Nutrition Flashcards
Risk Factors for Malnutrition
UBW (under body weight) =20% below IBW
Involuntary weight loss >10% within 6 months
NPO > 10 days: clinically we use inadequate > 7 days
Gut malfunction
Mechanical ventilation
Risk Factors for Malnutrition (cont.)
Increased metabolic needs: trauma or burn patients, high dose steroids
Alcohol/substance abuse
Protracted nutrient losses
Determination of Nutrition Risk
All hospitalized patients within 48 hours
Screening Tools
NUTRIC
Nutritional Risk Score (NRS-2002)
NUTRIC
High risk: 6-10 (5-9 w/o IL-6)
Low risk: 0-5 (0-4 w/o IL-6)
History
Dietary: intake, swallowing, ulcers, weight loss, anorexia, vomiting, diarrhea
Medical: surgical history, PMH
Medications: decrease nutrient absorption, alter taste, increase/decrease appetite, N/V
Anthropometrics (look at protein stores)
Somatic protein status: weight, triceps skin fold, arm muscle circumference, physical appearance
Preablbumin
Half life: 2-3 days
Normal concentration: 15-40 mg/dL
In real-life: > 10 mg/dL
C-Reactive Protein (CRP)
Normal concentration: < 1 mg/dL
Assess accuracy of pre-albumin
Pre-albumin decreases as CRP increases–> inflammation
Pre-albumin decreases as CRP normal–> malnutrition
Marasumus
Protein and calorie malnutrition–> decrease in total intake or utilization
Characteristics: wasting of skeletal and subQ fat, immunosuppression, cachectic appearance
Treatment: well-balanced substrate + Vitamin B
Kwashiorkor
Protein malnutrition–> adequate calorie intake
Characteristics: large belly
Who? Catabolic trauma or burn patients
Treatment: carbohydrates followed by high protein
Mixed
Chronically ill starved patients who are metabolically stressed
Characteristics: decrease in visceral proteins, poor wound healing, immunocompromised
Nitrogen balance
Measurement of urinary excretion of nitrogen as urea nitrogen (UUN)
Nitrogen released from protein catabolism that is converted to urea and excreted in the urine
Goal: +3 to +5
N(in)-N(out)
N(in)=24-hr protein intake/6.25
N(out)=24-hr UUN +4
Kcal requirements
Trauma/stress/surgery/burn/illness: 25-30 kcal/kg/day
Indirect Calorimetry (preferred in critically ill patients)
Provides energy expenditure at that ONE point in time and then extrapolated to 24 hours
TEE=REE x 1.2
RQ=Vco2/Voz
Goal: 0.85-0.95
< 0.85–>underfeeding
> 0.95–> overfeeding
Protein requirements
Mild/moderate (FLOOR PTs): 1-1.5 g/kg/day
Moderate/severe (ICU/SURGERY/TRAUMA/BURN): 1.5-2 g/kg/day
Non-Protein Calorie Distribution
Standard: 70/30
70% dextrose
30% fat
Sepsis/bloodstream infections (fungal) : 100/0
100% dextrose
0% fat
Adjustments:
Blood sugar: reduce dextrose
Triglycerides: reduce fat
Parenteral nutrition indications
Anticipated prolonged NPO > 7 days
Small bowel or colonic ileus–>bowel stomachs moving
Extensive small bowel resection
Malabsorptive states
Intractable vomiting/diarrhea
Enterocutaneous fistules
Inflammatory bowel disease
Hyperemesis gravidum
Bone marrow transplantation
PN initiation and discontinuation
Start at 25% of goal and titrate up to goal within 24 hours
Check BG every 4-6 hours
BG > 200: continue x 4 hours and repeat
BG < 200 after repeat: insulin
Cessation: decrease rate by 50% every 2 hours until < 50 mL/hr THEN d/c
Cycling: infusion over 12-18 hours/day
Max rate: 200 mL/hr
Peripheral Route of Administration
Barriers:
-Solutions are hypertonic (dextrose,AA)
-Requires large volumes of fluid (not best for HF, AKI)
-Limited in calories
-Short term access ( < 7-10 days)
Solutions:
-Restrict dextrose concentration to 5-10%
-Total osmolarity < 900 mOsm/L
Central Route of Administration
Advantages:
-Administration of hypertonic solutions (dextrose, AA)
-Larger amounts of calories
Disadvantages:
-Risk of infection
-Not a benign procedure (pneumothorax, air embolus, thrombus, etc)
Access:
-Subclavian (SC)–> in the chest
-Internal jugular (IJ)–> in the neck
-Femoral–> in the groin
Short-term: percutaneously
Long-term:
-PICC, tunneled, implanted port
Protein
1 gram- 4 kcal
Carbohydrates
1 gram= 3.4 kcal
Maximum carb rate=4-5 mg/kg/min
Restrictions: dextrose concentration must be < 10% in adults for a peripheral vein
Dextrose concentration must be < 12.5% in pediatrics
Fat (lipid)
1 gram=10 kcal: prevents essential fatty acid deficiency
DO NOT EXCEED 60% of calorie intake
DO NOT EXCEED 2.5 g/kg/day
4 g/kg/day in pediatrics
PROPOFOL IS 10% LIPID–>1.1 kcal/mL
Intralipid 10%
Soybean oil 10%–> high in linoleic acid (omega-6)
Glycerin 2.25%–> CHECK ALLERGIES
Egg yolk phospholipid 1.2%–> CHECK ALLERGIES
Water for injection
SMOFlipid
Soybean oil 30%–>high in linoleic acid
Medium-chain triglycerides 30%
Olive oil 25%–>omega-9
Fish oil 15%–>omega-3-CHECK ALLERGIES
Advantages of SMOFlipid
Improved liver function
Lower increase in TG levels
Less pro-inflammatory
Reduced risk of infection and decrease length of hospital stay
Administration of lipids
IV Fat Emulsion 10 and 20%–>peripheral vein, piggyback in PN, admix into dextrose/AA solution
Max hang-time: 12 hours
IV Fat Emulsion 30%–>total nutrient admixture (3-in-1)
Max hang-time: 24 hours
Electrolytes
Considerations:
-Renal disease: caution K+, Phos, Mg+
-Avoid Ca x Phos > 150–>precipitation
Sodium
1-2 mEq/kg
Potassium
0.5-1 mEq/kg up to 2 mEq/kg
Calcium
10-20 mEq
Magnesium
8-24 mEq
Phosphorus
15-45 mMol
1mMol=1.4 mEq
Chloride/Acetate
Cl: 2/3
Acetate: 1/3
Vitamins
Adult (>40 kg): 10 mL of multivitamin
-Small amount of Vitamin K (150 mcg)
Pediatric (3-40 kg): 2 mL of multivitamin
-Small amount of Vitamin K (150 mcg)
Trace Elements
Considerations:
Mechanical complications of PN
Clotting of the line
Displacement of the line
Infectious complications of PN
Catheter-related sepsis
Solution contamination
Bacterial translocation: if you stop feeding the gut, you stop making the acid to suppress bacteria allowing bacteria to go from below diaphragm to above diaphragm
-pneumonia, central line infection, abscess, multi-organ dysfunction syndrome
Metabolic complications of PN
Hyper/hypoglycemia
Electrolytes imbalances
Fluid imbalance
Liver dysfunction
-Steatosis
-Intrahepatic cholestasis
-Cholelithiasis
Clinical Signs of Refeeding Syndrome
Hypophosphatemia, hypomagnesemia, hypokalemia
Respiratory distress–>phos controls muscle contraction in diaphragm
Cardiac arrhythmia’s–> potassium controls
Anemia
Paraesthesia
Tetany
Risk factors of refeeding syndrome
Rapid feeding and excessive dextrose infusion
Low BMI ( < 16-18.5)
Excessive weight loss
Insufficient caloric intake
Low levels of Phos, K, Mg prior to feeding
Loss of subQ fat or muscle
Alcoholism, anorexia, marasmus
Prevention of Refeeding syndrome
REPLETE ELECTROLYTES BEFORE FEEDING
Day #1
Limit carbs to 100-150 gm
Limit fluids to 800 mL/day
Give only 50% of caloric needs
Thiamine 100 mg daily x 5-7 days
Essential fatty acid deficiency
Goal: 4-10% of daily calories
Onset: 10-14 days on fat-free nutrition
Symptoms: dry scaly skin, brittle hair, lack of luster
Prevention:
At least 500 mL of 10% fat emulsion at least 3-5 hours twice weekly
OR
At least 250 mL of 20% fat emulsion over at least 5-9 hours twice weekly
Baseline monitoring
CMP, Mg, Phos, Ca
Hepatic function
Pre-albumin/CRP
PT/INR
Blood glucose every 4-6 hours
Residuals, distention, vomiting, aspiration 4-6 hours
Daily monitoring
Vital signs
Intake/outtake
CMP
Feeding tube placement and patency
Twice weekly monitoring
Weight
CBC
Mg, phos, Ca
Prealbumin/CRP
Weekly monitoring
Albumin, transferrin, nitrogen balance
Liver function
Triglycerides
RQ
PT/INR
Clinimix/Clinimix E
Dextrose + AA +/- electrolytes
With or without electrolytes
CrCl < 50: clinimix
CrCl > 50: clinimix E
Peripheral or central
Indications for EN
if the gut works, use it
Oral consumption inadequate
Oral consumption contraindicated
Esophageal obstruction
Head and neck surgery
Dysphagia
Trauma
Cerebrovascular accident
Dementia
Contraindications to EN
Mechanical obstruction–>hernia, tumor, adhesions, scar tissue
Non-mechanical obstruction–>ileus
Intractable vomiting
Severe malabsorption
Severe GI hemorrhage
Fistulas
Advantages of EN
Provides GI stimulation
-Decreased chance for bacterial translocation
-Stimulates biliary flow
Avoids line injections and pneumothorax
MORE PHYSIOLOGIC THAN PN
Initiation of EN
Start at full strength at 25 mL/hr
Increase 25 mL/hr every 4-6 hours up to goal rate in 24 hours
Achieve 50-60% of goal calories within the first week
DO NOT START IF HEMODYNAMICALLY UNSTABLE–> intestinal ischemia
Monitor residuals every 4-6 hours
Hold for residuals > 500 mL
Which type of administration for EN
Low risk of aspiration: gastric
High risk of aspiration: jejunal
Vomiting: jejunal
Gastric residuals: jejunal
Long-term: PEG or PEJ
Bolus administration
Who? Patients with PEG/PEJ (nursing home, ambulatory)
What? > 200 mL formula over 5-10 minutes
Max volume 300-400 mL
Advantages: more convenient, requires minimal equipment, less interactions
Disadvantages: must be gastric tube, higher risk for aspiration
Intermittent administration
Administer > 200 mL formula over 20-30 minutes: 4-8 feedings per day
Advantage: helps tolerance
Disadvantage: more equipment required–>reservoir bag/bottle
Continuous infusion administration
most common
Who? Patients with jejunal tube
What? Administer continuously over 12-24 hours/day
Advantages: Low risk of gastric distention or aspiration, better tolerated
Disadvantages: More equipment required–>infusion pump, medication administration issues
Trickle or Trophic
What? Administer slow continuous infusion at 10-20 mL/hr
Advantages: prevent mucosal atrophy and bacterial translocation, shorten time on ventilator
Disadvantages: difficult to achieve sufficient calorie delivery
Types of formula
Jevity–>standard
Impact 1.5–>sepsis
Glucerna–>diabetes
Nepro–> renal disease
Carbohydrates
Glucose polymers in tube feed
Simple glucose for oral supplements
Protein
Intact and partially digested
Intact: requires complete digestion
Partially digested (elemental): beneficial for malabsorption or diarrhea
Fat
Long chain fatty acid
Medium-chain fatty acid: more water soluble leading to rapid hydrolysis–> no lipase
Fiber
Who? constipation
What? 1 packet/tbsp
How much? 3 g
Protein (prostat)
Who? Burn, trauma, etc
What? 30 mL tube
How much? 15 g
Juven
Who? Wound care, HIV/AIDS, Cancer
Glutamine
Who? Burn patients
What? 0.3-0.5 g/kg/day over 2-3 doses
DO NOT GIVE IF ON IMPACT 1.5–>already receiving
Probiotics
Who? Diarrhea
Inhibit pathogenic bacterial growth, block pathogen attachment, eliminate toxins, enhance host inflammatory response
Vitamins
Vitamin E and Vitamin C
Trace Elements
Who? burn, trauma, mechanically ventilated
Mechanical complications of EN
Clogging of the feeding tube
Tube malabsorption
Rhinitis: reposition daily, use smaller bore tube, change from NG to OG
Sinusitis
Metabolic complications of EN
Hyper/hypoglycemia
Goal: 140-180 mg/dL
Electrolytes imbalances–> hyponatremia is the most common
Fluid imbalance
Aspiration
Elevate the head of the bed by 30-45 degrees
Post pyloric delivery
Continuous tube feed at smaller volume
Prokinetics: metoclopramide or erythromycin, naloxone, methylnaltrexone
Nausea/vomiting
metoclopramide or erthyromycin
Diarrhea
Change to fiber-containing or small peptide
Consider C.diff
Evaluate medications: hyperosmolar meds, liquid formulations containing sorbitol, bowel regimen, broad spectrum antibiotics
