Download Dietary treatments for infantile colic

ENTERAL AND PARENTERAL NUTRITION
UPDATE
WITH THE NUTRITION CARE PROCESS
Suzanne Neubauer, PhD,RD,CNSC
Framingham State University
Overlook Health Center, Charlton, MA
January 31, 2013
Objectives
Calculate basic flow rates for enteral nutrition
considering interruption factors and fluid
needs.
 Calculate parenteral nutrition formulas,
including basic electrolyte considerations.
 Practice the nutrition care process for
enteral/parenteral cases, focusing on new
nutrition diagnosis and intervention
standardized language.

Critical Illness Guidelines 2012: Blood
Glucose Control

promote blood glucose control between 140 to
180 mg per dL in critically ill adult patients
 Tight blood glucose control (80 to 110 mg
per dL) and moderate control < 140 mg per
dL is not associated with
reduced hospital length of stay
Grade II (fair)
days on mechanical ventilation
Grade II (fair)
http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Critical Illness Guidelines 2012: Blood
Glucose Control
 Tight
blood glucose control (80 to 110 mg per dL)
is not associated with
 infectious complications in surgical (primarily
cardiac) patients
 Grade II (fair)
 cost of medical care
 Grade III (limited
 Tight blood glucose control (80 to 110 mg per dL)
increases risk of hypoglycemia
 Glucose level >180 mg per dL is associated with
increased mortality
 Grade II (fair)
http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Composition of Solution
3-in-1 Total nutrient admixture (TNA)
 2-in-1
 Lipids infused separately
 Favorable when patients have high protein or
minimal fluid needs and can maintain
euglycemia with addition of modest insulin
dose
 Must use laminar-airflow hood to decrease the
risk of contamination

5
Clinimix
http://www.clinimix.com/home
 Clinimix
 Sulfite-free (Amino Acid in Dextrose)
injections
 Clinimix E
 Sulfite-free (Amino Acid with electrolytes in
Dextrose with calcium) injections

6
Protein: Crystalline Amino Acids
Stock solutions range from 8.5% to 20%
 Usually expressed at final concentration
after dilution vs initial concentration
 How many g protein in 8.5% AA solution?
 8.5% = 8.5 g =
x
100 ml
1000 ml
 85 g/L
 How many calories in 8.5% AA?
 4 kcal/g
 85 g/L x 4 = 340 kcal

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Carbohydrate: Dextrose Monohydrate



Stock solutions range from 5.0% to 70%
Calories
 Anhydrous glucose: 4 kcal/g
 Hydrous in IV solution: 3.4 kcal/g
CPN Limits
 Average adult requires 1 mg/kg/min or 100 g/d
 5 mg/kg/min
 4 mg/kg/min in critically ill and 7 mg/kg/min in
hospitalized patients (Supp Line 2005;27:6)
 patients on ventilators: 4 mg/kg/min
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 patients with diabetes: 2-2.5 mg/kg/min
Carbohydrate: Dextrose Monohydrate
How many g carbohydrate in 25% dextrose
solution?
 25% = 25 g =
x
100 ml
1000 ml
 250 g/L
 How many calories in 25% dextrose solution?
 3.4 kcal/g
 250 g/L x 3.4 = 850 kcal

Glucose Tolerance: Mg/Kg/Min
Max: 5 mg/kg/min
 Solve for g Dextrose:
5 mg x 70 kg x (60 minutes x 24 hr) = 504 g
1000 mg/g

Solve for mg/kg/min:
504 g x 1000 mg/g = 5 mg/kg/min
70 kg x 1440 min

12
CHO in Peripheral Parenteral Nutrition

PPN:
 Maximum of 10%; 5% most common
 Osmolality
Maximum = 900 mOsm
(10 x g pro) + (6 x g CHO) + (.3 x ml fat)
total L
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Lipids: Administration
Slow and continuous 24-hour infusion can
improve hepatic reticuloendothelial function
 As opposed to short, < 10 hrs, infusion
 Usually infused over 12 hrs. if infused
separately
 IVFE infusion rate
 NOT > 0.11 g/kg/h

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Calculation Rules for Lipid
Maximum lipid:
 60% of total kcal
 2.5 g/kg body weight
 2 – 4% of total kcal as linoleic acid to prevent
EFAD
 10% of total kcal as fat meets EFA
 Maximum of 30% lipid for septic patients
 May use > 30% with hyperglycemic or
pulmonary compromised patients
 Usually begin with 1 g lipid/kg/day
15

Calculation Rules for Lipid Cont’d
Intralipid 10%: 1.1 kcal/ml; 11 kcal/g
 Total volume of lipid x .1 = g fat
 Intralipid 20%: 2.0 kcal/ml; 10 kcal/g
 Total volume of lipid x .2 = g fat
 Intralipid 30%: 3.0 kcal/ml; 10 kcal/g
 Total volume of lipid x .3 = g fat


Lipid available as 250 ml or 500 ml
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Diprivan (Propofol)

Administered intravenously to intubated/
mechanically ventilated adult ICU patients
 Provides continuous sedation
 Controls stress responses
 Usually infused at 10 mg/mL
Isotonic
Check rate and total volume infused daily
17
18
Supp Line. 2009; 31(6):12-19.
Propofol Calculations
Supp Line. 2009; 31(6):12-19.
Calculate 3-in-1 solution/2200 mL



Pt weight @ 55 kg
 requires 2200 kcal; 93 g protein; 2200 ml fluid
Protein: 93 g x 4 kcal/g = 372 kcal
 2200 kcal – 372 kcal = 1828 kcal remaining for fat
& CHO
Lipid: use 1 g/kg/day to start
 55 g x 1 g/kg = 55 g fat
 55 g fat x 10 kcal/g = 550 kcal
 1828 kcal – 550 = 1278 kcal remaining for CHO
Calculate 3-in-1 solution/2000 mL

CHO: 1278 kcal
= 376 g dextrose
3.4 kcal/g dextrose
Check maximum CHO
 5 mg x 55 kg x (60 x 24 hr) =
 5 mg
x 55 kg x 1440 min/day
1000 mg/g
 .005 g x 55 kg x 1440 min/day = 396 g CHO

PN Order
Divide g of each substrate by total volume of
fluid. Multiply x 100 for percent.
 93 g protein x 100 = 4.2% AA
2200 ml
 55 g lipid
x 100 = 2.5% lipid
2200 ml
 376 g CHO
x 100 = 17% CHO
2200 ml

PN Order
93 g protein = 1 L 10% AA
 55 g lipid
= 250 ml 20% lipid
 376 g CHO
= 1 L 30% dextrose
 Total fluid = 2250 ml
 Kcal:
 100 g protein; 400 kcal (21%)
 250 ml lipid; 500 kcal (26%)
 300 g CHO; 1020 kcal (53%)
 Total kcal: 1920

Daily Electrolyte Requirements
The ASPEN Adult Nutrition Support Core Curriculum,
2nd,
2012:248
24
The ASPEN Adult Nutrition Support Core Curriculum, 2nd, 2012:248
Electrolytes: Initial Dose
Generally aim for the middle of the normal
range
 Individualize based on renal function, GI losses,
acid-base balance and medications
 Can use multiple-electrolytes or several single
entity electrolyte solutions
 Dependent on the compatibility of each
electrolyte with the other components in the PN
admixture

Electrolytes: Sodium

Generally use approximately equal amounts of
chloride and acetate (1:1 ratio)
Acetate and chloride also found in AA
solution
 In metabolic acidosis use maximum acetate
and minimum chloride
Acetate is metabolized as bicarbonate
 In metabolic alkalosis use maximum chloride
and minimum acetate
Electrolytes: Sodium
Sodium Goal: 1 – 2 mEq/kg
 Use 1.5 mEq/kg
 1.5 x 70 kg reference man = 105 mEq/day
 2 L (not including IVFE) so 105/2 = 53 mEq/l
Sodium Chloride: 53 mEq
Sodium Acetate: 53 mEq

Electrolytes: Potassium & Phosphorus




Potassium available in chloride, acetate, and phosphate
salts
K: maintenance @ 1 mEq/kg = 70 mEq
 2 L (not including IVFE) so 70/2 = 35 mEq/l
 If serum K is low correct with a separate infusion of K
Phosphorus available as the sodium or potassium salt
Phosphorus: 25 mmol/day
 25 mmol Potassium Phosphate (37 mEq K)
 Remainder of K as KCl: 33 mEq
Electrolytes: Calcium

Ca available as gluconate (preferred form) or
chloride salt
 Gluconate preferred b/c more stable in
solution
Less likely to dissociate and precipitate with
Phosphorus
dose within accepted solubility range and
amino acid pH and concentration
 standard dose: 12 mEq/day
Electrolytes: Magnesium
Mg available as sulfate or chloride salt
 Mg Sulfate is preferred form
 Mg 8 – 20 mEq/day

(140)
Supp Line 2005;27:13-22
Supp Line 2005;27:13-22
References




Kingley J. Fluid and electrolyte management in
parenteral nutrition. Supp Line. 2005;27(6):13-22.
Whitmire SJ. Nutrition-focused evaluation and
management of dysnatremias. Nutr Clin Pract.
2008;23:108-121.
Schmidt GL. Techniques and Procedures: Guidelines
for Managing Electrolytes in Total Parenteral Nutrition
Solutions. Nutr Clin Pract 2001 16: 226
Baumgartner TG. Enteral and Parenteral Electrolyte
Therapeutics. Nutr Clin Pract. 2001;16:226-235.