Energy & Protein Needs in Hospitalized Patients - Practice Questions PDF

**TEST 1** **[Energy & Protein Needs in the Hospitalized Patient]** - Prediction is an estimate vs. indirect tells exactly how much the patient needs **Clinical Situations that Require Calorimetry** - Hypermetabolic patients - Malnourished or starvation adapted - Greatly Obese -...

**TEST 1** **[Energy & Protein Needs in the Hospitalized Patient]** - Prediction is an estimate vs. indirect tells exactly how much the patient needs **Clinical Situations that Require Calorimetry** - Hypermetabolic patients - Malnourished or starvation adapted - Greatly Obese - Peripheral edema - Hypoalbuminemia - Limb amputation - Non-healing wounds - Postoperative Start low and go slow with nutrients can result in **refeeding syndrome**- potentially fatal shifts in fluids & electrolytes that may occur in malnourished patients with artificial refeeding **Indirect Calorimetry (GOLD STANDARD)** - Calculates REE using **Respiratory Quotient (RQ)**\* by measuring whole body O~2~ (VO~2~) and CO~2~ (VCO~2~) gas exchange - \*ratio of CO~2~ produced : O~2~ consumed *Machine will tell us:* - EE= (3.94 x VO2) + (1.11 X VCO2) - RQ= VCO2/VO2 = - RQ \<.82 underfeeding risk for refeeding syndrome - RQ \>1 Overfeeding with excessive CO2 production risk for fatty liver - Goal.85 - RQ of macronutrients - CHO = 1 - PRO =.8-.9 - FAT =.7 (least amount of CO2 as a waste product) - Mixed Diet.85 - Goal is to NOT overfeed patients' total calories **Parameters for Estimating Needs** - Height - Weight: - Current/Actual Body Wt. - UBW - Dry weight - Weight for Height (BMI) influence prediction equation (obese vs morbidly obese) - \% wt change-significant changes - \% \> or \< IBW **Metabolic Rate** - BMR or BEE (MOST ACCURATE) - Conducted in a dark room after 8 hours of sleep and 12 hours fasted - Slightly more accurate - RMR or REE - Complete - Less restricted conditions - Usually slightly higher (5%) than BMR/BEE - Essentially used interchangeably and very close results - Different predictions equations use different terms **Activity Factory % Injury Factor** - **AF and IF can be used with Mifflin and HB** - **Common AF** - Bedrest 1.2 - Ambulatory 1.3; normal ADL's 1.5 - **Common IF** - Minor Surgery 1.2 - Skeletal Trauma 1.35 - Major Sepsis 1.60 - Burns 2.10 \*these factors are multiplied by your metabolic rate result from your prediction equation **EAL on Estimating Energy Needs** - **Adult Weight Management (AWM) Determination of Resting Metabolic Rate** - **AWM: Determining Energy Needs** - Estimated energy needs should be based on RMR. If possible, RMR should be measured (e.g., indirect calorimetry). If RMR cannot be measured, then the **Mifflin-St. Jeor equation** using **actual** weight is the most accurate for estimating RMR for overweight and obese individuals. - **Strong, Conditional** - **Mifflin-St. Jeor** - Men: (9.99 x w) + (6.25 x h) -- (4.92 x a) + 5 - Women: (9.99 x w) + (6.25 x h) -- (4.92x a) -- 161 - **Good for hospitalized patients that are NOT critically ill** - **Most accurate for obese patients** - Use actual body weight **Critically Ill Normal Weight any age or Obese \ - Legend: - B=Diagnosis of burn (present=1, absent=0) - O=Obesity, body mass index (BMI) \27 kg/m^2^ (present=1, absent=0) - S=Sex (male=1, female=0) - T=Diagnosis of trauma (present=1, absent=0)** ** - Spontaneously breathing: 629--11(A)+25(W)--609(O) - Ventilator-dependent (revised, 2002): 1784--11(A)+5(W)+244(S)+239(T)+804(B) **Assessing the Needs of the Obese in Critical Care** - Permissive underfeeding or **hypocaloric feedings** - Obese can be stressed and more likely to be insulin resistant - For all classes of obesity where the BMI is \>30, the goal of the Enteral Regimen should not exceed 60-70% of needs or: - 11-14kcal/kg of actual body weight - 22-25kcal/kg of ideal body weight **Calorie Estimations (nomograms)** - Basal Energy Needs 25-30 kcal/kg/IBW - Ambulatory w/ wt. maintenance: 30-35 kcal/kg - Malnutrition w/stress: 35-40 kcal/kg - Severe injuries and sepsis: 40-50 kcal/kg - Extensive Burns 50+ kcal/kg - You do not multiply these by an AF or IF - Fever: for every 1-degree F add 7% to BEE **Protein Needs in Critically Ill** (ideal body weight NOT actual!) - Normal 0.8-1.0 g/kg - Critically Ill 1.5-2.0 g/kg - Fever, Fracture, Wounds 1.5-2.0 g/kg - Burns 1.5-3.0 g/kg - Sepsis 1.2-1.5g/kg - Protein in the obese critically ill: - Class I and II obesity (BMI 30-40) = 2.0 g/kg of IBW - BMI \>40 = 2.5g/kg of IBW **[Enteral Nutrition: Krause Chapter 12]** **Enteral Nutrition (EN)** - Nutritional support via tube placement through the nose, esophagus, stomach, or small bowel (duodenum or jejunum) - **Preferred** - *"if the gut works, use it"* - Must have functioning GI tract - Using GI tract to provide nutrition - Exhaust all oral diet methods first - Start EN within 24-48 hours of injury - If patient has 2-3 ft of functioning GI tract use enteral nutrition vs parenteral - Progressively get to target goal - Via tube or catheter when oral intake is inadequate **Advantages of EN** - Intake easily/accurately monitored - Provides nutrition when oral is not possible or adequate - Costs less than parenteral nutrition (12 cans \~\$25-30) - Supplies readily available - Reduces risks associated with\ disease state - Preserves gut integrity - Complete bowel rest can cause breakdown of mucosal barrier and increase permeability to bacteria and contributes to sepsis & multi organ failure - Decreases likelihood of bacterial translocation - Preserves immunologic function of gut - Component of mucosa is GALT (gut associated lymphoid tissue) which comprises **½ of total body immunity**) - Immunoglobulins produced are secreted across GI mucosa to defend against pathogens in GI tract **Parenteral Nutrition (PN)** - Provision of nutrition intravenously (via bloodstream) - PPN -- using small veins in arm (IV) - CPN -- central (vena cava) increase RISK for sepsis, puncturing lungs/muscles, precipitates (iron or calcium), bacterial infection, etc. - An option...but only if it is greater than 7-10 days that you can't use guts **Conditions that Require Nutrition Support** - **Enteral** - Inability to consume adequate nutrition orally - Impaired ingestion - Impaired digestion, absorption, metabolism - Severe wasting or depressed growth - **Parenteral** - Gastrointestinal incompetency - Hypermetabolic state with poor enteral tolerance or accessibility Table23-1a  **Enteral Access Considerations** - Enteral access depends on: - Anticipated length of time - Degree of risk for aspiration or displacement - Presence or absence of normal digestion and absorption - Planned surgical interventions - Administration rates for viscosity and volume **Enteral Access: Clinical Conditions** - Duration of tube feeding - Nasogastric or nasoenteric tube for short term - Less than 3-4 weeks - Must have normal GI function and gag reflex - Check placement - Nasoduodenal or Nasojejunal (nose to small intestines) - Pts. with gastric motility disorder, esophageal reflux, nausea & vomiting issues - Weighted tips - Peristalsis pulls it into small intestines-can take several days - Percutaneous Endoscopic Gastrostomy (PEG) and Percutaneous Endoscopic Jejunostomy (PEJ) tubes for long term - \>3-4 weeks  **Complications** 1. Diarrhea - Frequently associate with enteral nutrition, usually because less fiber - True diarrhea - Most likely causes are bacterial overgrowth, antibiotic therapy and GI motility disorders - Hyperosmolar meds - Mg containing antacids, high sugars, sorbitol containing elixirs and electrolyte replacement supplements - Adjusting meds or administration routes can help - Addition of soluble fiber and pectins and antidiarrheal (Imodium) meds can help 2. Aspiration Pneumonia - Can result from enteral feeds - High-risk patients - Poor gag reflex - Depressed mental status - Reducing Risk: - Check gastric residuals if receiving gastric feeds - If GR's \>300 stop feeding and check for s/s of a problem - Abdominal distention, pain - Check if pt has gastroparesis - Consider use of a prokinetic (Reglan) - Check every 4 hrs or as needed - Elevate head of the bed \>30 degrees during feedings - Post-pyloric feeding (into the small intestines) - Use of Blue Dye is no longer recommended **Enteral Monitoring** - Establish Baseline using common lab tests - Preliminary Screen - Na^+^, Cl^-^, BUN, Cr, K^+^, HCO~3~, Glucose, CO~2~, Mg^++^, PO~4~ - Broad spectrum screening - Albumin, alkaline phosphatase, CRP, Prealbumin, lipase, AST, ALT - Indicators of formula tolerance - Stool frequency/consistency - Vomiting - Abdominal distention/bloating - May need to stop and restart conservatively - Blood Glucose levels can become insulin resistant - If pt has DM, sepsis or severely stressed pt cannot metabolize CHO adequately and may need insulin - Or may need to go from an intermittent feeding to continuous - Hydration status - Weigh initially then 3x/wk - If sudden change evaluate hydration status - Make sure 1mL H2O : per kcal - Check I/O's - Indicators - Hypernatremia (Na 145-150) elevated BUN, Hct, Dry mucous membranes, thirst, elevated temperature, decreased skin turgor, confusion, decreased urine output or dark color, wt. down 1kg = 2L of fluid - Hydration - Increase fluid if: infection, fever, diarrhea, increased protein intake, vomiting, drainage - Evaluation of Nutritional Response - Kcal count - N^+^ Balance - Est. Energy expenditure changes - Albumin, Iron, Transferrin, TIBC - Monitor Mg^++^ biweekly in malnourished pt. - Phos and liver fxn tests 2x/week **Refeeding Syndrome** - Happens after a period of starvation when carbohydrate is reintroduced into the plasma of anabolic patients - Affected by degree of starvation and rate and content of repletion - Refeeding syndrome more likely in TPN - **Growth of new tissue requires increased glucose, K^+^, Phos and Mg^++^** What happens when one is re-fed too fast (specifically CHO) **How to Fix Refeeding:** - Reduce the Rate - Electrolyte Supplements (via IV Fluids) - 7-10 days prior and decrease risk of refeeding **Rate & Method of Delivery** 1. **Bolus Feedings**---300 to 500ml rapid delivery via 60mL syringe several times daily - - - - - - 2. **Intermittent feedings** ─ 4-6 feedings over 20-60 minutes/day via gravity drip or pump - Pumps: a. Cyclic feedings---via pump usually at night 7p-7a over 12 hours b. Continuous feedings ---infusion pump- most commonly used in:  - Critically ill - High risk for aspiration  - Small bowel feedings\*  3. **Continuous method via pump** - Start at ¼ to ½ of goal rate (10-50mL) advance to the final rate as tolerated increasing the rate every 8-12 hours - Can begin at full strength if GI tract is functioning fully - Do not dilute with water, if having problems, decrease to last tolerated rate - If it is a hyperosmolar formula \>300-500 mOsm/L start slow and advance conservatively **[Parenteral Nutrition Support ]** **Indications for Total PN** - Are or will become malnourished - Do not have sufficient GI function to restore or maintain optimal nutritional status - Critical Illness with poor enteral tolerance or accessibility  - *Severe inflammatory bowel disease -- Crohn's, Ulcerated Colitis (IF moderate - use tube feed 1st)* **Access Decision:**  **Routes of Parenteral Nutrition** 1. Central Access (preferred) - CPN both long- and short-term placement - Inserted into the subclavian and advanced to the superior vena cava - Peripherally Inserted Central Catheter - Used for higher kcal amounts and \>10 days - 15-20% concentrations per volume 2. Peripheral Parenteral Nutrition (PPN) - Cannot exceed 800-900 mOsm/L (have to make up kcal in fat since low kcal per volume) - Usually have to use diluted larger volume infusions - Principle complication is phlebitis - Not a good option for cardiopulmonary, hepatic or renal - 10% dextrose concentration maximum for PPN (usually 2.5-5%) can't provide a lot of nutrition **Parenteral Components & Macros** - Protein (Amino Acids) - Formulated to provide Essential AA and Non-Essential AA - 3-20% of solutions - Ex. If you have a 10% AA stock there would be 100g of protein in a L (1000mL) - \% is usually expressed in final concentration once mixes with other nutrients (usually 2-5%) - Protein Requirements: 15-20% of total needs - 1.2 to 1.5 protein/kg -- IBW mild or moderate stress - g protein/kg IBW burns or severe trauma - Carbohydrates - Glucose or dextrose monohydrate - 3.4 kcal/g due to non-caloric water molecule - Solutions range from 5-70% dextrose/L - Ex. D50 stock would have 500g Dextrose in 1 L - Usual final concentrations between 2.5-25% - Glucose Infusion Rate (GIR); should not exceed dextrose infusion of 5-6 mg/kg/min, critical patients - Ex. 576 g x 1000/68 kg/ 1440 min = 5.8 - Excess glucose infusion rates can cause: - Increased ventilatory drive - Hyperglycemia - Hepatic abnormalities (fatty liver) - Typically, AA and lipids are provided and remaining kcals go to dextrose as long as GIR is not too high for patient Ex. If patients TPN regimen gives him 350 g of dextrose per day, how many kcals would that provide? 350 g x 3.4 kcals = 1190 kcals - Lipids - Intravenous Lipid Emulsions (ILE) - Provides kcals and EFA (Linoleic and Linolenic Acid to prevent EFAD) - 2-4% of kcals Linoleic -.25% of kcals from Alpha-Linoleic - **ILE Rules of Estimation and when to hold (stop):** 1. Should not exceed 2.0g/kg of BW daily 2. Usual administration 1-1.5g/kg of BW daily 3. Monitor TG, if \>400 HOLD ILE lead to hypertriglyceridemia, pancreatitis 4. Use a 1.2-micron filter 5. Don't forget to count lipid kcals from Propofol/Diprivan sedatives provide kcals - **Lipid Requirements:** - ILE Mixes - Soybean or safflower oil and egg yolk phospholipids (check for allergies) Primarily omega-6-proinflammatory - Multi oil ILE (Smoflipid) -- since 2016 in US - Omegaven- fish oil-based ILE -- decreased inflammation and immunosuppression - **3 Types of emulsions by %:** 1. 10% emulsions = 1.1 kcal/mL PPN 2. 20% emulsions = 2 kcal/mL typical with central TPN 3. 30% emulsions = 3 kcal/mL - Can hang as a separate bottle or be part of 3-n-1 admixture - Fat reduces irritation in PPN - Lipids can run for 12hr for 2-n-1 admixture/ Ok for 24hrs in 3-n-1 (acidic AAs) EX. 250 mL bottle of Intralipid 20%, Pt. gets 1 bottle of this per day, how many kcals provided? 250 mL x 2 = 500 kcals b\. What is rate of infusion? 250 mL/ 12 = \~21 mL/hour **Calculating Nutrient Needs** - Avoid excess kcal (\>40 kcal/kg) - Adults kcal/kg BW nomograms: 25-30 kcal/kg normal 28-30 kcal/kg surgery 30-40 kcal/kg severe injury 45-55 kcal/kg extensive trauma/burns *Obese/Morbidly obese use Mifflin, or other appropriate prediction equations in Critically Ill* **Parental Mixture Options** - Can add insulin and acid reducing medications to TPN bag - 2-n-1 -- all nutrients mixed except lipids; clinical - 3-n- 1 -- all nutrients mixed in the same IV bag to form a lipid emulsion; homecare **Electrolytes** - Use acetate or chloride forms to manage acidosis or alkalosis Ex. KCl, Na Acetate, K Acetate, NaCl  **Vitamins** - Iron not provided due to risk for bacterial growth with lipids; especially 3-n-1  **Administration** - Fluid provided through Parenteral Nutrition - Typical 1.5-3 L/day - Continuous or Cyclic (10-12 hours per day) - Start slowly (1L 1^st^ day; 2L 2^nd^ day) - Start low and go slow over 2-3 days - Or do not infuse \>150g of Dextrose first 24 hours - Stop slowly to avoid rebound hypoglycemia - reduce rate by ½ every 1-2 hours or switch to dextrose IV D10 **Monitoring** - Infection -- most common - Hemodynamic stability -- adequate BP - Catheter care site for organisms - Refeeding syndrome as mentioned in EN (more likely to happen with TPN) **Complications:** - Mechanical -- pneumothorax, subclavian artery injury, central vein thrombophlebitis, arteriovenous fistula, air embolism, catheter misplacement - Infection and sepsis -- catheter site, solution contamination - Metabolic -- dehydration, hyperosmolar, nonketotic, hyperglycemic coma; rebound hypoglycemia, uremia, electrolyte imbalance, hyperlipidemia - Gastrointestinal -- cholestasis, hepatic abnormalities, GI villous atrophy *Better to wait 7 days if gut has the chance to start working before taking these risks*