Nutritional Support

Question 1

When to give patient nutritional support

Answer 1

Give to patients identified as being malnourished:

• BMI <18.5kg/m2
• unintentional weight loss of >10% over 3-6/12
• BMI <20 kg/m2 and unintentional weight loss of >5% over 3-6/12

Considered in people identified as being at risk:

• eaten nothing or little >5 days, who are likely to eat little for a further 5 days
• poor absorptive capacity
• high nutrient lossess
• high metabolism

Question 2

Oral nutritonal support

Answer 2

1. Identify patients as above
2. check for dysphagia
3. if safe swallow, provide food and fluid in adequate quantity and quality
4. give a balanced diet
5. offer multivitamins and minerals

Question 3

Enteral nutrional support

Answer 3

1. Identify patients as above
2. Identify unsafe or inadequate oral intake with functional GI tract
3. Consider for enteral feeding
   - Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal tube)
   - Check NG placement using aspiration and pH (check post pyloric tubes with AXR)
   - Gastric feeding > 4 weeks consider longterm gastromy
   - Consider bolus or continuous feeding into the stomach
   - ITU patients should have continuous feeding for 16-24h (24h if on insulin)
   - Consider motility agent in ITU or acute patients for delayed gastric emptying. If this doesn’t work then try post pyloric feeding or parenteral feeding.
   - PEG can be used 4h after insertion

Question 4

Parenteral nutrional support

Answer 4

1. Identify patients as above
2. Identify unsafe/inadequate oral intake OR a non functional GI tract/perforation/inaccessible
3. Consider parenteral nutrition
   - For feeding < 14 days consider feeding via a peripheral venous catheter
   - For feeding > 30 days use a tunnelled subclavian line
   - Continuous administration in severely unwell patients
   - If feed needed > 2 weeks consider changing from continuous to cyclical feeding
   - Don’t give > 50% of daily regime in first 24-48h

Question 5

Prescription

Answer 5

For people not severely ill and not at risk of refeeding syndrome aim to give:

• 25-35 kcal/kg/day (lower if BMI > 25)
• 0.8-1.5g protein /kg/day
• 30-35 ml fluid/day
• Adequate electrolytes, minerals, vitamins