Exam 3 - Nutrition PDF

PEDIATRIC NUTRITION Nutrition Requirement Etiology & Causes of Malnutrition Infant Nutrition Basics Growth is NOT linear process Etiology...

PEDIATRIC NUTRITION Nutrition Requirement Etiology & Causes of Malnutrition Infant Nutrition Basics Growth is NOT linear process Etiology Variations include: Lack of caloric reserve => need constant 1. Age Acute VS Chronic causes source of calories 2. Organ fx EX: critical illness, HF, cystic fibrosis => may ↑ metabolic rate 3. Body composition need higher caloric needs than normal Growth rates higher in infancy EX of organ fx / body compos requirements: ↑ demands during illness Mechanism o Adult: Brain 2% ABW, 19% BEE Dependence / Independence o Neonates: Brain 10% ABW, 44% BEE Imbalance of energy needs & intake (~50% of neonate’s BEE is used by 3 causes: Typical infant growth their brain) 1. Inadequate caloric intake 3-4 kg is common for typical birth weight 2. Inadequate absorption (Important to keep infants with proper glucose stores bc Infant weight x2 (double) by 4-6 months 3. or Excessive energy expenditure a huge amount of metabolic demand is focused on their Infant weight x3 (triple) by 12 months brain to support their neurological development. Thus, Why does it matter? Infant length ↑ 50% by 12 month we really try not to let their glucose drop for an extended period) Morbidity & Mortality => linked to unfavorable Childhood & Adolescent Growth outcomes *** BEE is basal energy expenditure Preschool – Age 2-6 Caloric Requirements Peds Malnutrition Grow slow BUT constant (Calculation EX) Adipose tissue distribution begins after age 2 Malnutrition: deficiencies / excesses in nutrient intake, (kids ↑ their fat storers around 2 yo) imbalance of essential nutrients / impaired nutrient kcal/kg ↓ as we get older utilization Underlying medical condition may ↑ calories Middle Childhoods – Age 7-10 need per day & may require more calorically ð Result in wasting, stunting, under-/over-weight, Steady growth dense of formulas obesity, micronutrient deficiencies Female > Male in height & weight ð Refeeding Syndrome: acute health prob in Given in exam the char chronically undernourished kids Adolescences – Age 11-18 Anthropometry Begins before puberty & continues until growth is complete Growth charts w Z-scores, mild-upper arm Rate of weight gain ↑ circumference (MUAC) (time of rapid height & weight) o Z-score is statistical analysis telling Male > Female in height & weight us the distance & direction of an observation from a population mean Assessing Growth = the # of standard deviation from the Growth chart in length, weight, head mean circumference assessment EX: pt Z score for weight is - 4.2 meaning that it is 4.2 standard deviation lower than what we Protein Requirements (for reference) Which growth chart? 1. WHO for < 2 yo would consider to be like the 50th percentile (4.2 can be either +/- indicating higher/lower 2. CDC for 2-20 yo 3. ≠ charts for boys & girls deviation from mean) Failure to thrive = Growth faltering https://www.cdc.gov/growthcharts/clinical_charts.htm o Fall of 2 major percentiles (Cross 2 percentiles!!!) o Weight < 3-5th percentile  Breastfeeding Maternal Medications in Breastfeeding Formula Feeding Indications If no CI, American Academy of Pediatrics Drugs to AVOID fall into 2 main categories Variety of types recommends: o Exclusive breastfeeding for 1st 6m 1. Rx can harm infant directly Indications o Optimally continue for @ least 1 year ð Ex: immunosuppressant, chemo, radioactive agents, etc. Substitute or supplement feeds for mothers o May extend beyond 1 year if desired who do not or cannot breastfeed WHO suggests up to 2 years 2. Rx ↓ milk production Infant with human milk intolerance Breast feeding advantages ð Ex: decongestants, ergots, etc. Maternal infection transmittable through breastfeeding (ex: HIV, HSV) Newborn Mother People who are in recovery for opioids use disorders. Maternal chemotherapy - Optimal nutrients - ↓ post-partum bleeding There is illicit drugs CI BUT opioid use disorders is not Infant failing to gain weight despite - ↓ infection risk - Faster time to attainment of like an absolute CI (case-by-case-based) => Note optimization of breastfeeding - ↓ immune-mediated pre-pregnancy weight specifically about Methadone here!!!! diseases risk (breastfeeding burns lots of cal) Human Milk Fortifiers Data are limited (Below are resources) - Psychological & cognitive - ↓ breast & ovarian cancer risk Breast milk does not adequately meet benefit - ↑ child spacing (kc sinh con) Primary literature nutritional needs of pre-term infants - Mother-infant bond LactMed – free-app Human milk fortifiers ↑ calories, minerals, CDC vitamins, & protein WHO: breastfeeding & maternal meds – not When added to human milk, provide ↑ calorie Breast milk frequently updated content to 20-28 kcal/oz Briggs Pregnancy & Lactation Available as liquid & powder Caloric density: 20 kcal/oz Components Maternal Medications: Things to consider o Lipids Risk-Benefit of therapy § 50% of caloric content § Long-chain FAs Infant characteristics (prematurity / size/ age) o Proteins Proportion of feedings that are breast milk § 70% whey Rx characteristics*** § 30% casein o High oral bioavailability = more likely o Carbohydrates to be absorbed in infant § Lactose o PK characteristics Breastfeeding CONTRAINDICATIONS Active, untreated maternal TB HIV (+) Human T-cell lymphotropic virus Ebola infections (Type I & II) (suspected / confirmed) Untreated brucellosis Illicit drugs use DRUGS!!! Term Formulas Cholecalciferol Iron Calculation Modeled after breast milk Vitamin D3 = Cholecalciferol (Calculation EX) o Provide19-20 kcal/oz Dosed in mCg or international units (IU) Carbohydrate source is lactose Dosing based on elemental iron, but often o Cholecalciferol 400 IU = 10 mCg Contain cow’s milk protein ordered in mg of ferrous sulfate o Transition towards mCg after FDA ALL infants should receive iron-fortified Common [ferrous sulfate] is 75 mg/ mL (15 mg formula rules changed labeling requirements elemental iron/ mL Usually not concentrated Use caution when selecting products!!! Ex: 4 kg patient requires 3 mg/kg/day of iron o ↓ water content to ↑ caloric content o “drops” VS mL supplementation Specialty Formulas Cholecalciferol indications 1. Step 1: Calculate dose 2. Step 2: Determine product DON’T assume every formula is the same Premature neonates 3. Step 3: Find mL needed Pre-term / enriched formulas < 1.5 kg: 200 IU QD (5mCg) Zinc o Higher kcal/ounce (22-30 kcal/oz) o May be hospital only VS transitional > 1.5 kg: 200-400 IU QD (5-10 mCg) Soy-based Essential trace element absorbed in small Term infants intestine Lactose-free Hypoallergenic or non-allergenic Partially / Fully Breastfed: 400 IU QD (10 mCg) Deficiency => dermatitis, diarrhea, infections, Anti-reflux altered wound healing Formula fed: 200-400 IU QD (10 mCg) until o Normal [ ] = 70-150 mCg/dL Typical Feeding receiving 1000 mL/ formula/ day (~ 30 oz/ day) Supplementation / replacement Term, healthy infants will feed with an average Iron Supplementation o PO or IV of 6-9 times per day o Dosing based on elemental zinc ***NOT for all, ONLY in certain situations Some infants require more frequent feedings § Zinc sulfate 44 mg = 10 mg o Improve infant coordination Premature neonates elemental zinc o Stimulate milk production Breastfeeding parents often encouraged to 2 mg/ kg/ day (elemental) breastfeed 8-12 times per day initially Term infants Feeding schedule for 1st year of life Breastfed, healthy: NOT routinely indicated As infants grow older: Deficiency: 3 mg/ kg/ day (elemental) o ↓ amount of feedings per day Use Caution when selecting products!!! o ↑ oz per feeding Many ≠ [ ] / formulations available q2-4h Newborn Ferrous sulfate contains ~ 20% elemental iron ~ 2 oz / feed Need to talk same “language” as prescriber 5-8 times / day 2 – 4 months 3-6 oz / feed 3-5 times / day 6 – 8 months 6-8 oz / feed 3-5 times / day 12 months ~ 8 oz / feed  Initiation of Complementary Foods Calculating Feeding Requirements Alternative Routes of Administration Typically begins @ 6m (Calculation EX) Short term: NG, ND, NJ, orogastric tube Introduce single ingredient foods 1st Long-term: PEG, PEJ, surgical jejunostomy or Information needed: gastrotomy (G-tube) DO DON’T Age Parenteral nutrition - Introduce 1 new food q4-5d - NEVER put anything but - ↑ serving size gradually breast milk / formula in a bottle Post-conceptional age if patient was preterm - Emphasize all food gr - NEVER give the following to Underlying medical conditions Various considerations must be considered children < 1 yo Current weight Note: DON’T assume meds can go every route Honey Number of feedings a day Cow’s milk Choking hazards When formula requirements exceed fluid requirements, Potential allergens always calculate based on caloric needs Special exceptions Calculating Fluid Requirement Fluid restricted patients Holliday-Segar Method Use calorie-dense formulas in these patients (Calculation EX) Failure to thrive (growth faltering) Up to 10 kg: 100 mL/kg Use “catch-up” growth plan 10-20 kg: 1000 mL + 50 mL/kg for every kg To calculate caloric need, use weight that greater >10 corresponds with 50th percentile on growth > 20 kg: 1500 mL + 20 mL/kg for every kg chart greater >20 Multiply the desired weight by the kcal/ kg/ day value for age to get the new daily requirement Fluid Selection Use this new daily requirement to decide how Beyond scope of lecture much breast milk / formula to use per feeding IV fluids used in pediatric patients may be ≠ Non-Oral Nutrition than adults Fluid selection may be impacted by: Exclusively oral nutrition may not be possible due to: o Patient age (need for glucose) o Underlying disease states (HF) Consumption issues o Special nutritional requirements Digestion issues (short gut) (ketogenic diet, metabolic diseases) High energy needs (CF, burns, CHF, infection…) Suggested reading: Meyers RS. Pediatric fluid and Poor growth electrolyte therapy. J Pediatr Pharmacol Ther 2009; Specialty nutrition needs (metabolic, 14:204-11 ketogenic) Inability to safety take oral Malnutrition ADULT NUTRITION Calculations Mg = 8 – 24 mEq/day on avg - IBW è Start @ 8 mEq/day if Mg is normal Male = 50 kg + (2.3 x inches over 60 inches) Added as magnesium sulfate à no need to balance Female = 45.5 kg + (2.3 x inches over 60 inches) Consider additional supplementation Phos = 15 – 45 mMol/day on avg - NBW è Start @ 0.3 mMol/kg & titrate up as needed, based on response NBW = IBW + 0.25 (wt – IBW) Needs to be included w other negative anions for balancing Use NBW if ABW is ≥ 130% of IBW CAUTION in renal failure Use ABW if ABW is < 130% of IBW Must convert mMol into mEq § 1 mMol KPhos = 1.47 mEq KPhos - Nitrogen Balance § 1 mMol NaPhos = 1.33 mEq NaPhos Nitrogen Balance = (N in) – (N out) § “Average” = 1 mMol Phos = 1.4 mEq Phos Chloride = 50 – 100 mEq/day on avg !"#$%&' )'%*+,- ,-*./+ (1) è Aim for about 2/3 amount w Cl N in = 3.!5 Acid in PN à Balance >< Acetate (the “Base”) *6.25 g Protein = 1 g Nitrogen Consider acid/base status & CMP Titrate based on response N out = 24-hour UUN (g) + Factor (3-5 g) Acetate *Use 4g as estimate / adjust per specific indications è Aim for about 1/3 amount w Acetate - TEE Base in PN à Balance >< Cl (the “Acid”) TEE = REE x stress/activity factor(s) Converted 1:1 to Bicarb in the system Consider acid/base status & CMP - MIVF Titrate based on response MIVF = 30 – 40 mL/kg/day It is harder for body to reverse alkalosis - Protein Balancing Ions Maintenance 0.8 – 1 gm/kg/day Positives Negatives Mild – Moderate Stress 1 –1.5 gm/kg/day Phos (floor pt) Na Cl Moderate – Severe Stress K 1.5 – 2 gm/kg/day Acetate (ICU, trauma, surgery, burn) Positives (Na + K) – Negatives (Phos) = Remaining to balance (Cl & Acetate = 2/3 & 1/3) - Calories Total positive and negative ion balance must equal 0 Total calories (ICU / surgery) = 25 – 30 kcal/kg/day Consider acid/base status & CMP - Electrolytes Additional losses can contribute Na = 80 – 200 mEq/day on avg Titrate based on response è Aim for ½ NS to start Calculate per 1L, then extrapolate to whole bag - Additives Consider free water deficit & overall fluid balance MVI – 10 mL K = 60 – 150 mEq/day on avg MTE – 1 mL è 0.5 – 1 mEq/kg to start Consider previous K+ administration May need to ↓ in renal failure Ca = 10 – 20 mEq/day on avg è Start @ 10 mEq/day if Ca is normal Added as calcium gluconate à no need to balance >< Cl May need to monitor ionized Ca (iCa) or corrected [Ca] based on albumin  Abbreviations ABW – actual body weight AdjBW – adjusted body weight DBW – dosing body weight IBW – ideal body weight NBW – nutritional body weight UBW – under body weight EN – enteral Nutrition PN – parenteral nutrition TPN – total parenteral nutrition TNA – total nutrient admixtures CRP – C-Reactive protein UUN – urinary urea nitrogen BEE – basal energy expenditure (bare minimum of calorie to stay alive) REE – resting energy expenditure (sitting & not having physical activity) TEE – total energy expenditure NPC – non-protein calories (carb & fat) CVC – central venous catheter PICC – peripherally inserted central catheter SC – subclavian = under clavicle (collarbone) IJ – internal jugular = neck MIFV – maintenance intravenous fluids MVI – multivitamin MTE – multi-trace element CMP – comprehensive metabolic panel MODS – multi-organ dysfx Calculate Weights 6. Risk factors - Dry weight = admit weight = actual weight UBW = 20% below IBW - IBW Involuntary weight loss > 10% within 6 months Male = 50 kg + (2.3 x inches over 60 inches) o Surrogate marker Female = 45.5 kg + (2.3 x inches over 60 inches) o Consider other disease states (cancer, YB) *** 60 inches = 5 ft NPO > 10 days * o Clinically we use inadequate intake > 7 days Adjusting Weights Gut malnutrition * - Dosing Body Weight (DBW) o Mechanical ventilation * DBW = IBW + 0.4 (wt – IBW) o ↑ metabolic needs * Use if ABW is ≥ 130% of IBW o Trauma / Burn pts Applies for dosing certain Rx o High dose steroids - Nutrition Body Weight (NBW) o EtOH / Substance abuse NBW = IBW + 0.25 (wt – IBW) o ↓ functional proteins Use if ABW is ≥ 130% of IBW o “Empty” calories (ex: EtOH does not have protein) Applies for calculating fluid, electrolyte, & nutrition (FEN) parameters Protracted nutrient losses o Chronic disease states Nutritional Support è Nutritional Therapy * ICU patients - Preserve lean body mass - Maintain immune fx - Determination of Nutrition Risk - Avert (Prevent) metabolic complications Risk factors for malnutrition - Alleviate stress response Intake anticipated to be insuwicient Provide macro- & micro- nutrient delivery Identify who will benefit most from early nutrition therapy Careful glycemic control (maintain BG) All hospitalized patients w/in 48 hrs. Begin EN early Many screening and assessment tools exist o Benefits: o Mini Nutritional Assessment (MNA) § ↓ disease severity, ↓ complications, ↓ ICU length of stay o Malnutrition Screening Tool (MST) § ↑ pt outcomes o Malnutrition Universal Screening Tool (MUST) o NUTRIC Nutritional Assessment § High risk: 6-10 (5-9 without IL-6) 1. Risk Factors of Malnutrition § Low risk: 0-5 (0-4 without IL-6) 2. History o Nutritional Risk Score (NRS-2002) 3. Anthropometrics o Short Nutritional Assessment Questionnaire (SNAQ) 4. Classification of Malnutrition o Subjective Global Assessment (SGA) 5. Nitrogen Balance 2. History Dietary o Diet PTA, intake, swallowing, ulcers, hx weight loss, anorexia, vomiting, diarrhea Medical o Surgical hx o PMH Medications o ↓ nutrient absorption o Alter taste o ↑ / ↓ appetite o N/V 3. Anthropometrics 5. Nitrogen Balance ç KNOW calculation in exam Somatic (muscle) protein status Measurement of urinary excretion of nitrogen as urea nitrogen o Weight (urinary urea nitrogen = UUN) o Triceps skin fold o Nitrogen is released from protein catabolism o Arm muscle circumference à converted to urea o Physical appearance à excreted in urine è Look at the trends!!! o Stress ↑, protein catabolism ↑, & UUN ↑ o Measured from a 24-hour urine collection Visceral protein status o Represents 85-90% of Total urine excretion Albumin 3.5 – 5 gm/dL Non-urinary sources of nitrogen loss can include sweat, feces, respirations, GI Transferrin 250 – 300 mg/dL fistula, wound drainage, skin exfoliation, burns Transthyretin (pre-albumin) 15 – 40 mg/dL Nitrogen balance study used to assess adequacy of protein repletion Retinol binding protein 2.5 – 7.5 mg/dL o Ideal Goal: +3 to +5 grams è May not accurately represent nutrition statis in ICU setting o Want (+) nitrogen to retain nitrogen for protein è Look at everything & need more info to determine malnutrition Formula C-Reactive Protein (CRP) Nitrogen Balance = (N in) – (N out) o Positive acute phase reactant (↑ by @ least 25% during inflammation) !"#$%&' )'%*+,- ,-*./+ (1) o Normal < 1 mg/dL (in clinical practice) N in = 3.!5 o Used to assess accuracy of pre-albumin *6.25 g Protein = 1 g Nitrogen o Prealbumin is falsely ↓ in the presence of inflammation: § Prealbumin ↓ as CRP ↑ => inflammation N out = 24-hour UUN (g) + Factor (3-5 g) § Prealbumin ↓ as CRP normal => malnutrition *Use 4g as estimate / adjust per specific indications 4. Classification of Malnutrition Protein-calorie malnutrition (Marasmus) – EVERYTHING LOW (calories & protein) Nutritional Requirements o ↓ total intake and/or utilization of food 1. Caloric Requirements o Wasting of skeletal muscle and SQ fat 2. Protein Requirements o Immunosuppression in severe cases o Cachectic appearance 1. Caloric Requirements Protein malnutrition (Kwashiorkor) – ONLY protein low Estimate Caloric Needs o Adequate caloric intake; relative protein malnutrition o Harris-Benedict Equation o Catabolic (breaking down protein) trauma patients, burn patients Basal Energy Expenditure (BEE) – basal minimum of calorie to stay alive Mixed OR o Chronically ill starved patients who are metabolically stressed Resting Energy Expenditure (REE) – sitting & not having physical activity o ↓ visceral proteins, poor wound healing, immunocompromised Marasmus Kwashiorkor “Stress” or Activity Factor to use with Harris-Benedict Equation (protein & calorie) (protein) Large belly, diarrhea, change in % of REE Activity Factor Peeling & alternatively pigmented skin pigment, ↓ muscle mass, Maintenance 120 – 130 1.2 – 1.3 Symptoms skin, hair loss, edema, swelling, failure to gain weight, fatigue, skin folds are formed Mild; Moderate 150 1.5 hair changes Severe; Thermal burn 200 + 2 Wasting of Muscles Quite evident NOT evident Provide a well-balanced substrate Provide carbs followed by high TEE = REE x stress/activity factor(s) Treatments Consider addition of vitamin B protein 1. Caloric Requirements (continued) 2. Protein Requirements Calorie General Guidelines Protein General Guidelines Non-stressed Maintenance 0.8 – 1 gm/kg/day 20 – 25 kcal/kg/day Non-depleted Mild – Moderate Stress 1 –1.5 gm/kg/day Trauma/ Stress/ Surgery (floor pt) Critically ill 25 – 30 kcal/kg/day Moderate – Severe Stress 1.5 – 2 gm/kg/day Major Burns (ICU, trauma, surgery, burn) Obesity (BMI > 30) FYI 2 gm/kg/day (IBW) Obesity: BMI 30-50 11 – 14 kcal/kg/day (ABW) Severe Obesity (BMI ≥ 40) FYI 2.5 gm/kg/day (IBW) Obesity BMI > 50 22 – 25 kcal/kg/day (IBW) Additional Considerations o Adequate calories MUST be present for appropriate protein utilization § Ensure adequate NPC Indirect Calorimetry § Usually include protein in calculation of total calories o Preferred method for critically ill patients o Provides energy expenditure (REE, RQ) at that ONE point in time, then Protein “tolerance” maybe ↓ in some disease states (renal / hepatic failure, etc) extrapolated to 24h NPC Distribution o Abbreviated Weir equation: o Standard Distribution = 70 / 30 (carb / fat) § TEE = REE x 1.2 § 70-85% dextrose (carb) o For all energy production, O2 is consumed & CO2 is produced § 15-30% fat § RQ = VCO2 / VO2 o Adjust based on tolerance (adjust ratio depending on pt) § Blood sugars Respiratory Quotient Value § TG => less fat needed => maybe 80 / 20 § RQ from Indirect Calorimetry o 100 / 0 during sepsis or blood stream infections Parenteral Nutrition - Definition: PN is process of supplying nutrients via IV delivery system (ex: protein, carb, fat, electrolytes, vitamins, minerals) - Synonyms: HA, HAL, HAF, TPN, PN, IVH, IVA, CHA (central), PHA (peripheral), PPN, total nutrient admixture, TNA, 3-in-1, triple-mix - Indications of PN = CI of EN ç MEMORIZE Anticipated prolonged NPO course (> 7 days) Inability to absorb nutrients via the gut, such as secondary to: o Small bowel or colonic ileus o Extensive small bowel resection o Malabsorptive states o Intractable vomiting/diarrhea o Enterocutaneous fistulas o Inflammatory bowel disease o Hyperemesis gravidum – non-stop vomiting in pregnancy o Bone marrow transplantation (mucositis) - Route of Administration 1. Peripheral 2. Central 1. Peripheral PN 2. Non-Protein Calories (NPC) – Carbs & Fats Dextrose & aa solutions are hypertonic è Not well tolerated via a peripheral vein a. Carbohydrates (Dextrose) Restrict final [dextrose] to 5-10%, OR total osmolarity to < 900 mOsm/L MAX [dextrose] available D70% (D70W) Addition of other substances to solution may enhance vein tolerance 1 g Dextrose = 3.4 kcal Requires large volumes of fluid Limitations: final [dextrose] > 10% (adults) and > 12.5% (peds) should NOT be o May not be the best choice for HF or AKI/CKD pts infused into peripheral vein due to vein irritation Limited in calories MAX carb utilization: 4 – 5 mg/kg/min (double check) o Secondary to the osmolality AND fluid Short term access (< 7-10 days) b. IV Fat (Lipid) Emulsion o Does this patient need PN at all? I. Intralipid Pharmacy/MD error? Provide a concentrated source of calories o è Always double-check to confirm peripheral route was intentional o 10% lipid supplies 1.1 kcal/mL In NICU, all TPNs are peripheral o 20% lipid supplies 2.0 kcal/mL Peripheral route is ok for pediatrics & is rare for adult o 30% lipid supplies 3.0 kcal/mL 1 g Lipid = ~ 10 kcal 2. Central PN Prevent essential FAs deficiency Advantages Intralipid 10% consists of: o Allow administration of hypertonic solutions o Soybean oil 10% (high in linoleic acid, an omega-6 FA) o More calories can be delivered o Glycerin 2.25% (check for allergies) Disadvantages o Egg Yolk Phospholipid 1.2% (check for allergies) o Infection risk è Appropriate central line is key to prevention o Water of injection o Central line is not a benign procedure § Pneumothorax II. SMOFlipid (most pt get this) § Air embolus SMOFlipid consists of: § Thrombus o Soybean oil 30% (omega-6 FA) Central Venous Access o Medium-chain TG 30% o Central venous catheter (CVC) insertion sites § Rapid available energy source § Subclavian (SC) – under clavicle (collar bone) à not often use o Olive oil 25% § Internal jugular (IJ) – neck à worst option among 3 § Omega-9 mono-unsaturated FA § Femoral – groin o Fish oil 15% (check for allergies) o Short-term: § Omega-3 (source of EPA & DHA) § Percutaneously inserted Compared to pure soybean oil products (e.g., Intralipid): o Long-term: o Improved liver function (lower ALT/AST concentrations) § PICC (peripherally inserted central catheter) o Lower ↑ in TG levels from baseline § Tunneled Compared to non-omega-3 PN: § Implanted port o Less pro-inflammatory o Less negative impact on liver function Meeting Energy Requirements o ↓ risk of infection 1. Protein Calories o ↓ length of hospital stays 1 g Protein = 4 kcal o Many hospitals actually order protein in gm/day III. Additional Lipid Considerations Standard aa products Maximum intake – DO NOT EXCEED o Travasol 3.5%, 5.5%, 8.5%, 10% o 60% of caloric intake as lipid o FreAmine III 3%, 8.5%, 10% o Generally, 1 – 1.5 gm/kg/day of lipids in adults o Aminosyn II 3.5%, 5%, 7%, 8.5%, 10% § MAX of 2.5 gm/kg/day of lipids in adults if tolerating o 4 gm/kg/day of lipids in infants/pediatrics Remember: Propofol is a 10% lipid solution; provide 1.1 kcal/mL  b. IV Fat (Lipid) Emulsion (continue) PN Initiation & D/C Guidelines Administration - Start @ ~25% of goal & achieve final rate w/in 24h o IV fat emulsion 10% & 20% are iso-osmolar (isotonic) with serum - EX titration method § May infuse via peripheral vein Start @ 50 mL/h x 4h (~25% of goal rate) § Piggyback into PN Then 75 mL/h x 4h § Admix into dextrose/aa solution to ↓ osmolarity Then 100 mL/h x 4h o IV fat emulsion 30% Then ↑ to final rate w/in 24h ( if more than 100 mL/h) § MUST be incorporated into a total nutrient admixture (3-in-1) - Initiation Infectious Complications Check BG q4-6h o IV lipids provide an environment suitable for pathogen growth Before each ↑ in rate § Hang-time of IV fat emulsion by itself should be limited to 12 If BG > 200, continue @ same rate x 4h & recheck hours after opening of manufacturer packaging If repeated BG > 200, consider insulin therapy o If added as TNA (3-in-1), safety is increased to 24 hours - D/C ↓ rate by ½ q2h until rate < 50 mL/h, then D/C Administration of PN - Total nutrient admixture (“custom” TPN) Cycling PN Dextrose, AA, & Lipids in 1 bag - Infusion over ~12-18h/ day “3-in-1” = TPN (total parenteral nutrition) - Transitioning to EN or PO intake - Convention administration (“custom” TPN) - Pts who desire time free from infusion pump (ex: home PN pt) Dextrose & AA in 1 bag - Rate of infusion cut back (tapered) during 1st/last hour of infusion to prevent dys-glycemia Lipid 2–3x / week as a separated IVPB - NO SPECIFIC GUIDELINES for cycling PN (~ MAX 200 mL/h) - Pre-mix solution for injection (“standard” TPN) Available with OR without electrolytes Additives NO lipids 1. Electrolytes In-line filters 2. Vitamins - ↓ infusion of particulates, micro-precipitates, microorganisms, pyrogens, & air 3. Trace Elements - Filter sizes: 4. Medications? 1.2 – micron filter can be used for ALL total nutrient admixtures (TNAs) OR 3-in-1 (w lipids) 1. Electrolytes 0.22 – micron filter ONLY used for 2-in-1 Sodium (Na), Potassium (K), Magnesium (Mg), Calcium (Ca), Phosphorous (Phos), Chloride (Cl), Acetate Pre-mix PN solution In pt w renal disease 1. Clinimix (w/o electrolytes) o CAUTION should be used with K, Phos, & Mg 2. ClinimixE (with electrolytes) Acid-Base balance obtained through balance of Chloride & Acetate - “Standard” TPN = not able to customize these products AVOID Ca + Phos precipitation - Contains: AA + Dextrose +/- Electrolytes o AVOID Ca (mg/L) x Phos (mMol/L) > 150 Electrolytes includes Na, K, Mg, Ca, Phos, Cl, Acetate - Lipid compatible 2. Vitamins - Peripheral & central line preparations Thiamine (B1), Riboflavin (B2), Niacin (B3), Folic acid (B9), Pantothenic acid (B5), - Dosing ----------------------------------------------------------------------à Pyridoxine (B6), Biotin (B7), Cyanocobalamin (B12), Ascorbic acid (C), K, A, D, E Adult & Peds (> 40 kg) o 10 mL/day of injectable adult multivitamin-12 (MVI) o Contain small amount of vit K (150 mcg) Peds (3-40 kg) o 2 mL/day of injectable peds MV o Contain vit K 3. Trace Elements (Multi-trace elements = MTE) Complications PN Liver dysfx (chronic liver disease / LFTs > 2x ULN) - Mechanical (catheter-related) o D/C trace elements Clotting of line o Supplement individually Displacement § Zinc (Zn) 5 mg (1 mL) - Infectious § Selenium (Se) 60 mcg (1 mL) Catheter-related sepsis Solution contamination Renal disease (CKD/ESKD on HD) Bacterial translocation o Consider checking serum lvls if use expected beyond 14 days o Time-dependent passage of bacteria or endotoxins from GI tract to extra- o CAUTION use Selenium (Se) & Chromium (Cr) intestinal sites o ≠ rules apply for continuous renal replacement therapy (CRRT) o Enteric organisms cause systemic infections § Pneumonia Iron (Fe) § Central line infections o DO NOT give Fe in TPN bag è Give separately § Abscesses o NOT RECOMMENDED the addition of Fe to PN § Multi-organ dysfunction syndrome (MODS) § Can destabilize IV fat emulsion in 3-in-1 formulations o Infectious morbidity & mortality § May contribute to infectious complications - Metabolic è Monitor QD Electrolyte imbalances 4. Medications Fluid imbalances For the most part, addition of meds in PN formulation is NOT ADVISED Hyper- & Hypo-glycemia Famotidine may be utilized for GERD or stress ulcer prophylaxis Liver fx abnormalities PPIs is NOT COMPATIBLE with PN o Steatosis (fatty liver) Insulin o Intrahepatic cholestasis o Regular Insulin ONLY (usually don’t mix in the bag except pt has to be o Cholelithiasis very stable on TPN ß not rec anyways) o Common regimen: 0.1 units/g of dextrose Monitoring PN § If BG > 150 mg/dL, 0.15 units/g of dextrose - Baseline § If BG > 300 mg/dL, DO NOT initiate PN until < 200 mg/dL CMP § Max amount: 0.3 units/g of dextrose Liver fx § 5 – 10 units “stick” to the bag Mg, Ca, Phos Pre-albumin/CRP Questions to Consider When Initiating PN è Look @ calculation sheet to study!!!! PT / INR 1. Is PN indicated? - Q4-6H 2. Which product? Finger sticks for glucose 3. Access/lines? o Correct elevated [glucose] w insulin via infusions &/or sliding scale 4. Which weight? ABW / IBW/ NBW? Residuals, distention, vomiting, aspiration 5. How much fluid (MIVF)? 6. Protein, dextrose, fat? 7. Calories? 8. Electrolytes? Na, K, Ca, Mg, Phos, Cl, Acetate? 9. Vitamins, trace elements, additional meds? 10. Baseline labs? 11. Ongoing monitoring?  1. Refeeding Syndrome Constellation (imbalance) of fluid, micronutrient, electrolyte, & vitamin imbalances Occurs w/in 1st few days of feeding a starved pt Potentially life threatening Clinical findings of Refeeding Syndrome o Hypo-Phos, Hypo-Mg, Hypo-K o Respiratory distress (Phos) o Paresthesia (Phos) o Tetany (Phos) o Cardiac arrhythmias (K+) o Hemolytic anemia Risk Factors for Refeeding o Rapid feeding, excessive dextrose infusion o Low BMI (< 16-18.5 kg/m2) o Excessive weight loss o Insuwicient caloric intake o Low levels of K, Phos, or Mag prior to feeding o Loss of subcutaneous fat or muscle mass o High-risk comorbidities: alcoholism, anorexia, nervosa, Marasmus Prevention of Refeeding Syndrome o Replete electrolytes (1st) before initiating feeds o Initiation recommendations (Day #1): § LIMIT carbohydrates (dextrose) to 100-150 gm § LIMIT fluids to 800 mL/day § Provide adequate amounts of electrolytes § Provide ~ 50% of total caloric needs ð Calculate normal & cut in ½ the caloric needs o Advance calories/dextrose by 20-33% of goal q1-2 days as tolerated o Give Thiamine 100 mg QD x 5-7 days 2. Essential FA Deficiency (EFAD) EFA Requirements o Estimated to be 4 – 10% of daily calories Additional Complications o EFAs include linoleic & linolenic acids 1. Refeeding Syndrome Mechanism of EFAD 2. Essential FA Deficiency o Continuous infusion of hypertonic dextrose will ↑ circulating insulin lvls o Inhibits lipolysis & FA mobilization Clinical onset of EFAD o Several weeks on a fat-free PN regimen (10–14 days) Symptoms o Dry scaly skin, brittle hair, lack of luster Prevention of EFAD o Rec minimum requirement is to provide ~ 4% of caloric intake as lipids o Provide at least 500 mL of 10% fat emulsion over @ least 3-5h twice weekly OR o Provide at least 250 mL of 20% fat emulsion over @ least 5-9h twice weekly  Enteral Nutrition Determining Route of Access - “If the gut works, use it” - Risk of aspiration - Oral consumption inadequate If low risk, may utilize gastric - Oral consumption CI If high risk, jejunal (post-pyloric) is preferred Esophageal obstruction - Tolerance Head & neck surgery Vomiting – use jejunal Dysphagia Gastric residuals – use jejunal Trauma - Duration of therapy Cerebrovascular accident Long term – PEG / PEJ Dementia - Advantages Confirm Proper Placement - Verify before initiating feeding Provides GI stimulation o ↓ chance for bacterial translocation => ↓ infectious morbidity & mortality Post pyloric o Stimulates biliary flow thru biliary tract Lung placement Avoid risks associated with IVs Pneumothorax o Non-invasive tube placement at the bedside - Auscultation o Line infections, pneumothorax, etc. - Abdominal x-ray (“KUB”) More physiologic than PN Stomach, kidneys, ureters, bladder - Cortrak® Bolus feeds are more physiologic than continuous Less stringent (nghiêm ngặt) protocol for administration Real-time display of position during placement Less expensive (depending on the formula) NO imaging required Contraindications to EN = Indications for PN ç MEMORIZE Methods of Administration 1. Bolus Mechanical obstruction 2. Intermittent o Hernia, tumors, adhesions, scar tissue, etc. 3. Continuous infusion Non-mechanical obstruction – ileus 4. Trickle & Trophic o No peristalsis, decreased perfusion, post-op, etc. 5. Cyclic Intractable vomiting Severe malabsorption Severe GI hemorrhage Certain types of fistulas o High output, proximal small bowel Route of Administration – 1st letter: where tube feed starts & 2nd letter: where tube feed ends 1. Nasogastric (NG) / Orogastric (OG) 2. Nasojejunal (NJ) / Orojejunal (OJ) o Dobhop® o Cortrak® / Corpak® 3. Gastrostomy 4. Jejunostomy 5. PEG / PEJ ***Gastrotomy: larger diameter (thicker) Jejunostomy: longer tube, more bent 1. Bolus Initiation & Advancement of Tube Feeding Mimics meals - Initiate full strength @ 25 mL/h Administer > 200 mL formula over 5 – 10 min - Advance (↑) 25 mL/h q4-6h as tolerated up to goal rate o MAX volume 300 – 400mL Check residuals q4-6h Used mainly for pt w gastrostomy May hold for residuals > 500 mL o Nursing facilities Dilution of formula has limited benefit è NOT REC o Ambulatory settings EN – ICU Initiation Points Advantages Disadvantages - Achieve > 50 – 60% goal calories w/in 1st week (if not, consider PN) - More convenient for pt - Cannot feed into small bowel (Gastric ONLY) - DO NOT initiate if hemodynamically unstable - Requires minimal equipment (syringe) - Higher aspiration risk & intestinal SEs Concern for intestinal ischemia - Less DI - NO NEED bowel sounds / flatus for initiation EN promotes gut motility 2. Intermittent NPO Times Administer > 200 mL formula over 20 – 30 min (gravity drip) - Minimize holding times 4 – 8 feedings / day Inadequate nutrient delivery May stimulate ileus development (ileus = guts stop moving) Advantages Disadvantages - Pt undergoing frequent surgical procedures have fewer infections when EN is not stopped for - Help tolerance - Requires reservoir bottle / bag each procedure 3. Continuous Infusion Formula Selection Administer continuously over 12 – 24 h/day 1. Patient characteristics: Requires infusion pump Functional capacity of GI tract PEFERRED when feeding into the jejunum Underlying disease Rate mL/h Nutritional requirements 2. Formulary availability Advantages Disadvantages Immune-modulating Contents - Lower gastric distention & aspiration risk - Problematic for med administration Impact 1.5 ® kcal/mL - Better tolerated by pt - Requires infusion pump Arginine T lymphocyte fx 4. Trickle or Trophic Glutamine Antioxidant, immune support, & nitrogen retention Slow continuous infusion at 10 – 30 mL/h Omega-3 FAs ↓ inflammation, arrhythmia incidence, ARDS, & sepsis Antioxidants Selenium, ascorbic acid, & vit E Advantages Disadvantages - Prevent mucosal atrophy & bacterial - Diwicult to achieve suwicient calorie Target Pt Population Major elective surgery translocation delivery Trauma - Shorten time on ventilator & ↓ mortality Burn Head / neck cancer Mechanically ventilated 5. Cyclic Use w CAUTION Severe sepsis Administer over 8 – 20 h/day Advantages ↓ ventilator time Often infused overnight ↓ infectious morbidity Advantages: ↑ independence for pt ↓ length of hospital stay EN Nutrient Composition 2. Glutamine 1. Protein ↓ hospital & ICU length of stay Intact protein ↓ mortality in burn pt o Requires complete digestion into smaller peptides NO systemic epect when given by EN route à NO SEs Partially digested (peptide-based) 0.3 – 0.5 g/kg/day divided in 2–3 doses o Elemental à easier for body to use b/c already broken down DO NOT supplement if already receiving Glutamine via immune-modulating => Maybe beneficial for pt w mal-absorption, diarrhea formula (ex: Impact 1.5®) 2. NPC a. Fat 3. Probiotics Long-chain FAs Microorganisms conferring potential health benefits to host: Medium-chain FAs o Inhibit pathogenic bacterial growth o More water soluble o Block pathogen attachment o Rapid hydrolysis o Eliminate toxins o Little / NO pancreatic lipase for absorption o Enhance host inflammatory response b. Carbs Clinical ewicacy data are mixed/ lacking Glucose polymers mainly used for tube feeding formulas May ↑ complications (ex: diarrhea) Simple glucose used for oral supplements (higher in osmolality) 4. Vitamin & Trace Elements Adjunctive Therapies Used for antioxidant ewects and/or repletion 1. Modular Supplements Vitamin E & C 2. Glutamine Trace elements 3. Pro-biotics o Selenium, zinc, copper, chromium, manganese (Se, Zn, Cu, Cr, Mn) 4. Vitamins & Trace Elements Beneficial in most ICU patients o Emphasis on burn, trauma, & mechanically ventilated 1. Modular Supplements Consider organ dysfx as previously discussed Complications EN 1. Gastrointestinal 2. Metabolic 3. Mechanical 4. Medication-related Prokinetic Agents è ↓ motility Metoclopramide 10 mg IV/PO/feeding tube QID o Also N/V Erythromycin base 250 – 500 mg PO/feeding tube TID or 3 mg/kg IV Q8H o QTc proongation Naloxone 8 mg via feeding tube QID o Diarrhea (opioid withdraw) >< constipation (opioid SE) Methylnaltrexone weight-based dosing IV x1 o NOT 1st line o Mainly last line 1. Gastrointestinal 3. Mechanical High gastric residuals Clogging of feeding tube o Lower cut ops do not protect patient from complications Tube malposition (abdominal X-ray – “KUB”) o Residuals Bacteria loves growing in plastic § < 500 mL: DO NOT HOLD unless intolerance signs o Rhinitis § 200 – 500 mL: implement risk reduction measures to avoid § Reposition daily aspiration § Use smaller bore tube § Cutows may vary by site § Change from NG to OG Aspiration o Sinusitis o Elevate head of bed (HOB) 30 – 45º o Administer as continuous infusion 4. Medication-related o Change to post-pyloric delivery Clogged feeding tubes o Consider prokinetic Rx or Narcotic antagonists o Poorly crushed meds N/V or ↓ motility o Inadequate flushing o Consider prokinetic Rx § Flush with at least 15 – 30 mL of sterile water before & after med o Metoclopramide, erythromycin may be given § Flush with 5 – 10 mL between each med Abdominal distention o Flushing also ensures adequate med administration Diarrhea o Check meds, formula o Formula § Change to soluble fiber-containing or small peptide formulations o Suspect Clostridium dipicile colitis o Consider other infectious etiologies o Evaluate medications: § Hyperosmolar medications § Liquid formulations with sorbitol § Bowel regimen § Broad spectrum antibiotics Constipation o Check meds Drug-tube feed interactions 2. Metabolic Hyper- / Hypo-glycemia o Check meds, insulin regimen o Stress o Infection Overhydration / Dehydration o Monitor fluid status Electrolyte imbalance o Hypo-Na is most common Glycemic Control in ICU Goal BG ≤ 180 mg/dL, ≤ 150 mg/dL (in practice) Prompted ICYs to review goal ranges Guidelines for Medication Delivery via Enteral Feeding Tubes ç MEMORIZE Special Considerations & Disease States Liquid medications are preferred whenever possible. 1. Acute Renal Failure o AVOID viscous formulations due to risk of clogging tube: Use a normal EN formula UNLESS electrolyte profile dictates otherwise § Syrups HD/Continuous Renal Replacement Therapy § Mineral oil o CRRT: ↑ protein requirement to prevent nitrogen deficit (MAX 2.5 g/kg/day) § Granules § Need more protein b/c filter takes out some If using oral dosage forms, crush tablet to a fine powder (or empty capsule o HD: 0.8-1.2 g/kg/day protein contents) & mix in water. o Loss of water-soluble micronutrients (Se, Zn, thiamine) o Can sometimes crush tablets / open capsules o Pre-albumin accumulates due to renal elimination o Dilute in 15 – 30 mL of sterile water § Falsely high DO NOT CRUSH 2. Hepatic Failure o ISMP published list Traditional nutritional assessment tools are inaccurate due to presence of ascites, o Delayed / extended release (ER, XR, XL) intravascular volume depletion, edema, portal HTN, & hypo-albuminemia o Enteric coated Standard enteral formulations for most liver disease pt o Buccal or sublingual o Branched chain aa (BCAA) for encephalopathic pt refractory to other tx o Carcinogenic, teratogenic, or cytotoxic (hazardous) 3. Pulmonary Failure o +/- Capsules Fluid-restriction, calorically dense formulations – 1.5-2.0 kcal/mL Administer each medication separately. Monitor phosphate closely Ensure adequate flushing with water between each medication. o Component of adenosine triphosphate (ATP) & 2,3-disphosphoglycerate (2,3- Dilute hypertonic medications/ those irritating to gastric mucosa in at least 30 mL DPG) è essential for normal diaphragmatic function of water before administering. 4. Acute Pancreatitis Metabolic changes à may need more proteins Monitoring EN o ↑ protein catabolism 1. Gastrointestinal § Inability of exogenous glucose to inhibit gluconeogenesis Gastric residuals o ↑ energy expenditure Emesis o ↑ insulin resistance Check q 4-6 hrs o ↑ dependence on fatty acid oxidation for energy Stools daily EN vs. PN o Frequency of stools, volume of stools o Recovery & resumption of oral intake occurs w/in 3-7 days, not requiring PN Bloating/ distention Protein requirements – 1.2-1.5 g/kg/day Bronchial/ tracheal aspirate o Consider adding glutamine Glucose 2. Metabolic o Safe, same maximum as other patients Intake/output (I/Os); bowel movements Lipid infusions Weight → 2-3 times per week o Safe if TG levels are w/in normal limits → monitor closely Serum electrolytes, glucose, BUN/SCr [CMP] Parenteral nutrition does not apect pancreatic secretion & function o Daily until stable → twice weekly → weekly 5. Burn Mg, Phos, Ca, triglycerides, LFTs Metabolic changes o Weekly o ↑ basal metabolic rate and nitrogen loss Albumin, prealbumin/CRP, nitrogen balance o Glycolysis, proteolysis, lipolysis o Weekly Nutritional requirements o High in protein (2-2.5 g/kg/day) & calories 3. Mechanical o Early feeding with EN Feeding tube placement Supplements Feeding tube patency o Adult multivitamin o If TBSA > 10%: Ascorbic acid, Vitamin E, Se, Zn o If TBSA > 20%: Oxandrolone/ Growth hormones o Vitamin D (if deficient); Vitamin A (if on CS) Clinical Applications #1 PHRM 864 Parenteral & Enteral Nutrition Fall 2024 1. EN vs PN? (indicate which is most appropriate for each patient and why) a. TR is a 32 yof pregnant with twins at 10 weeks GA admitted for hyperemesis gravidarum. She is unable to tolerate PO for the past 3 days despite being started on an ondansetron infusion one week ago. Her physician anticipates her NPO status will continue and wishes to start nutrition. b. AS is a 65 yom admitted yesterday s/p cardiac arrest 2/2 to a large b/l PE. He has been stabilized and is no