ENTERAL AND PARENTERAL NUTRITION UPDATE
WITH THE NUTRITION CARE PROCESS
Suzanne Neubauer, PhD,RD,CNSCFramingham State University
Overlook Health Center, Charlton, MAJanuary 31, 2013
Objectives
Calculate basic flow rates for enteral nutrition considering interruption factors and fluid needs.
Calculate parenteral nutrition formulas, including basic electrolyte considerations.
Practice the nutrition care process for enteral/parenteral cases, focusing on new nutrition diagnosis and intervention standardized language.
Critical Illness Guidelines 2012: Blood Glucose Control promote blood glucose control between
140 to 180 mg per dL in critically ill adult patients Tight blood glucose control (80 to 110
mg per dL) and moderate control < 140 mg per dL is not associated with reduced hospital length of stay
Grade II (fair)days on mechanical ventilation
Grade II (fair)http://www.adaevidencelibrary.com/topic.cfm?cat=1035
Tight blood glucose control (80 to 110 mg per dL) is not associated with infectious complications in surgical (primarily cardiac) patients
Grade II (fair)cost of medical care
Grade III (limited Tight blood glucose control (80 to 110
mg per dL) increases risk of hypoglycemia
Glucose level >180 mg per dL is associated with increased mortalityGrade II (fair)
Critical Illness Guidelines 2012: Blood Glucose Control
http://www.adaevidencelibrary.com/topic.cfm?cat=1035
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Composition of Solution
3-in-1 Total nutrient admixture (TNA) 2-in-1
Lipids infused separately Favorable when patients have high
protein or minimal fluid needs and can maintain euglycemia with addition of modest insulin dose
Must use laminar-airflow hood to decrease the risk of contamination
Clinimix
http://www.clinimix.com/home Clinimix
Sulfite-free (Amino Acid in Dextrose) injections
Clinimix E Sulfite-free (Amino Acid with
electrolytes in Dextrose with calcium) injections
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Protein: Crystalline Amino Acids
Stock solutions range from 8.5% to 20% Usually expressed at final concentration
after dilution vs initial concentration How many g protein in 8.5% AA
solution? 8.5% = 8.5 g = x
100 ml 1000 ml 85 g/L
How many calories in 8.5% AA? 4 kcal/g 85 g/L x 4 = 340 kcal
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Carbohydrate: Dextrose Monohydrate
Stock solutions range from 5.0% to 70% Calories
Anhydrous glucose: 4 kcal/g Hydrous in IV solution: 3.4 kcal/g
CPN Limits Average adult requires 1 mg/kg/min or 100
g/d 5 mg/kg/min 4 mg/kg/min in critically ill and 7 mg/kg/min
in hospitalized patients (Supp Line 2005;27:6)
patients on ventilators: 4 mg/kg/min patients with diabetes: 2-2.5 mg/kg/min
How many g carbohydrate in 25% dextrose solution? 25% = 25 g = x
100 ml 1000 ml 250 g/L
How many calories in 25% dextrose solution? 3.4 kcal/g 250 g/L x 3.4 = 850 kcal
Carbohydrate: Dextrose Monohydrate
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Glucose Tolerance: Mg/Kg/Min
Max: 5 mg/kg/min Solve for g Dextrose:5 mg x 70 kg x (60 minutes x 24 hr)
= 504 g 1000 mg/g
Solve for mg/kg/min:504 g x 1000 mg/g = 5 mg/kg/min
70 kg x 1440 min
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CHO in Peripheral Parenteral Nutrition
PPN: Maximum of 10%; 5% most
common Osmolality
Maximum = 900 mOsm(10 x g pro) + (6 x g CHO) + (.3 x ml
fat)total L
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Lipids: Administration
Slow and continuous 24-hour infusion can improve hepatic reticuloendothelial function As opposed to short, < 10 hrs,
infusion Usually infused over 12 hrs. if
infused separately IVFE infusion rate
NOT > 0.11 g/kg/h
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Calculation Rules for Lipid
Maximum lipid: 60% of total kcal 2.5 g/kg body weight
2 – 4% of total kcal as linoleic acid to prevent EFAD 10% of total kcal as fat meets EFA
Maximum of 30% lipid for septic patients
May use > 30% with hyperglycemic or pulmonary compromised patients
Usually begin with 1 g lipid/kg/day
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Calculation Rules for Lipid Cont’d
Intralipid 10%: 1.1 kcal/ml; 11 kcal/g Total volume of lipid x .1 = g fat
Intralipid 20%: 2.0 kcal/ml; 10 kcal/g Total volume of lipid x .2 = g fat
Intralipid 30%: 3.0 kcal/ml; 10 kcal/g Total volume of lipid x .3 = g fat
Lipid available as 250 ml or 500 ml
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Diprivan (Propofol)
Administered intravenously to intubated/ mechanically ventilated adult ICU patients Provides continuous sedation Controls stress responses Usually infused at 10 mg/mL
IsotonicCheck rate and total volume infused daily
Calculate 3-in-1 solution/2200 mL Pt weight @ 55 kg
requires 2200 kcal; 93 g protein; 2200 ml fluid Protein: 93 g x 4 kcal/g = 372 kcal
2200 kcal – 372 kcal = 1828 kcal remaining for fat & CHO
Lipid: use 1 g/kg/day to start 55 g x 1 g/kg = 55 g fat
55 g fat x 10 kcal/g = 550 kcal 1828 kcal – 550 = 1278 kcal remaining for
CHO
CHO: 1278 kcal = 376 g dextrose3.4 kcal/g dextrose
Check maximum CHO 5 mg x 55 kg x (60 x 24 hr) = 5 mg x 55 kg x 1440 min/day 1000 mg/g .005 g x 55 kg x 1440 min/day = 396 g
CHO
Calculate 3-in-1 solution/2000 mL
PN Order Divide g of each substrate by total
volume of fluid. Multiply x 100 for percent.
93 g protein x 100 = 4.2% AA 2200 ml 55 g lipid x 100 = 2.5% lipid 2200 ml 376 g CHO x 100 = 17% CHO 2200 ml
PN Order 93 g protein = 1 L 10% AA 55 g lipid = 250 ml 20% lipid 376 g CHO = 1 L 30% dextrose Total fluid = 2250 ml Kcal: 100 g protein; 400 kcal (21%) 250 ml lipid; 500 kcal (26%) 300 g CHO; 1020 kcal (53%) Total kcal: 1920
Electrolytes: Initial Dose
Generally aim for the middle of the normal range
Individualize based on renal function, GI losses, acid-base balance and medications
Can use multiple-electrolytes or several single entity electrolyte solutions
Dependent on the compatibility of each electrolyte with the other components in the PN admixture
Electrolytes: Sodium
Generally use approximately equal amounts of chloride and acetate (1:1 ratio)
Acetate and chloride also found in AA solution
In metabolic acidosis use maximum acetate and minimum chlorideAcetate is metabolized as bicarbonate
In metabolic alkalosis use maximum chloride and minimum acetate
Sodium Goal: 1 – 2 mEq/kg Use 1.5 mEq/kg
1.5 x 70 kg reference man = 105 mEq/day
2 L (not including IVFE) so 105/2 = 53 mEq/lSodium Chloride: 53 mEqSodium Acetate: 53 mEq
Electrolytes: Sodium
Electrolytes: Potassium & Phosphorus Potassium available in chloride, acetate, and
phosphate salts K: maintenance @ 1 mEq/kg = 70 mEq
2 L (not including IVFE) so 70/2 = 35 mEq/l If serum K is low correct with a separate
infusion of K
Phosphorus available as the sodium or potassium salt
Phosphorus: 25 mmol/day 25 mmol Potassium Phosphate (37 mEq K) Remainder of K as KCl: 33 mEq
Electrolytes: Calcium
Ca available as gluconate (preferred form) or chloride salt Gluconate preferred b/c more
stable in solutionLess likely to dissociate and precipitate with Phosphorus
dose within accepted solubility range and amino acid pH and concentration
standard dose: 12 mEq/day
Electrolytes: Magnesium
Mg available as sulfate or chloride salt
Mg Sulfate is preferred form Mg 8 – 20 mEq/day
References
Kingley J. Fluid and electrolyte management in parenteral nutrition. Supp Line. 2005;27(6):13-22.
Whitmire SJ. Nutrition-focused evaluation and management of dysnatremias. Nutr Clin Pract. 2008;23:108-121.
Schmidt GL. Techniques and Procedures: Guidelines for Managing Electrolytes in Total Parenteral Nutrition Solutions. Nutr Clin Pract 2001 16: 226
Baumgartner TG. Enteral and Parenteral Electrolyte Therapeutics. Nutr Clin Pract. 2001;16:226-235.