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NUTRITION SUPPORT
FOR A CONSULT - PLEASE ORDER VIA CIS OR PAGE THE NUTRITION
OR LEAVEA MESSAGEAT
275-3i15.
SUPPORT DIETITIAN
FOR UNIT
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General Rules:
- Use the gut first.
- Recommendations
for estimating calorie, fluid and protein needs (Adults Only)
- Use Ham wi formula for ideal body weight: Males = 48 kg + 2.7 kgfor each inch patient's height is over 5'
Females = 45.5 kg + 2.2 kg for each inch patient's height is over 5'
% Jdeal Body Weight (JBW) = Actual Weight -i- Ideal Body Weight
- If <I 25% JBW, use actual weight for calculations but adjustments should be made for obesity* (> 125% JBW)
*{(Actual weight - Ideal body weight) X 0.25} + Ideal body weight = Adjusted Body Weight (ABW)
-Severely malnourished patients «80% JBW or ~ 15% weight loss/6 months) must be started at
10 kcal/ kg/day and advanced by 5 kcal/kg/day to 30 kcal/kg/day to prevent refeeding syndrome.
(Need to closely monitor K, P04, Mg and replete aggressively.)
Total volume =
_
A. Usual Fluid Requirements
25 - 30 mllkg/day
Total calories =
_
B. Usual calorie requirements
25 - 30 kcal/kg/day
C. Usual protein requirements
1.2 -1.5 gmlkg/day except;
-Renal Failure without dialysis, or Hepatic Failure with Mental Status Changes 0.8-1.2 gm/kg/day
-Large open wounds 1.5 - 2.0 gm/kg/day
Protein =
_
D. Propofol is lipid based and provides 1.1 kcal/ml and 0.1 gm Fat/ml.
Enteral/Parenteral nutrition should be adjusted to account for propofol calories to avoid overfeeding.
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Enteral Fonnularv
Products
(all formulas are lactose-free):
-Jevity 1.2. This is our 'House Formula'. A fiber containing intact nutrient product acceptable for most patients.
It provides 1.2 kcal/ml, 55.5 gm protein/liter and is -80% free water.
-Promote with Fiber. This is similar to Jevity 1.2 but has 35% more protein. It is useful in patients with large decubiti, bums
and GVHD of the skin. It provides 1.0 kcallml, 62.5 gm protein/liter and is -83% free water.
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-Osmolite 1 Cal. Similar to Jevity 1.2 except it has no fiber and is lower in potassium, magnesium and phosphorus. It is useful
in older patients who do not tolerate the fiber load of Jevity 1.2, and in borderline renal failure patients where electrolyte
management is an issue. It provides 1.06 kcal/ml, 44.3 gm protein/liter and is -84% free water.
-Nepro. Designed for the renal failure patient. This may be given via a feeding tube or by mouth. It is also relatively
r-estricted in the potassium, phosphorus and magnesium content.
It provides 1.8 kcaJ/ml, 81 gm protein/liter and is -73% free water.
Active dialysis patients may require additional protein:
- Procel protein powder can be given as a bolus via FT - 1 scoop contains 28>kcal, 5 gm protein.
-TwoCal HN. For the fluid restricted patient with normal renal function or the patient on active dialysis.
It provides 2.0 kcallml, 83.5 gm protein/liter find is -70% free water.
-Vivonex RTF. This is low-fat elemental feeding. The protein source is 100% free amino acids which requires less digestion
and is absorbed more efficiently than long chain peptide formulas, These qualities make it useful in post-op trickle feeding
and GI impairment/pancreatitis.
It provides 1.0 kcal/ml, 50 gm protein/liter, 12 gm fat/liter and is -85% free water.
Enteral Feeding Pearls:
-Placement of a transpyloric feeding tube is recommended in the patient with decreased mental status or a history of gastric
residuals. This can be facilitated by infusing 10 mg Reglan (metocIopramide) IV, 10 minutes before the tube is placed and
inserting all but 10 em of the feeding tube (10-10-10 rule).
-The ICU's also have the Cortrak device to aid with difficult placement of a transpyloric feeding tube - note that 43" and 55"
feeding tubes are available for this device. The 55" feeding tube can be useful in the very obese pt to allow proper placement.
(presently on hold - being reviewed for use at this time)
-Reglan PO can also be given tid/qid to aid with gut motility in patients with gastroparesis or history of gastric residuals.
-NYS Public Health Law prohibits using greater than a 12 Fr nasogastric tube for enteral feedings.
---NSS recommends an 8 Fr Corpac feeding tube for routine NG or NO feedings.
-A significant tube feeding residual is ~200 ml in NGIND/PEG feedings.
-Monitoring should include a baseline and weekly weight, a weekly prealbumin and aspiration precautions (HOB >30°).
-Crushing sustained released and enteric-coated medications for administration via the feeding tube is not recommended.
-Enteral feedings should he held 2 hours before and after the administration of po ciprofloxacin and 30 minutes before and
after carafate. Phenytoin (Oilantin) can be ordered at SMH in IV form (injection - not suspension) to be given via FT - enteral
feedings do NOT need to be held if Phenytoin is ordered in this manner.
TPN Guidelines:
Acceptn ble indications
for Parenteral
Nutrition
Patient cannot receive oral nutrition OR enteral nutrition via feeding tube, PEG, JT etc and the following:
-NPO > 7 days in previously well-nourished patients who are not catabolic.
-Recent GI surgery with anticipated NPO status> 7 days or severe nutritional risk.
-Bowel rest is indicated to be part of the therapeutic plan. (e.g. advanced pancreatitis, ileus, bowel obstruction,
inflammatory bowel disease, fistulas, etc.)
-Inadequate absorptive surface. (e.g. Short gut syndrome, intractable sprue/celiac, other specific intestinal mucosal
injuries, and severe mucositis in poorly nourished patient)
-To supplement patients at severe nutritional risk pre-operatively who can't be enterally fed.
-Anticipated frequent interruption of oral or enteral intake in patients at severe nutritional risk.
-Hyperemesis gravidarum or frequent vomiting, if not responsive to enteral feedings.
Unacceptable
indications
for parenteral
nutrition
-Gastroparesis or gastric ileus with a functional small bowel.
-Patient cannot take oral nutrition BUT enteral nutrition via a feeding tube is still possible.
-Mental status changes or Neurogenic dysphagia (stroke, Parkinson's, Alzheimer's, etc).
-Patient has inadequate oral intake.
-Patient refuses enteral support,
-Advanced directive against artificial or invasive nutritional therapies precludes parenteral nutrition as well.
-Cornpetent patient refuses enteral support.
-Incompetent patient repetitively removes feeding tubes. (Patient restraint or mechanical securing of
naso-enteric access should be addressed - nasal bridle.)
TPN CALCULATIONS:
Designing Parenteral Nutrition .(2-in-1)
See General Rules for obesity adjustments and refeeding cautions.
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Total fluid volume =
A. Usual Fluid Requirements
25 - 30 ml/kg/day
Total calories =
B. Usual calorie requirements
25 - 30 kcal/kgJday
C. Fat Requirements (Lipid Emulsion of20% provides 2 kcaIlml)
Usually provide 15-30% of total kcal or 0.8-1.0gmlkg/day (not to exceed 50% of total calories).
In general, lipids are provided over 12 hours for central PN (TPN) and 24 hours for periperhal PN (PPN).
-If the patient is allergic to eggs, soybeans. or safflower; a test dose must be administered
(20% lipids 0.5mll minfor 15 minutes before the first lipid infusion)
-Propofol is provided in a 10% lipid emulsion and provides 1.1 kcal/ml and 0.1 gm Fat/ml.
Parenteral nutrition should be adjusted to accountfor propofol calories andfat.
0.30 X Total calories
Fat calories
7
2
=
Total volume of20%
Total volume of20%
lipids (ml)
-+
lipids (ml)
12 hours =
(Total fluid volume - Total volume of20%
ml/hr x 12 hours 20% lipids
lipids) =
Volume of amino acids dextrose solution (011)
-+
Volume of amino acids dextrose solution (ml)
1000 = __
Volume of amino acids dextrose solution (liters)
D. Protein Requirements (Amino Acids provides 4 kcal/gm)
Majority ofTPN patients - Use 1.2 -1.5 gm/kg/day except;
-Renal Failure without dialysis, or Hepatic Failure with Mental Status Changes
-Large open wounds 1.5 - 2.0 gm/kg/day
Protein
(gm)
=
Grams of protein desired
4 kcal/gm X grams of protein
-i-
_
_
Fat calories
---
=
q
=
Volume of the amino acid dextrose solution (liters)
0.8-1.2 gm/kg/day
Protein Calories
= grams
of protein/liter
E. Carbohydrate Requ irements (Dextrose Provides 3.4 kcal/gm)
-Start at 3.6 - 4 gm/kg/day to a maximum of7 gm/kglday (5 mg/kg/min)
Total calories - Fat calories - Protein calories
Carbohydrate
calories
Grams of carbohydrates
7
3.4
-+
= Carbohydrate
calories
grams of carbohydrates
=
Volume of the amino acid dextrose solution (liters) = gram dextrose/liter
Q A safe peripheral parenteral nutrition formula to start with is 1.2 Uday (50 ml/hr) with 50 gm amino acids/L,
100 gm dextrose/L, standard additives and 240 ml/day 20% lipids (10 rnl/hr x 24hr).
This will provide 1440 rnl, 60 gm protein and 1128 kcal per day.
Q A safe central parenteral nutrition formula to start with is 1.2 Uday (50 ml/hr) with 50 gm amino acids/L,
150 gm dextrose/L, standard additives and 240 ml/day 20% lipids (20 ml/hr x 12hr).
This will provide 1440 ml, 60 gm protein and 1332 kcal per day.
Electrolyte
ITInnagement with parenteral
nutrition:
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-Acute electrolyte management should occur outside of the TPN.
-Normal Saline is equivalent to ) 50 meq Na & CI per liter.
-If the corrected S Ca is low, double the Ca to 9 meq / liter.
-lftheSMg
is low double the Mg to 10 meq / L.
-To manage low S CI, maximize the CI anion. Write MAX for CI in CIS.
-To manage low S C02, minimize the CI anion (will default to maximize acetate which is metabolized to C02).
Write MIN for CI in CIS.
-For each O. I meq /dl increase in SK desired, increase the potassium 10 meq over baseline.
-Use caution when increasing the P04 in the TPN as there are concentration dependent incompatibilities with Ca.
(Rule of thumb: 45-Ca = 2 x P(4)
Parenteral
Nutrition Monitoring and Pearls:
-Parenteral nutrition must be ordered daily in CIS by 11:00 a.lll. The daily infusion will be available in the late afternoon.
(If necessary to contact the Pharmacy regarding TPN, please call 275-2682.)
-Comprehensive metabolic profile (PF14), P04, Mg, prealbumin, triglycerides and weight baseline and then weekly.
Basic metabolic profile (PF8) with P04, Mg for three days then three times a week. Serum glucose every 6 hours until stable.
-Potassium, magnesium and phosphorus may need to be reduced in renal insufficiency.
-Copper and manganese should be held with biliary obstruction.
-If Triglyceride level is> 400, hold lipids.
-Vitarnin K in TPN is included in the multivitamin.
Adjust warfarin dose as needed.
-Insulin can be added to TPN bag to aid with glucose control. (Start with 0.05 -1.0 units of insulin per gram of dextrose OR half to
two-thirds of the total amount of sliding scale insulin required over the previous 24 hours if already on TPN).
Ifpt. is on the insulin drip protocol, do NOT add insulin to TPN bag.
-Pepcid IV can be added to TPN (protonix cannot be added to TPN).
-If the TPN is unavailable for any reason; an infusion of DlOW (central formula) or D5W (peripheral formula) infused at the TPN
rate will prevent rebound hypoglycemia.
-To taper a TPN to OFF, decrease the infusion to 1/2 the hourly rate for I hour and then to off. This will minimize the risk of
rebound hypoglycemia.
-If planning to discharge patient home with TPN, please phone consult Hornecare Nutrition Support @ 275-3995 as soon as
possible to allow TPN to be cycled, patient training to occur, and insurance coverage to be addressed.
Additional Information - PO supplements:
-Ensure - available in Vanilla only. Provides 250 kcal, 9 gm protein per 8 oz.
-Ensure Plus - available in Vanilla, Chocolate, and Strawberry. Provides 355 kcal, 13 gm protein per 8 oz.
-Enlive (clear liquid fat-free fruit beverage) - available in Apple. Provides 300 kcal, 10 gm protein per 80z.
-Mightyshakes - available in Vanilla, Chocolate, and Strawberry. Provides 200 kcal, 6 gm protein per 4 oz.
-Scandishakes - available in Vanilla, Chocolate, and Strawberry packets - needs to be mixed with 8 oz whole milk.
Provides 600 kcal, 12 gm protein per pkt/8 ozwhole milk mixture. _"~'I
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"-"--"- "="" -ht.: ~ .•". ~ C"T'-~'-Procel protein powder - available for additional protein. Can be given with foods/liquids or as a bolus via FT.
One (1) scoop/pkt contains 28 kcal, 5 gm protein.
-LiquaFiber - available for additional fiber. Can be given with foods/liquids or as a bolus via FT.
Each 15ml dose provides 5 gm fiber (from maltodextrin).
Usual dose is 15ml up to TIO.
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Indirect Calorimetry:
- The metabolic cart measures the oxygen consumed and C02 produced by the patient and then calculates the resting energy
expenditure CREE) for the patient using the Weir equation.
- The Respiratory Quotient (RQ) is the ratio of C02 produced to oxygen consumed and reflects which fuels
(Carbohydrate/Fat/Protein) are being oxidized.
- Metabolic Cart can be ordered on patients in CIS under Respiratory - Misc.
It is helpful to ask nursing and/or lill to inform the respiratory technician that the metabolic cart has been ordered.
-Requirements for a valid measurement include:
-hernodynamically stable patient
-chcst tubes cannot have any leaks
-:S I0 for PEEP
-must have a cuffed ETT
-cooperative or sedated patient
-S50% Fi02
-cannot be on pressure control with PEEP of:S 10
-~ 4 hours must pass after vent setting changes and/or changes
in tube feed f0I111Ulaand/or tube feed rate
-The normal range for RQ is 0.7 - 1.0.
-The range or actual calories required for the most intubated/ICU patients is approximately
REE to REE + 10%.
EXAMPLE TPN:
50 yo female with flare of crohn's disease. MD wants "bowel rest" on TPN.
Pt is 5'8" and 89 kg. Ideal Body Wt (mW) = 63.-6 kg -> pt isI40%mW.
Adjusted Body Wt (ABW) = «89-63.6) x .25) + 63.6 = 70 kg -> use this wt for calculations.
Current Labs: 143
3.4!
121
17!
14/76
10.7 \
iCa++ = 3.4!, P04 = 3.0, Mg++= 1.8
Alb = 1.9!, Prealb = 7!, T.Bili = 1.2, D. Bili = 0.7!, Trig
=
138
A. Usual Fluid Requirements
25-30 nil/kg/day
Total fluid volume = 1750-2100 ml
B. Usual calorie requirements
25-30 kcal/kg/day
Total calories = 1750-2100 kcal
Start with goal of 1800 kcal and 1800 ml O.8Ll
C. Fat Requirements (Lipid Emulsion of 20% provides 2 kcaIlml)
Usually provide 15-30% of total kcal
0.30 X Total calories =
540
Fat calories
540 Fat calories + 2 kcal/ml =
270 ml 20% Lipids/day
270 ml + 12 bours = 22.5 mllbr
Suggest rounding to 22mVhr x 12 hours = 264ml 20% Lipids/day x 2 kcaVml
= 528 Fat
calories
1800 ml- 264 ml = 1536 ml for volume of amino acids dextrose solution
1536 ml + 24 hours = 64 mllhr
1536 ml + 1000 = 1.536 liters
D. Protein Requirements (Amino Acids provides 4 kcaIlgm)
Majority ofTPN patients - Use 1.2 -1.5 gmlkg/day
Protein = 1.3 x 70 = ---2.L gm of protein
4 kcallgm x grams of protein =
364
Protein Calories
Grams of protein + Total fluid volume(L) = 59 gmlliter of Amino Acids
E.
Carbohydrate Requirements (Dextrose Provides 3.4 kcallgm)
Start at 3.6 - 4 gm/kg/day to a maximum of7 gmlkglday (5 mg/kg/min)
Total calories - Fat calories - Protein calories = 908 Carbobydrate
calories
Carbohydrate
calories + 3.4kcallgm = 267
grams of carbobydrates
Grams of carbohydrates
+ Total fluid volume(L) =
174 gmlliter of Dextrose
Custom Central TPN: TPN Rate@64ml1hr(1536mIld)
wi 59 gmIL Amino Acids
174 gmIL Dextrose
22 mlIhr 20% Lipids x 12 br
= 264
mild
This will provide 1800 kcaIld (26 kcal/kgABW) and 1800 mIld (26 ml/kgABW)
wi 91 gm proteinld (1.3 gmlkgABW)
267 gm dextrose/d (3.8 gm/kgABW)
53 gm fat/d (29010 calories from fat)
Additives:
•
•
•
•
Suggest
Suggest
Suggest
Suggest
IV repletion ofK+ and Ca++ prior to starting TPN.
MIN Chloride in TPN -> this will maximize acetate which will be metabolized to C02).
increase to 9.0 mEqlL Calcium in TPN.
standard amounts for all other additives.