Hospital-based nutrition Flashcards
When should you begin feeding a hospitalized patient who cannot feed themselves?
Depends on four factors:
- Patient’s preexisting nutritional status
- Patient’s level of illness
- Consequences to the patient of inadequate nutrition
- The risks of feeding them.
Guidelines:
- Previously well nourished adult who cannot eat but who has minimal acute medical illness: Might go 10-14 days without food before they begin to develop potentially serious nutritional deficiencies.
- Previously undernourished adults with minimal medical
illness, or previously well nourished individuals with serious acute medical illness (infection, surgery, cancer): Might go 5-7 days without food before they begin to develop potentially serious nutritional deficiencies - Previously undernourished adults with serious medical illness: may develop potentially serious nutritional deficiencies in 3-5 days if they are not fed.
How do you estimate the number of calories per day that a sick patient in the hospital will need?
A general range of TEE for sick people might range from 22-25 kcal/kg/day for someone who is not that sick to 30-32 kcal/kg/day for someone who is very sick.
You then take the person’s weight in kg times a number of kcal/kg/d that you think is appropriate to calculate the person’s daily energy needs.
Since the enteral diet comes in 1 kcal/ml, the number of kcal/day that they need equals the number of ml/day that you need to infuse via the tube.
You then divide that number by the number of hours in the day to get an hourly infusion rate.
This can be hard to tolerate at first though, so good to start with less
What’s an approach to writing an order for nutritional support in a hospitalized patient?
Calculate energy need and then start with less and add up to that value after seeing how pt tolerates feeding. Check if stomach is still full or if get vomiting/regurgitation.
Make sure to include vitamins (thiamine and folate and a multiple vitamin) and micronutrients, especially if pt is malnourished to start.
Arginine and glutamine for nitrogen balance
How do you determine if a person who is getting long term nutritional support is being fed adequately?
If someone is going to need tube feedings for a long time (months), then you may want to check to see if your “guess” about their energy needs is actually appropriate to meet their ongoing needs
If too much, will be fine at first and then will get hyperglycemia. Reduce the feedings and should get better over a couple of days. Insulin doesn’t usually help because already have full glycogen stores.
If you under-feed a person, they will be in negative nitrogen/protein balance (breaking down muscle to donate amino acids to gluconeogenesis to produce glucose for their brain). You can estimate how much protein is being broken down by measuring urinary nitrogen over 24 hours and multiplying it by 6.25. If that’s more grams of protein than what you’re feeding the pt, they’re in negative balance. Consider increasing amount of food.
What are some of the special issues associated with feeding a hospitalized patient with liver disease?
Diets lower in aromatic AA and higher in branched chain AA may be helpful
Patients with end stage liver disease may develop “hepatic encephalopathy” (due in part to high levels of ammonia in their blood which accumulate because of an inability of their liver to incorporate the ammonia into urea).
These patients may also have ascites which is due to salt and water retention.
For these reasons it may be prudent to limit protein, salt and water intake in a person who has hepatic encephalopathy.
This must be weighed against the possible deleterious effects of underfeeding a person who may already be malnourished.
Some clinicians think that part of the alterations in consciousness seen in patients with end stage liver disease come from the accumulation of “false neurotransmitters” that derive from high levels of aromatic amino acids seen in these patients. For this reason some advocate the use of diets that are high in branched chain amino acids to both give adequate protein without fostering the production of these “false neurotransmitters” in the brain. Here again, the data in support of this idea is not strong.
If a patient can’t eat on their own, what is the best method of delivery of nutrients?
Enteral
The risks are lower than parenteral and there are benefits to delivering the nutrients by the normal physiological route including nourishing the GI epithelium which is important in long term nutrient absorption and acts as a barrier to colonic flora.
What is the average protein requirement for sick patients?
0.8-1 g protein/kg body weight/d.
What are some of the special issues associated with feeding a hospitalized patient with pulmonary disease?
Higher fat and less calories may be beneficial
If you overfeed a patient, they will tend to try increase their rate of oxidation of nutrients and as a result consume more oxygen and produce more CO2. With more CO2 production comes the need for more ventilation.
If a person is having trouble getting off a ventilator you do not want to over feed them.
However you also do not want to underfeed them which could lead to weakness of their respiratory muscles.
There is more CO2 produced for each O2 consumed when glucose is burned as compared to fat. For this reason some people say that to minimize CO2 production while still giving adequate energy you might consider feeding people on a ventilator a high fat diet. The evidence in favor of this idea is limited.
What are some of the special issues associated with feeding a hospitalized patient with kidney disease?
Volume (Na and water) overload is a problem
The kidneys are responsible for excreting urea. If they do not work the levels of blood urea nitrogen (BUN) increases. The source of this nitrogen is protein catabolism. For this reason some clinicians would limit the amount of protein a person with renal failure gets each day.
Here again, this must be weighed against the risk of providing too little protein to a person who may already be undernourished. In general, you certainly do not want to overfeed protein to a person with end stage renal disease, but neither do you want to overly restrict it.
The calculation of nitrogen balance is more difficult in these individuals but can be done.
What are some of the special issues associated with feeding a hospitalized patient with cardiac disease?
Patients with cardiac disease can be admitted with complications of CAD such as angina or an acute MI or problems of volume overload from congestive heart failure (CHF).
For patients with CAD it may be useful to take the opportunity of hospitalization to have a nutritionist discuss a saturated fat restriction in the diet.
For overweight or obese patients, restriction of energy may also be important.
For patients with CHF, the main dietary constituent to restrict is Na+. A standard approach is to place these patients on a 2 g Na+ diet. A “cardiac diet” is often an option for hospitalized patients. This diet typically is a low fat, low sodium, low saturated fat diet.
What are some of the special issues associated with feeding a hospitalized patient with diabetes?
Control of blood glucose levels depends in part on dietary carbohydrate intake as well as the use of glucose lowering medications.
Often insulin is used to control glucose in the hospital. The most important thing in dosing insulin with meals is the amount of carbohydrate in the meal. Ideally, a hospital will offer a diabetic diet with controlled carbohydrate content with each meal. This is sometimes not available. In this situation, patients should be advised to be aware of the carbohydrate content of the meals that they order from the hospital menu.
Some hospitals have a “diabetic diet” as an option for inpatients. These diets are often restricted in calories, fat and simple sugars. While it may be helpful to have patients consume a diet like this, we often adjust anti-diabetic medications in the hospital based on blood sugars obtained in the hospital. If the patient goes home and eats substantially more than they did in the hospital, the program of medications used in the hospital may no longer be appropriate.
Another option may be to have the patient eat in the hospital more like they will eat at home. That way medications can be adjusted to a diet that is more like what they will be eating at home.
