Hospital Based Nutrition

Question 1

When do you begin feeding a hospitalized patient who can’t feed themselves?

Answer 1

Depends on four factors:

1. preexisting nutritional status,
2. level of illness
3. The consequences to the patient of inadequate nutrition
4. The risks of feeding them

Previously well nourished adult w/ minimal acute medical illness: 10-14 d before developing deficiencies.

Prev. undernourished adult w/ min medical concerns or well nourished w/ serious medical illness: 5-7 d before nutritional deficiencies

Undernourished w/ serious medical illness: 3-5 d

Question 2

Risk of enteral feeding

Answer 2

• aspiration of food into lungs

* **But this is the method of choice whenever possible

Question 3

Risk of parenteral feeding

Answer 3

• risk from placement of central venous catheter

- risk of infection from a central line that contains nutrients in high concentration.

Question 4

Range of TEE for mildly to very sick

Answer 4

mildly ill: 22-25 kcal/kg/d
very sick: 30-32 kcal/kg/d

Multiply weight in kg times kcal/kg/d.
Enteral diet comes in 1kcal/ml. So number of kcal/d equals the number of ml/d that needs to be infused. Divide by 24 hrs to get hrly infusion rate
-But start with lower infusion rate to avoid vomiting/aspiration
-gradually increase over days
-if rate is lower than adequate, make sure to give vitamins and micronutrients to malnourished pts: esp thiamine and folate and multi-vitamin (IV)

D5 is 5% dextrose in water (5g, 20 calories per hour)

Question 5

How to monitor the adequacy of feeding

Answer 5

Overfeeding:

• They do fine for several days while they fill up glycogen stores, then they develop hyperglycemia
• Hard to fix with insulin
• Need to lower number of calories they get each day and may take several days for situation to reverse itself.

Underfeeding:

• They will be in negative nitrogen/protein balance (breaking down muscle to give aa to gluconeogenesis)
• lose weight over time
• To estimate grams of protein being broken down, multiply the number of grams of urinary nitrogen by 6.25. If number of grams of protein they are losing is greater than what you’re feeding them, consider increasing amount of food.

Question 6

Average protein requirement for sick patients

Answer 6

0.8-1 g protein/kg body weight/d

Question 7

Issues in feeding a pt in respiratory failure

Answer 7

• concern that overfeeding causes pts to consume more oxygen and produce more CO2, and need for greater ventilation
• don’t want to underfeed for risk of weakening respiratory muscles
• limited evidence for feeding high fat diet (bc more CO2 is produced for each O2 when glucose is burned)

Question 8

Risks of nutritional intervention in Liver Failure

Answer 8

• They may have hepatic encephalopathy, ascites: so it may be smart to limit protein, salt and water intake
• risk, though, of underfeeding someone who is already malnourished.
• argument for use of diets high in branched chain aa (avoid production of bad “false neurotransmitters” in brain)

Question 9

Renal failure and feeding

Answer 9

• if kidneys don’t work, they can’t excrete urea and BUN rises
• nitrogen is from protein catabolism
• some argue for limit of protein
• risk of providing too little protein to an already malnourished person
• don’t over feed or overly restrict

Question 10

Cardiac disease and feeding

Answer 10

• might be useful to discuss saturated fat restriction in the diet
• restriction of energy may also be imp for overweight/obese
• CHF? restrict Na: 2g Na diet
• cardiac diet: low fat, low sodium, low saturated fat

Question 11

Diabetes and feeding

Answer 11

• dose insulin with amount of carbs in meal
• diabetic diet: restricted in calories, fat, and simple sugars
• another option is to have them eat more like they will at home so meds can be adjusted while they are in hospital and will work when they go home