• Metabolic parameters Table 23-7 p549
• serum lytes, BG, Hb, etc
• General
• Volume of infusate, oral intake, urinary output
• Infection
• Clin Observations temp., WBC, cultures

48
Refeeding syndrome

• With intro of energy substrates following a
  period of no intake, may cause Refeeding Syndrome
• Shift of phosphorus, potassium from serum to
  intracellular sites for ATP production
• causes hypophosphatemia, hypokalemia
• Can be severe and life threatening
• Needs to be monitored and may require additional
  IV replacement of P and K

49
Transitional Feeding

• Parenteral to Enteral
• begin at 30 cc/hr
• increase 25-30 cc/hr every 8 to 24 hours
• Parenteral solution is reduced accordingly
• Parenteral to Oral
• Monitor oral intake less predictable than above
• Reduce Parenteral accordingly
• Enteral to Oral
• Adjust to intermittent feeding first

50
Nutrition Support in Other Settings

• Long-term Care
• More happening in nursing facilities
• Home Care
• People are at home receiving nutrition support
• Concerns
• motivation
• familys ability to handle
• benefit of receiving nut support
• limitations such as physical

51
Ethical Issues

• End of life decisions
• Based on advance directives from patient
• What is the patients desire about end of life
  support?
• Standards and Guidelines
• American Society of Parenteral and Enteral
  Nutrition
• Guidelines for use of nutrition support

52
1000 ml D5W would provide

• 5 grams of amino acids
• 5 grams of D glucose
• 50 grams of dextrose
• 5 grams of fat
• 5 grams of water

53
Problems

• 3 liters of D5W was given via peripheral IV over
  a 24 hour period. How many kcals did it provide?
  (1 gram Dextrose monohydrate 3.4 kcals)
• (5 g/100ml) (1000ml/l)(3 l)(3.4 kcal/g)510 kcal

54
Problem

• 2.5 l of 3.5 Dextrose
• (3.5 g/100ml)(1000ml/l)(2.5 l)(3.4 kcal/g)
• 297.5 kcal

55
Problem

• 3 l of 25 Dextrose and 3.5 Amino Acids
• How many kcals and kcal from each?
• (25g/100ml)(1000ml/l)(3 l)(3.4kcal/g) 2550kcal
  from CHO
• (3.5g/100ml)(1000ml/l)(3 l)(4kcal/g) 420 kcal
  from PRO
• Total 2550 420 2970 2550/297086 from CHO
  and 14 PRO

56
Problem

• 500 ml of 10 fat emulsion distributed in 2.5 l
  of TPN solution which has a final concentration
  of 20 Dextrose and 3.5 Amino acids.
• How many total kcals and what from each energy
  nutrient?

57

• (20 g/100ml)(1000ml/l)(2.5 l)(3.4 kcal/g) 1700
  Cal from CHO
• (3.5 g/100ml)(1000ml/l)(2.5 l)(4 kcal/g) 350
  Cal from PRO

58
Problem (cont)

• 10 fat emulsion (1.1 kcal/ml) (500 ml) 550
  kcal from Fat
• Total 1700 350 550 2600 kcal
• 1700/2600 65 from CHO
• 350/2600 13.4 from Pro
• 550/2600 21 from Fat

59
Nut Assessment

• Pt requires 2200 kcal
• 60 kcal from CHO
• 25 kcal from fat
• 15 kcal from PRO
• How would you formulate this?
• Fat first you need 2200 x .25 550 kcal
• 20 fat emulsion _at_ 2.0 kcal/ml
• 550 kcal/ 2 kcal/ml 225 ml 20 soln

60
Nut assessment

• Final volume of 2000 ml
• Fat contributes 225 ml
• For 60 Cal from CHO 2200 kcal x .6 1320
  kcal/3.4 kcal/g 388 g CHO needed
• Using a 50 Dextrose solution at 50 g/100 ml
• How much of this solution would you need to add?
• 388g/50 g/100 ml 776 ml of the 50 Dextrose
  solution CHO contributes 776 ml

61
Protein needed?

• For 15 Cal from Protein 2200 kcal x .15 330
  kcal/4kcal/g 82.5 g PRO
• Using a 10 amino acid solution at 10g/100 ml
• 82.5 g/10g/100 ml 825 ml of the 10 amino acid
  solution
• The amino acid solution contributes 825 ml
• Total volume 225 ml(fat) 776(CHO) 825(AA)
  1826 ml
• Add Vitamins and Minerals
• Add water to make the required volume