DEPENDS ON PRODUCT percent does not Rise DIRECTLY 10% = 1.1 kcal/mL 20% = 2 kcal/mL

9 - Nutritional Elements + Requirements Flashcards by Karlo Sison

45 mL/kg/day

Water Requirements - Volume Status

DEHYDRATION

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40 mL/kg/day

Water Requirements - Volume Status

POST-OPERATIVE

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35 mL/kg/day

Water Requirements - Volume Status

EUVOLEMIA

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30 mL/kg/day

Water Requirements - Volume Status

ELDERLY or CHF

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AMINO ACIDS

Energy Source

4 kcal / gram

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FAT

Energy Source

*DEPENDS ON PRODUCT**
percent does not Rise DIRECTLY*

10% = 1.1 kcal/mL

20% = 2 kcal/mL

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CARBOHYDRATE

energy Source

3.4 kcal/gram

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What is the GOLD STANDARD for
Estimating Energy Requirements?

INDIRECT CALORIMETRY

Harris-Benedict

Fixed kcal/kg/day

Mifflin-St Jeor

Penn State Uni Predictive equations

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Healthy + Normal Nutrition Status

How many kcal/kg/day does
ASPEN & SCCM recommend?

energy requirements

20-25
kcal/kg/d

first determine if obese or not

use ACTUAL BODY WEIGHT

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ILLNESS or METABOLIC STRESS
w/ BMI <30

How many kcal/kg/day does
ASPEN & SCCM recommend?

energy requirements

25-30
kcal/kg/d

use ACTUAL BODY WEIGHT

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ILLNESS or METABOLIC STRESS
BMI >30

How many kcal/kg/day does
ASPEN & SCCM recommend?

energy requirements

11-14
kcal/kg
in combination with HIGH PROTEIN FEEDING

OR
Penn State / Mifflin-St Jeor Equation
uses Actual Body Weight

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MAJOR BURN INJURY

How many kcal/kg/day does
ASPEN & SCCM recommend?

energy requirements

> 30
kcal/kg/day

use actual body weight

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Fixed kcal/kg

Calculation used for ENERGY REQUIREMENTS

WEIGHT used for OBESE PATIENTS
Ranges are availble for
Both ABW & IBW

Confirm weight used to derive calorie range before using

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During periods of inadequate protein or energy intake,
what type of CATABOLISM occurs FIRST?

MUSCLE CATABOLISM –> AMINO ACIDS

*<75g** of skeletal muscle protein is catabolized to
*supply AA precursors** for liver gluconeogenesis & energy production

Protein Depletion >20% of body stores will lead to:
VVV
Comprimised IMMUNE SYSTEM –> INFXN & DEATH

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Mild Protein Depletion
Albumin > 3.0 g/dL

What are the DAILY PROTEIN REQUIREMENTS?

1.1-1.3
g/kg/d

Need Normal Renal & Hepatic Function

Use ACTUAL BODY WEIGHT, unless OBESE –> IBW if obese

Obesity hypocaloric feeding regimens require HIGHER protein amounts

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*Moderate** Protein Depletion
*Albumin 2.5 - 2.9 g/dL**

What are the DAILY PROTEIN REQUIREMENTS?

1.3-1.5
g/kg/d

Need Normal Renal & Hepatic Function

Use ACTUAL BODY WEIGHT, unless OBESE –> IBW if obese

Obesity hypocaloric feeding regimens require HIGHER protein amounts

SEVERE Protein Depletion
Albumin < 2.5 g/dL

What are the DAILY PROTEIN REQUIREMENTS?

1.5-2
g/kg/d

Need Normal Renal & Hepatic Function

Use ACTUAL BODY WEIGHT, unless OBESE –> IBW if obese

Obesity hypocaloric feeding regimens require HIGHER protein amounts

Parenteral Sources of

PROTEIN

Amino Acid Solutions

Base Compounds solution = 3.5-20%
mis of essential + non-essential Amino Acids

*Final concentration = 2.5-10%**
*Central** concentration max of 10% // peripheral concentration max = 2.5-3%

Function of FATS

Nutritrient Requirements

Essential component of:
Cell membranes / padding organs / Insulation

Precursor of:
PROSTAGLANDINS

Esential Fatty Acids:

Linoleic & Linolenic Acids

Fat Deficiencies

Esential FA’s = Linoleic & Lonolenic Acids

Diffuse Dermatitis

CLOTTING = platelet aggregation

Diminished Would healing

Hemolytic anemia

Hepatic dysfunction

FAT REQUIREMENTS

% / Min / Max

30% of total kcal
as a starting point

Min = 5% of WEEKLY caloric intake from fat
to prevent essential FA deficiency

*MAX = 60% of total daily calories**
*<2.5g/kg/day**

Parenteral Source of FAT

Nutrient Requirements

Fat = Most Concentrated Energy Source

INTRALIPID FAT EMULSION
10% = 1.1 kcal/mL
20% = 2 kcal/mL
30% = 3 kcal/mL, used in compounding 3in1 TPNbags only

SMOFlipid 20% =2 kcal/mL
Has fish oil + MCT + Olive Oil + Soybean Oil
theoretically should be less pro-inflammatory, but is not proven

Fat Infusion Considerations

DURATION // SPEED

*Isotonic Solutions** may be given directly through Peripheral Vein
*10% & 20%**

Run over:
12-24 hours

do NOT infuse over:*
*> 30 - 50 mg/kg/hr**

CONTRAINDICATIONS

of FAT INFUSION

Elevated
TG’s >300mg/dL
need to use less fat for patient, ~5% kca

EGG ALLERGY

*PANCREATITIS DUE to HYPERtg’s**
pancreatitis due to other things is FINE, only from HYPERtg’s is contraindicated*

**When do FAT / CALORIC requirements** **NEED TO BE ADJUSTED?**

If patient is on: **FAT-BASED IV SOLUTIONS** = **_PROPOFOL_** has a lot of fat in it already.

**Carbohydrate (Dextrose)** **Caloric Conversion**

**3.4 kcal/gram** DEXTROSE

**Protein** **Caloric Conversion**

**4 kcal/gram** **Protein**

**Fat** **Caloric Conversion**

**10% Lipid Emulsion = 1.1 kcal/mL** **20% Lipid Emulsion = 2 kcal/mL**

* *Respiratory Quotient = RQ** * *VCO₂ / VO₂** **_What Values mean what?_** **Indirect Calorimetry**

**_\<_** **0.7** = *UNDERFEEDING* Want to be ~ 0.82 - 0.85 **_\>_** **1 = OVERFEEDING**

**Goal for: NITROGEN BALENCE** N2 (in) - N2 (out) N2 (in) = protein/6.25 (include both oral and IV protein) N2 (out) = [UUN g/ml) x 24 hr urine volume (mL)] + 2-4 (insensible losses)

**SLIGHTLY POSITIVE**

**Carbohydrate Requirements**

Make up the **rest of the energy requirements** after accounting for calories from **fat / protein** Usually: **45 - 65% of total calories** * *Parenteral = Dextrose** * *Enteral =** Sucrose / Fructose / Corn Syrup+Maltodextrin

**Concentration / Max Infusion Rate** **Dextrose Infusion Considerations**

Dextrose **5-35% of final concentration** Central Max = 35% Peripheral Max = **10-12.5%** Max Infusion Rate: **3-5 mg/kg/min**

**MICRONUTRIENT Nutrition Requirements**

**Must be added** to PN Amount depends on many factors: **Hepatic / Renal Fxn Fluid / Cardiac Status Prior Nutritional Status** **Electrolytes are DOSED BY WEIGHT**

**MVI-12**

Contains the: * *RDA of 12 Vitamins** * *10 mL/d** Some other products also contain RDA for * *Vitamin K** - need to give seperately * *10mg weekly** or **1.5 mg/day**

**What Additional Vitamins might need to be added?**

_FOR **ALCOHOLICS**_ **FOLATE + THIAMINE** * *Vitamin K** might need to be given seperately * *10mg weekly** or **1.5 mg/day**

**Special Considerations for** **SELENIUM**

**Excreted VIA KIDNEYS** **Normal Need = 60mcg** * *Renal Failure/Disease** * *HALF = 30 mcg** * except for CRRT, use standard dose*

**Special Considerations for TRACE ELEMENTS**

**ZINC** **COPPER** **MANGANESE** **Chromium** urine / bile excretion **Selenium** kidney excretion 60mcg --\> 30mcg **Iron** not normally required unless long term TPN

**Special Indications for ZINC**

**_GI Fistula_** **_Wound Healing_** **Zing --\> 3-12mg/day ABOVE normal requirements** * ALSO:* * *Increase DOSE (2.5-5mg normal) for RENAL patients**