Download Nutrition and Pharmacists

Gastrointestinal Disorders
Recently Published Guidelines 2009
• American Society for Parenteral and Enteral Nutrition (ASPEN)
• The European Society of Clinical Nutrition and Metabolism (ESPEN)
Patient Case (followed throughout this lecture)
• 47 yr old cachectic appearing female admitted with abdominal pain. Reports history of Crohn’s
disease with previous bowel resection. History of drug abuse and psychiatric disorder (bulimia)
• Anthropometric Measurements – Ht 66” Wt 47 kg BMI 16.7 kg/m2
• Upon admission she has ordered: GI consult and Surgery consult
Nutritional board certification for pharmacist
• One of the 8 Board Certification Specialties, 350 board certified Nutrition support pharmacists in the
United States. BCNSP first recognized in 1988, Only Nuclear pharmacy has been recognized longer
Nutrition and Pharmacists
Inpatient role
• PN (parenteral nutrition)
• Electrolyte management
• Fluid management
• Drug–nutrient interaction (feeding tubes)
Community role
• Caloric supplements
• Herbal supplements
• Mineral supplements
• Vitamin supplements
• Drug–nutrient interactions
Malnutrition and the IMPACT on Pharmacists
Kinetics in Malnutrition affects how drugs are distributed throughout the body.
• Albumin – most malnourished patients have lower albumin which causes decreased protein binding of
medications and a higher free drug concentration
• Fat mass – can be decreased or increased which can affect drug distribution and Volume of
distribution (Vd)
• Total body mass
• Decreased organ function – which could change drug metabolism and drug excretion
• Enzyme synthesis – can also be decreased in the malnourished patient changing drug levels
• Underweight diseases such as:
• Scurvy, Anemias, Beri Beri, Pellagra, Rickets which are individual type conditions
• We also see significant changes in immune function in the malnourished patient.
• We also have Overweight diseases such as:
• Diabetes, Coronary artery disease, Hypertension, Hyperlipidemia
• Join degeneration
Definition of Malnutrition – Created by difference between nutritive intake and nutritive utilization.
• This is observed as the loss of significant portions of lean body mass OR observed as health
complications related to nutritional status (e.g. Immune function & organ dysfunction)
Types of malnutrition
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Marasmus. Kwashiorkor. Mixed, Cytokine induced, Obesity
Single - Nutrient Deficiencies – Vitamins, Trace Elements, Essential Fatty Acids
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1. Marasmus
• Malnutrition related to both a decrease in protein and caloric intake
• Occurs through simple starvation
2. Kwashiorkor
• Kwashiorkor is called the “Disease of the displaced child”
• The reason for this is in Third World countries when a new baby is born to a mother where a
previous child is still suckling. The previous child gets removed from the breast and the new baby is
allowed to nurse. The older child now only receives what is available which many times includes
carbohydrates with minimal protein intake.
• Diet based on starches and vegetables
• Protein malnutrition (Children with potbellies and some with gray hair)
3. Cytokine Induced malnutrition
• This is the type of malnutrition seen many times in the intensive care unit.
★ Cytokine induced malnutrition is caused by increased needs OR metabolism combined with a lack of
sufficient intake.
• Change in nutrient utilization caused by a much higher rate of protein catabolism, and sometimes an
increased rate of metabolism (caloric utilization).
★ This type of malnutrition cannot totally be addressed by nutrition alone. Patients with this type of
malnutrition must be treated for their disease before nutrition can exert much influence.
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Obesity
Described sometimes as malnutrition (mal = bad) because of too MUCH nutrition
Associated with different disease states such as diabetes, cardiovascular disease, etc.
This continues to be a large problem especially in the United States
International Consensus Guideline Committee – Recommend definition of 3 types of malnutrition
Etiology based:
1. Starvation related malnutrition – “Marasmus”
2. Chronic disease related malnutrition
3. Acute disease or acute injury related malnutrition
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Starvation related malnutrition “Marasmus” as a response to nutrition. Patients being re-fed and their
responding back to baseline as far as weight. (showing good outcomes)
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Disease-related malnutrition “Injury related” whether they are acute or chronic patients do not
necessarily returned to baseline in terms of their weight. This has to do with the changes of nutrient
utilization.
Nutritional Assessment
Nutrition Screening
• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• Requires ALL patients to be nutritionally screened within 24 hours of admission.
• Identify patients “at risk for malnutrition”
• Nutrition Assessment within 48 hours and Nutrition Care Plan instituted
nutritional assessment is defined by The American Society of Parental and Enteral nutrition (ASPEN)
• “Comprehensive approach to defining nutritional status that uses medical, nutritional, and medication
histories, physical examination, anthropometric measurements and laboratory data.”
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The purpose of Nutritional Assessment
1. Evaluate the current nutritional status patients and identify those who are at risk of complications of
malnutrition.
2. Determine the nutritional requirements of those patients.
3. Decide on a mechanism to meet those requirements.
The ASPEN guidelines of 2009 defined nutritional status as:
• Usually defined by recent weight loss of >10-15% OR
• Actual body weight < 90% of ideal body weight
The European guidelines ESPEN mentions severe nutritional risk factors
• Weight loss > 10 - 15% within 6 months
• BMI < 18.5 kg/m2
• Subject global assessment of Grade C
• Serum albumin < 3gm/dl
Tools of the Trade
Anthropometric Measurements
Anthropometric measurements are the physical measurements which include:
• Height and Weight are the 2 most critical measurements in determining nutritional status
• Other measurements and include: Waist, Hips, Midarm muscle circumference (MAMC), Skinfold
thickness (1000 measurements needed to be skilled), Waist circumference, Hip circumference, and Grip
strength (newer in determining lean body mass changes)
Ideal Body Weight
• The divine method:
• Males – 50 + ( 2.3 X height in inches > 60)
• Females – 45.5 + ( 2.3 X height in inches > 60)
• Adjusted bodyweight calculations are problematic
• (Other measurements of IBW include: Robinson, Hamwi, & Miller methods)
Other definitions of IBW (ABW = Actual Body Weight)
• Under-nutrition
• Severe malnutrition is the Actual Body Weight (ABW) < 69% of IBW
• Moderate malnutrition is ABW 70-79% of IBW
• Mild malnutrition is ABW 80-90% of IBW
• Normal
• ABW 90-120% of IBW
• Over-nutrition
• Overweight is actual body weight (ABW) ≥ 120% of IBW
• Obese ABW > 150% of IBW
• Morbidly Obese ABW > 200% of IBW
Body Mass Index (BMI)
• Calculation of BMI – Is becoming more fashionable to use in the assessment of malnutrition
• BMI = Weight in Kg / [Height in meters]2
• Undernutrition
• Severe BMI < 16
• Moderate BMI 16 – 17
• Mild BMI 17 – 18.5
• Healthy
• BMI 19 – 24.9
• People with a normal BMI are relatively thin individuals
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• Over-nutrition
• Overweight BMI 25 – 30
• Moderate/Obese BMI 30 – 40
• Morbid Obesity BMI > 40
Biochemical Assessments (and controversies)
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Creatinine-Height Index (CHI), Visceral proteins, Indices of Immune Function (DCH and TLC), and
Prognostic Inflammatory and Nutrition Index (Alpha-1-acid glycoprotein x C reactive protein / albumin
x prealbumin)
Creatinine Height Index (CHI)
• Good measure of Lean body mass
• Percentage of creatinine excretion compared to ideal from previous testing based on same height
• Uses 24hr urine creatinine which is compared to ideals based a normalized chart
• Then we have percentages (100-CHI %) based on the normalization chart giving us an idea of
malnutrition 5 - 15% → mild, 16 – 30% → moderate, > 30% → severe
Visceral proteins (don’t “hang your hat” on ANY of these markers)
Albumin
• Insensitive index of protein malnutrition, because it has a very long half-life (18 - 20 days) large body
pool – Showing a “delayed response” to malnutrition
• Affected by liver, renal, GI dysfunction, infection, stress, and hydration
★ Low albumin is associated with poor clinical outcomes BUT not necessarily related to nutrition
• Low albumin can exacerbate ascites, edema. (via 3rd spacing)
Transferrin-transports ferric iron to the liver and reticulo-endothelial system (RES)
• More sensitive than albumin to changes in nutritional status b/c of shorter half-life = 8 days
• Also affected by illness, hydration status, iron stores
• Prealbumin (transthyretin)
• Transport protein for thyroxine and vitamin A
• MORE Sensitive to protein depletion (half-life = 1-2 days)
• Most useful in measuring response to nutrition support
• Also affected by metabolic stress, renal / liver diseases and steroid therapy
• Retinol-Binding Protein
• Transport protein for Vitamin A
• Half-life = 12 hours (very short)
• Also affected by metabolic stress, liver/ renal dx, vitamin A deficiency
• Not many labs offer this test
Guidelines have comments about biochemical markers
• The ASPEN guidelines (American version) states:
• Traditional protein markers (albumin, prealbumin, transferrin, retinol binding proteins) are
reflections of the acute phase response and do not accurately represent nutritional status in the ICU
• The (ESPEN) European guidelines:
• The working group considers hypoalbuminemia to reflect inflammatory activity, and as such a risk
factor rather than a nutritional status.
Hepatic reprioritization – are responsible for changes in Visceral proteins that are not nutritionally related
• Hepatic reprioritization occurs when macrophages are activated / stimulated to produce Tissue Necrosis
Factor (TNF) or some of the more pro-inflammatory interleukins (IL1, IL6).
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This causes a secretion of Hormonal Milieu which increases metabolic stress and positive acute phase
reactants synthesis
To measure hepatic reprioritization the positive acute phase reactants are measured.
• They include the elevation of both C reactive protein and Ferritin
Metabolic Stress - Hormonal - 40
• Patients experiencing Hormonal Milieu can have the following increases of these hormones. One can
only imagine what would happen (from a metabolic perspective) if a patient experienced an increase of
all of these hormones.
↑ Glucagon
↑ Insulin
↑ACTH
↑ Cortisol
↑ Catecholamines
↑ Histamine
↑ Growth hormone
↑ TSH
↑ Thyroxin
↑ Aldosterone
↑ Vasopressin
This is a schematic of what was just described. This gives us an idea of what cells are being affected, and in
what direction things are going.
Malnutrition? – Albumin changes in “Mad dog” Redvelski
• Joe “Mad Dog” Redvelski had a normal Albumin 4.9 mg/dl then after a horrific car accident his
Albumin decreased to 1.4mg/dl in the same day.
• This good reflection on how albumin can change without involving nutritional status.
• Increasing inflammatory response and metabolic stress (car accident) the liver moves from transport
proteins synthesis to acute phase protein synthesis
What happened in hepatic reprioritization?
• Responses are from an Inflammatory Response to an injury not nutrition
Decrease production of:
• Albumin, Retinol binding protein, Transferrin, Prealbumin, Other transport proteins
Increased production of:
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C reactive protein, Fibrinogen, Antitrypsin, Antichymotrypsin, and Other acute phase proteins
Why is Mad Dog’s albumin low?
• Dilution – Albumin can be diluted from fluid resuscitation
• Catabolism – which can be fairly immediate due to Hormonal Milieu
• Third spacing – caused leaking of albumin into a 3rd space
• Synthesis? – decrease in synthesis of albumin
Will albumin respond to 40 kcals/kg (5000 calories)? No, additional calories will NOT correct albumin
levels. Remember Hepatic Reprioritization – Nutrition alone will not fix this problem
An article in 1948 showed researchers who gave a group of men malaria versus another group who had
a decreased intake of nutrition. It was found that the group who had a decrease in intake had no change
in their albumin level. The group that was given malaria their albumin levels dropped due to the stress
response of having malaria.
Real Life situation where overfeeding was tried to correct a low albumin level
• Ht 5'5, weight on initial assessment 140 pounds. She had the jejunostomy feeding at home getting
approximately 1350 kcals. Caloric intake was increased via TPM showing a significant weight gain of
12 pounds in 33 days, BUT her albumin showed NO change. This causes more damage.
• What happened? Normal protein metabolism is about 250 g per day turnover with 7 g comprising a free
amino acid pool which re-circulates and re-synthesize This is based on a normal intake of 70-100 g
protein per day
• Hepatic reprioritization increases catabolism (not necessarily hypermetabolism). The turnover more
than doubles to 500-600 g per day. The free amino acid pool increases > 10 times (100 g)
• 20 g for WBC of 15,000, 25 g for acute phase proteins, and an increase in gluconeogenesis
(changing proteins into carbohydrates as part of the inflammatory process)
•
Tale of Two Patients
61 year old female
• Hx of abdominal pain
• Poor intake x 6 months
• Weight loss
• BUN 12
• BMI 12.5 (skinny)
• Admission Albumin 4.3
32 year old female
• Pancreatitis
• Poor intake x 3 days
• No recent weight loss
• BUN 5 (displays acute starvation)
• BMI 22
• Admission Albumin 2.8
• The 61-year-old with a “skinny” BMI had a 4.3 albumin level until she had a surgical procedure which
caused her albumin to drop due to stress response
• The 32-year-old with pancreatitis has a low 2.8 albumin with an elevated C-reactive protein and low
prealbumin until she had her pancreatic pseudocyst drained which relieve inflammation
• This shows that changes in albumin are more from inflammation rather than nutritionally related
Nutrition alone will not TREAT must fix the source of the stress
★
Nutritional Status – Subjective Global Assessment
Clinical evaluation of nutritional status can best be done by Subjective Global Assessment. This is a
validated instrument which looks at weight changes, dietary intake, history of medical type symptoms, as
well as anthropometrics (all encompassing). This method was used to establish the European guidelines.
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Clinical Evaluation
• Subjective Global Assessment
• Only validated instrument
• Weight changes
• Dietary intake changes
• Gastrointestinal symptoms
• Functional changes
• Anthropometrics
• Disease state history
• Physical exam
• Lean body mass (LBM)
• Fat mass
• Single nutrient deficiencies
• Family member interviewed
Nutrition Focused – Medical History
This can be a part of this objective global assessment. These issues should be discussed as you interview a
patient on their recent nutritional status.
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Acute illnesses
Chronic illnesses
Weight changes
Food intolerance
• GI related
• Taste of food (bad/good)
• Appetite
• Nausea/vomiting
• Diarrhea
• Chewing/Swallowing (dentures?)
Nutrition Focused – Social History
• Economic – economic factors play a role in better nutrition
• Education – knowing what foods are important can contribute to better nutrition
• Emotional – psychiatric disorders can be related to significant malnutrition (eating disorders & anxiety)
• Drug use – drug abuse can lead to malnutrition. Drug use may change appetite, taste of food, etc.
• Special diets – unusual weight loss diet OR medical diets due to organ dysfunction (gluten free)
Patient Case
• Visual assessment – patient malnutrition is that of marasmus
• Known drug and psych history
• Chronic GI Disease – Crohn’s disease
• BMI = 16.7 kg/m² which is moderate malnutrition
Interview
• Patient is only eating 50% of meals last week – Patient has bulimia
• 6 kg weight loss over the last month (>10% weight loss)
Diagnosis
• Marasmus type malnutrition with possible cytokine component which could be associated with her
Crohn’s disease (inflammatory).
• Considering body mass index (BMI), and recent weight loss she is severely malnourished
• Our patient is at high risk of surgical and medical complications.
• Depending on consults she may need additional bowel resection.
Determining Needs - 66
Now that we’ve discussed how to assess the patient as to where they are in their nutritional status. It is now
important to understand what needs to be done to improve their nutritional status.
• Weight and Height (lean mass) – This is where most of your caloric expenditure occurs.
• Nutritional status and risk
• Metabolic stress level – Acute disease or injury and she has a Chronic disease
• Formulas – REE, etc.
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Things to Consider - 67
• Resting energy expenditure (REE) – Harris Benedict studied this, and the formulas are still used today.
• Measured energy expenditure (MEE) (indirect calorimetry)
• Body weight – Normal versus Actual versus Ideal versus Adjusted body weight
• AGE – Teenager versus Adult versus Geriatric (Caloric needs change with different age groups)
• Paralyzed versus combative
• Tachycardic, hyperthermic – These also increase caloric expenditure hence increase caloric need
Requirements (NORMAL) - 68
• Patients with normal adult weight usually require:
• 20 – 25 kcal/kg
• 0.8 – 1 g/kg of protein
• 30% of total kilocalories (kcal) as fats
Caloric Requirements
Method 1 (weight based)
• Based on lean body weight the below formula calculates adjusted body weight.
• Adjusted body weight is starting to no longer be used in calculating calories.
• (ABW – IBW) x 0.3 + IBW = Adjusted body weight
Estimated caloric needs
• Healthy, normal nutrition status = 25 kcal/kg
• Mildly malnourished / mild stress = 30 kcal/kg
• Critically ill, hypermetabolic = 30-35 kcal/kg
• Major burn injury = 40+ kcal/kg
Caloric requirements due to stress
• High stress – 32 - 35 kcal per kilogram
• Moderate stress – 28 - 32 kcal per kilogram
• Mild stress – 25 - 28 kcal per kilogram
• > 200% IBW → morbidly obese – 15 - 18 kcal per kilogram
Patients who are depleted or have a chronic condition before stress may have increase caloric
requirements
Method 2 (equation)
Harris Benedict Equations → Calculation of the Basal Energy Expenditure (BEE)
• BEE (females) = 655 + 9.6 (wt) + 1.8 (ht) – 4.7 (age)
• BEE (males) = 66 + 13.7 (wt) + 5 (ht) – 6.8 (age)
• (Weight in kg, height in cm, age in years)
• Been around since 1918
Total Energy Requirements (TEE)
• (BEE) x (Activity Factor) x (Stress factor)
Below are listed the activity factors and stress factors that maybe used with the Harris Benedict equation
to find the TEE.
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Activity Factors
Confined to bed 1.2
Ambulatory 1.3
Stress Factors
Major surgery 1.2–1.3
Infection 1.2
Fracture 1.2–1.4
Sepsis 1.8
Burns 1.8–2.0
Equations for BEE
These are a few of the equations used in calculating BEE
• Owen, Mifflin-St. Jeor, Penn St, Swinamer, Ireton-Jones, Any of 200+ other equations
Method 3
Indirect Calorimetry
• Measures Oxygen consumption and carbon dioxide production to determine energy expenditure
(Fick)
• Consider the Gold Standard because it is based on the individual patient
• Increase by 20-25% for malnourished individuals but only in weight gain situations
SensorMedics – Vmax 29n (metabolic cart) – Example patient’s energy expenditure
• Measured Resting Energy Expenditure (REE) 4468 Kcal/day
• Using Oxygen consumption and carbon dioxide production
• Predicted Basal Metabolic Rate (BMR) via Harris Benedict equation = 2225 Kcal/day
• The measured resting energy expenditure is double that of the Harris Benedict.
• This is an example of how calculations can sometimes be inaccurate
Carbon Dioxide Production
• A significant amount of Carbon dioxide production can be seen with significant amount of caloric
overfeeding. The below formula represents carbohydrate metabolism
• (CH2O)6 + 6O2 → 6CO2 + 6H2O – 6CO2/6O2 = RQ 1.0
• The bottom formula represents fat synthesis. As fat synthesis occurs the body releases significant
amounts of carbon dioxide (CO2) causing many patients to have difficulty in getting off the ventilator.
• 4 (CH2O)6 + O2 → CH3(CH2)14COOH + 8CO2 + 8H2O – 8CO2/1O2 = RQ 8.0
Fatty liver due to overfeeding
• This is what can be caused by significantly overfeeding a patient for 2 to 3 weeks
• Fat in the liver causes significant decrease in function and possible hepatitis
Calculating Protein Requirements
• Normal – 0.8 - 1 g per kilogram
• High stress – 1.8 - 2.2 g per kilogram
• Moderate stress – 1.4 - 1.8 g per kilogram
• Mild stress – 1 - 1.4 g per kilogram
• Greater than 200% of ideal body weight – 1 g per kilogram
Patients who are depleted or have a chronic condition before a stress may have higher protein requirements
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Chronic Disease
High stress
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High output fistula
Cancer
Decubitus ulcers
Other open wounds
Moderate stress
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Mild stress
• Starvation
• Dialysis
Multiple regular surgeries
COPD
Low output fistulas
Pancreatitis
Acute disease or injury
• When pancreatitis becomes severe and acute it is moved to the high stress situation.
High stress
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Burn
CHI
Sepsis
Severe pancreatitis (ICU admission)
Severe trauma
Moderate stress
• Multiple fractures
• Major surgery
• Multiple
debridements
Mild stress
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Single fractures
Minors surgery
Pseudo obstruction
Perioperative
★ Nitrogen balance study (more efficient than weight-based calculation)
More efficient way of determining protein requirements
Nitrogen balance study → measures URINE proteins losses
Here we measure the amount of nitrogen loss, and replace that with nitrogen containing protein.
• Utilization of a 24 hour urine collection will give you actual protein losses based on excretion of
urinary nitrogen
• E.g. Urine Volume collected is 3000ml/24hrs
• Concentration 600mg/dL (30dL x 600mg/dL=18gm N)
• Obtain grams of nitrogen in a 24 hour urine (TUN)
• Add 4 for insensible losses
• Serous wounds losses will require extra.
• Add 2 to provide positive nitrogen balance
• 18gm + 4 + 2 = 24 gm or Total Nitrogen loss
• Multiply grams of nitrogen by 6.25 to calculate protein
• 24 gms Nitrogen x 6.25 gm protein / gm nitrogen = 150 gm protein
• Make calculations that would put the patient into positive nitrogen balance
Example of nitrogen balance study and protein requirement calculation
• Ten days after admission patient in has an order for 24 hour urine collection for urine urea nitrogen.
Urine Volume collected is 3000ml; Concentration 600mg/dL. Calculate the grams of nitrogen lost,
THEN calculate grams of PROTEIN required to give the patient a 2 plus nitrogen balance (not including
any open wounds). (4 points)
Answer:
• 18 grams nitrogen lost (18,000mg) (2 points)
Calculation 3000mL = 30 dL; 30dL X 600 mg/dL = 18,000 mg = 18 gm
• 150 grams protein for 2 plus nitrogen balance (2 points)
• Calculation 18gm + 4 for insensible losses + 2 for positive balance
• 24gm N x 6.25gm protein/gm nitrogen = 150 gm protein
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Importance of providing appropriate energy
Underfeeding
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Poor wound healing
Decreased organ function
Loss of immune function
Loss of muscle mass (especially
diaphragm)
Overfeeding
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Pulmonary compromise (CO2)
Fatty infiltration of the liver
Poor glucose control
Immune compromise
Azotemia
Methods of calculating MAINTENANCE Fluid Requirements
1st method of calculating fluid requirements
For fluid issues there are a couple of ways to calculate fluid requirements.
• 1 ml of fluid for every kcal provided → common way to provide MAINTENANCE fluid requirements
2nd way of calculating fluid requirements
• Use nutritional fluids for maintenance only
• This also allows for calculating fluid requirements for pediatric patients
• 100ml/kg → first 10 kg
• 50ml/kg → second 10 kg
• 20ml/kg → 21kg+ (For every kilogram after 20 kg)
• For adult patients 20 mL/kg + 1100ml = maintenance fluid requirements (Shorter method)
3rd method (weight based)
25 - 40 ml/kg/day
• Add 150 ml for each degree of body temperature above 37°C
• Replace fluid lost in nasogastric tube output, fistula, stool, wound output
Adjustments
• Renal Failure – fluid restriction most of time except in the case of acute renal failure where you have
high urine output
• Dehydration – requires more fluid replacement
• Heart Failure – fluid restriction
Special considerations
Glucose
• Glucose is normally 55-60% of total Kcals
• Glucose intolerance – May require lower glucose and higher fat
• Insulin resistance
• Diabetic
• Family history – genetic history may show an intolerance to glucose
• Head injury – can cause hyperglycemia
• Glucocorticoid therapy – side effect of hyperglycemia
Protein
• Protein losing states such as:
• Open wounds, Fistulas, and Decubitus
• Protein excretion
• Hepatic failure – inability to catabolize and re-synthesize protein appropriately
• Renal failure – where the body is unable to rid itself of urea
• Renal failure with dialysis (Protein removing process)
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Geriatrics – may have lower protein requirements
Lipids
• Normally 25-30% of total Kcals in lipids
• Monitor for Hypertriglyceridemia
• COPD – have CO2 retention may need glucose calories decreased and lipid calories increased because
of the amount CO2 that carbohydrates releases in their metabolism
• Essential fatty acid deficiency (EFAD) – may be seen in a lipid free parenteral nutrition setting
• These patients will need long chain fatty acids LCFA-Omega 6’s
• Omega 6 fatty acids are pro-inflammatory (other non-pro-inflammatory fatty acids are available only
in Europe at this time)
The Nutritional Formula
1. Caloric requirement
2. Protein requirement
3. Fat calorie requirement
4. Glucose calorie requirement
5. Fluid requirement
Nonprotein Calorie Issue (controversy)
• The controversial nonprotein calorie issue is with parenteral nutrition patients only
• Nonprotein calories is not an issue with a “plate of food”
• Nutrition label of “Weight Watchers product” will not discuss nonprotein calories
• This is also true with a tube feeding label like ensure
Patient Case
We have determined that our patient is probably moderate to high stress due to her being malnourished,
and inflammatory process occurring (Crohn’s disease) which may require surgery. Our patient also has
preexisting conditions, and recent significant weight loss. She also has bulimia
• Estimated needs
• 1500-1650 (32-35 kcals/kg)
• 70 g (1.5 g/kg protein)
• 2040 ml fluid
Nutritional Delivery
How do we deliver specialized nutrition?
• Supplement oral intake such as: Shakes, Juven, other protein supplements
• Enterally feeding – If patient is unable to eat.
• Parenterally – If all else fails
The 11th Commandment if the patient’s gut works use it!
Enteral Feeding
• Bowel sounds – patients without bowel sounds does not contraindicate them for enteral feeding
• NG output – an increase in nasogastric output may indicate a gastric ileus causing less function in the
gastrointestinal tract (decrease peristalsis).
• Patient considerations – Bowel movements, Ileus, Obstruction, Fistula, or Pancreatitis
• Types of tubes that we have – Nasogastric (NG), PEG, Transpyloric, Jejunal
Advantages of enteral nutrition
• Maintains structure and function of gut
• Maintains gut immune function
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Fewer metabolic/infectious/mechanical complications
Access for orally administered drugs and it is cheaper
Parenteral Nutrition
• Provide nutrition when the gut is nonfunctional
• In cases of severe pancreatitis we will not want to use the gut for feeding
• Patient’s gut needs rest because of a fistula (time to heal)
• Burn patients are unable to eat enough
• Provide nutrition beyond what can be provided through the gut
• Example are: multiple trips to the operating room, and hypermetabolic patients like burn patients.
Special Populations
Hepatic Failure
• Hepatic Encephalopathy
• Use amino acid solutions with a higher concentration of branched chain amino acids
• Reduce protein intake to 0.5 – 0.7 g/kg/day initially then Advance to 1–1.5 g/kg/day as tolerated
• Give patients as much protein as they can tolerate, because they are catabolic
• Monitor blood glucose concentrations carefully
• Carbohydrate metabolism may be compromised
• Lipids should be administered judiciously
• Fat metabolism can be altered, and monitoring needs to occur
Renal Failure
• Protein Requirements
• Acute renal failure – dialysis allow removal of uremia – Higher protein need of 1.5 – 1.8 g/kg/day
• Chronic renal failure (no dialysis) – 0.6 - 0.8 g/kg/day
• Chronic renal failure (dialysis) – 1 - 1.5 g/kg/day)
• These patients may require Fluid Restriction
• Mineral restrictions such as: Phosphorous, potassium and magnesium
• Continuous renal replacement therapy (CRRT) – Very catabolic process and need aggressive protein
replacement and careful electrolyte monitoring
Diabetes mellitus
• May need to use less dextrose and more lipids and protein due to hyperglycemia
• Treatment with insulin is allowed – Bolus feeding versus Continuous feeding
Patient Case
• Route – Probably intravenous initially
• She is at risk of developing a Fistula or Obstruction
• Special considerations – Steroid therapy monitor glucose, Fistula would require increase protein
Review
• Establish nutritional status
• Estimate requirements
Physical
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• REE
• History (nutritional and medical)
• Stress (acute and chronic)
• Biochemical
• Activity
• Determine route of
administration
• Oral
• Enteral
• Parenteral
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