sodexo dietetic internship clinical resource guide

1

Sodexo Dietetic Internship Clinical Resource Guide

2

Table of Contents

Page(s)

Nutrition Assessment

Anthropometric Assessment ...................................................................................... 5-7 Height ................................................................................................................................. 5 Demi-span .......................................................................................................................... 5 Knee height ........................................................................................................................ 5 Weight ................................................................................................................................ 5-7 Dry weight .......................................................................................................................... 7

Nutrition Focused Physical Exam ................................................................................ 8-9 Weight Loss ........................................................................................................................ 8 Intake.................................................................................................................................. 8 Muscle Wasting .................................................................................................................. 8 Fat Loss ............................................................................................................................... 9 Edema ................................................................................................................................. 9 Hand Grip ........................................................................................................................... 9

Estimating Nutrient Requirements ............................................................................. 10-11 Energy ................................................................................................................................. 10 Non-critical care ................................................................................................................. 10 Mifflin-St Jeor ..................................................................................................................... 10 Harris-Benedict .................................................................................................................. 10 Kcal/kg ................................................................................................................................ 10 Activity and stress factors ................................................................................................. 10 Critical care ......................................................................................................................... 11 Penn State 2003b ............................................................................................................... 11 Penn State 2010 ................................................................................................................. 11 ASPEN/SCCM guidelines for obese patients ..................................................................... 11 Ireton-Jones ....................................................................................................................... 11

Protein ......................................................................................................................... 11 Non-Protein Calorie: Nitrogen Ratio ................................................................................. 12

Fluids ............................................................................................................................ 12

Biochemical Tests

Hepatic Transport Protein Assessment ...................................................................... 13 Albumin .................................................................................................................... 13 Pre-albumin ........................................................................................................................ 13

Blood Glucose Assessment.......................................................................................... 13-14 Diagnosis of diabetes ......................................................................................................... 13 Monitoring ......................................................................................................................... 13 A1c ...................................................................................................................................... 13 Estimated average glucose (eAG) ...................................................................................... 13 Diabetic Ketoacidosis (DKA) .............................................................................................. 14 Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) ......................................... 14

3

Electrolyte Assessment ............................................................................................... 14-16 Hypo/Hypernatremia......................................................................................................... 14 Hypo/Hyperkalemia ........................................................................................................... 14 Hypo/Hypercalcemia ......................................................................................................... 15 Hypo/Hyperphosphatemia ................................................................................................ 15 Hypo/Hypermagnesemia ................................................................................................... 16

Hydration Status .......................................................................................................... 16-17 Hypo/Hypervolemia .......................................................................................................... 16 Electrolyte concentration and osmolality of common IV fluids ....................................... 17

Nutritional Anemias .................................................................................................... 17-18 Iron Deficiency Anemia ...................................................................................................... 17 Anemia of Chronic Disease ................................................................................................ 17 Megaloblastic Anemias ...................................................................................................... 17

Disease Specific Lab Tests ........................................................................................... 18-19 Chronic Kidney Disease ...................................................................................................... 18 Refeeding Syndrome .......................................................................................................... 18 Hyperlipidemia/CVD .......................................................................................................... 18 Metabolic Syndrome ......................................................................................................... 19

Nutrition Support

Enteral Nutrition .......................................................................................................... 19-22 Indications .......................................................................................................................... 19 Contraindications ............................................................................................................... 19 Feeding Routes and Access Devices .................................................................................. 20 Delivery Methods............................................................................................................... 20 Formula Selection: types ................................................................................................... 20-21

Polymeric ...................................................................................................................... 20 Monomeric or hydrolyzed ............................................................................................ 20 Blenderized ................................................................................................................... 20 Disease specific ............................................................................................................. 20 Modular products ......................................................................................................... 21

Initiation and Progression ................................................................................................. 21 Initiation ........................................................................................................................ 21

Medication administration ................................................................................................ 21 Drug-nutrient interactions ................................................................................................. 21-22 Monitoring and Complications .......................................................................................... 22

Monitoring .................................................................................................................... 22 Gastric residual volumes (GRV) ............................................................................. 22 Gastroparesis ................................................................................................................ 22 Bowel Sounds................................................................................................................ 22 Complications ............................................................................................................... 22 Mechanical .................................................................................................................... 22 Aspiration ...................................................................................................................... 22 Dehydration .................................................................................................................. 22 Biochemical ................................................................................................................... 22 Diarrhea ........................................................................................................................ 22

4

Parenteral Nutrition .................................................................................................... 23-30 Overview ............................................................................................................................ 23

Indications ..................................................................................................................... 23 Contraindications.......................................................................................................... 23

Delivery Methods............................................................................................................... 23-24 Central Parenteral Nutrition (CPN) .............................................................................. 23 Peripheral Parenteral Nutrition (PPN) ......................................................................... 24

Components ....................................................................................................................... 24 Dextrose ........................................................................................................................ 24 Protein ........................................................................................................................... 24 Lipids ............................................................................................................................. 24 Electrolytes ................................................................................................................... 25 Vitamins ........................................................................................................................ 25 Trace Elements .............................................................................................................. 25

Calculations ........................................................................................................................ 25-26 Continuous vs. Cyclic .................................................................................................... 27 Considerations .............................................................................................................. 27 Glucose Infusion Rate (GIR) .......................................................................................... 27 Fat Load ......................................................................................................................... 28 Osmolality ..................................................................................................................... 28

Compoundability ............................................................................................................... 28 Initiation ............................................................................................................................. 29 Monitoring ......................................................................................................................... 29 Discontinuation .................................................................................................................. 29 Complications..................................................................................................................... 29-30

Hyper/hypoglycemia .................................................................................................... 29 Essential fatty acid deficiency ...................................................................................... 29 Hypertriglyceridemia .................................................................................................... 30 Refeeding Syndrome .................................................................................................... 30 PN Associated Liver Disease ......................................................................................... 30 Azotemia ....................................................................................................................... 30

International Dysphagia Diet Standardization Initiative (IDDSI) ............................... 30-31

Pressure Injuries .......................................................................................................... 31-32

5

1. Anthropometric Assessment

Height

• Demi-span: useful for patients who can’t stand for an actual height measurement. Requires no special equipment Using the left arm, measure the distance from the tip of the middle finger to the middle of the sternal notch. Make sure patient’s arm is horizontal and in line with the shoulders Height is calculated using the following formulas: Females: height in cm = (1.35 x demi-span in cm) + 60.1 Males: height in cm = (1.40 x demi-span in cm) + 57.8

• Recumbent Length: can be used to estimate height in a comatose or critically ill patient. Use a tape measure to measure recumbent length while the patient is resting in bed.

• Forearm (ulna) length: another method for estimating height in patients who can’t stand. Measure ulna length (in centimeters) between the point of the elbow and the midpoint of the prominent bone of the wrist. This value is compared with a standardized height conversion chart. The chart may be found at http://www.rxkinetics.com/height_estimate.html

• Measuring knee height is another measure that may be used to estimate height. Special calipers are required, and it is rarely used in the hospital setting. Details about knee height can be found on the website given above.

Weight

• IBW and %IBW While there are several ways for estimating ideal body weight, the most common method is the Hamwi method: Females: IBW = 100 lb for 5 feet + 5 lb for each inch >60 inches Males: IBW = 106 lb for 5 feet + 6 lb for each inch > 60 inches Frame size adjustment: to adjust for differences in body build, frame size needs to be taken into consideration. In theory, this can be done by measuring wrist circumference or measuring elbow breadth. In practice a range of +/- 10% is added to the calculated IBW. For example, if a patient’s IBW was calculated to be 120 lb, 10% of that weight, or 12 lb would be added and subtracted from the IBW. The patient’s IBW range would then be 108-132 lb.

• Adjustment of IBW:

Spinal cord injury adjustment: paraplegia subtract 5-10% from IBW Quadriplegia subtract 10-15% from IBW

http://www.rxkinetics.com/height_estimate.html

6

• Amputation adjustment: If an amputation has occurred, the IBW estimation must be adjusted. Equation: adjusted IBW = 100% - % amputation/100% x IBW for original height Percentage of body weight contributed by specific body parts Hand: 0.7% Forearm with hand: 2.3% Entire arm: 5% Foot: 1.5% Lower leg with foot: 5.9% Entire leg: 16% Example: a male with an IBW of 166# who had a BKA (below the knee amputation), would have lost 5.9% of his weight. 5.9% of 166# is 9.8#. 166-9.8#=156.2# would be his new IBW.

• Percentage of IBW calculation: %IBW = current body weight/ideal body weight x 100

• UBW Comparing IBW to Usual Body Weight %UBW = current body weight/usual body weight x 100 However, looking at the % of weight change is the most useful piece of data and may be used to help diagnose malnutrition % weight change = UBW – current weight/UBW x 100 If the weight loss was unintentional, it may be categorized as significant or severe. Refer to the section on Nutrition Focused Physical Exams for more information

• Adjusted weight for obesity The use of an adjusted weight for patients with obesity is a bit controversial. ASPEN and AND do not recommend the use of an adjusted weight. However, some facilities do still use an adjusted weight. The concept behind using an adjusted weight is that since fat is not metabolically active tissue, if you assessed energy needs using the patient’s actual weight, you would be providing too many calories. However, there is no research to support this practice.

In general, facilities that use an adjusted weight when a patient is 125-130% of their ideal weight. While there is more than one formula to calculate an adjust weight, the most commonly used formula is:

Adjusted body weight = 0.25 (actual weight – IBW) + IBW Example: actual weight 250#, IBW 130# Adjusted body weight = 0.25 (250 – 130) + 130 0.25 (120) = 30 30 + 130 = adjusted weight of 160#

• BMI: calculation and classifications

Body mass index (BMI) is a calculation based on height and weight and can be used to assess the severity of obesity. There are limitations with the BMI and multiple factors can impact the relationship between BMI and body fat. These factors include age, gender, muscle mass and ethnicity.

7

• BMI may be calculated using either pounds and inches or kilograms and centimeters: BMI = weight (kg)/height (m²) BMI = weight (lb)/height (in²) x 703

Classification of Overweight and Obesity by BMI

BMI <18.5: underweight 18.5-24.9: normal weight 25.0-29.9: overweight 30.0-34.9: obesity class 1 35.0-39.9: obesity class II >40.0: extreme obesity class III

• Waist to Hip Ratio and Waist Circumference There are two methods for measuring abdominal fat; waist circumference and waist to hip ratio. These methods have been used to show an increased risk for diabetes, coronary artery disease and hypertension.

Disease risk relative to waist circumference and weight: Men ≤ 40” or women ≤ 35” Overweight: increased risk Obesity class I: high risk Obesity class II: very high risk Obesity class III: extremely high risk

Men > 40” or women >35” Overweight: high risk Obesity class I: very high risk Obesity class II: very high risk Obesity class III: extremely high risk

Waist to Hip Ratio: Male: ≤0.95 Female: ≤0.80 Low health risk

Male: 0.96-1.0 Female: 0.81-0.85 Moderate health risk

Male: ≥1.0 Female: ≥0.85 High risk

• Dry Weight

A dry weight is most often associated with those undergoing hemodialysis. A weight gain of several kilograms between dialysis treatments in not uncommon. After underdoing dialysis and having that excess fluid removed, a patient will be weighed. That weight is considered their dry weight, or actual weight without the extra fluid weight.

8

2. Nutrition Focused Physical Exam

Based on criteria from the Academy/ASPEN, the diagnosis of malnutrition may be present under 3 different conditions or categories. These are: in the context of an acute illness or injury (<3 months); in the context of chronic illness (>3 months); in the context of social or environment circumstances Weight loss:

• Acute illness or injury

• Chronic illness

• Social or environmental circumstances

Moderate Malnutrition Severe Malnutrition

% weight loss Time % weight loss Time

5 1 month >5 1 month

7.5 3 months >7.5 3 months

10 6 months >10 6 months

20 1 year >20 1 year

Intake:

• Acute illness or injury


<75% of estimated energy requirements for >7 days

≤50% of estimated energy requirements for ≥5 days



1-2 1 week >2 1 week







10 6 months >10 6 months

20 1 year >20 1 year

9

• Chronic illness


<75% of estimated energy requirements for ≥1 month

≤75% of estimated energy requirements for ≥1 month

• Social or environmental circumstances


<75% of estimated energy requirements for ≥3 months

≤50% of estimated energy requirements for ≥1 month

Muscle wasting: areas to examine for muscle wasting include: temples, clavicles, shoulders, interosseous muscles, scapula, trapezius, thigh and calf.

Fat loss: loss of subcutaneous fat (orbital, triceps, fat overlying the ribs)

Acute Illness or Injury Chronic Illness Social or environmental Moderate

Malnutrition Severe

Malnutrition Moderate

Malnutrition Severe


Malnutrition Severe

Malnutrition

mild moderate mild severe mild severe

Edema: generalized or localized fluid accumulation which is evident on exam

Acute Illness or Injury Chronic Illness Social or environmental

Moderate Malnutrition

Severe Malnutrition


Severe Malnutrition


Severe Malnutrition

mild Moderate to

severe mild severe mild severe

Hand grip: based on normative standards supplied by the manufacturer of the measurement device


Malnutrition Severe


Malnutrition Severe


Malnutrition Severe

Malnutrition

NA Measurable

reduced NA

Measurably reduced

NA Measurable

reduced


Malnutrition Severe


Malnutrition Severe


Malnutrition Severe

Malnutrition

mild moderate mild severe mild severe

10

3. Estimating Nutrient Requirements:

• Energy-noncritical care: According to the Academy’s EAL, the Mifflin-St. Jeor equation provided a more accurate estimation of energy needs than the Harris-Benedict equation for both obese and nonobese, noncritically ill patients. o Mifflin St. Jeor

Females: REE = 10W + 6.25H – 5A -161 Males: REE = 10W + 6.25H – 5A + 5 W=actual weight in kg; H=ht in cm; A=age in years

o Harris -Benedict Females: BEE = 655.1 + 9.6W + 1.9H – 4.7A Males: BEE = 66.5 + 13.8W + 5H – 6.8A W=weight in kg; H=ht in cm; A=age in years (EAL reports that H-B equation is more accurate when used with actual body weight)

o Kcal/kg Some dietitians prefer to use the kcal/kg method, which is quick and easy. Can be used with either actual or ideal weight, based on the dietitian’s clinical judgement.

o Normal needs 25-30 kcal/kg Mild stress 30-35 kcal/kg Moderate/severe stress 35-45 kcal/kg

o Activity and stress factors Both activity and stress factors need to be used with the Mifflin-St. Jeor and Harris-Benedict equations. A dietitian’s clinical judgement will need to be used to determine the appropriate activity and stress factors to determine total energy needs. Activity Factors Confined to bed: 1.2 Ambulatory: 1.3 Moderate activity: 1.35-1.45 Stress Factors Mild infections, minor trauma or surgery: 1.2 Moderate infections, major surgery or trauma, closed head injury: 1.4 20-40% body surface area burns: 1.8

11

• Energy-critical care: The Academy’s EAL recommends that if indirect calorimetry is not available

to estimate energy needs, then the Penn State equations are the most accurate.

o Penn State 2003b: recommended for nonobese, and obese, vent-dependent, critically ill

patients <60 years of age.

RMR = Mifflin (0.96) + VE (31) + Tmax (167) – 6,212

VE = expired minute ventilation; Tmax = maximum body temperature in previous 24

hours in degree Celsius

o Penn State 2010: recommended for obese, vent-dependent, critically ill patients >60

years of age.

RMR = Mifflin (0.71) + VE (64) + Tmax (85) – 3,085

VE = expired minute ventilation; Tmax = maximum body temperature in previous 24

hours in degree Celsius

o ASPEN/SCCM Guidelines for Obese (BMI >30), Critically Ill Patients

11-14 kcal/kg (actual body weight) or 22-25 kcal/kg (ideal body weight)

o Ireton-Jones

1925 – 10 (age) + 5W + 281(S) + 292 (T) + 851 (B)

S = Gender → male=1, female=0 T= Trauma present → yes=1, no=0

B= Burn present → yes=1, no=0

• Protein

Normal-maintenance 0.8-1.0 gm/kg

Mild stress 1.2-1.5 gm/kg

Moderate to severe stress Moderate to severe stress 1.5-2.0 gm/kg

Obese, critically ill 2.0-2.5 gm/kg IBW or 1.2 gm/kg actual weight (when using hypocaloric feedings)

Pressure injuries 1.2-1.5 (stage 1-2) 1.5-2.0 (stage 3-4)

Protein repletion 1.2-2.0

Severe trauma, burns 1.5-2.0

There are no clear and consistent guidelines for the best weight to use when calculating protein

needs (except for ASPEN guidelines specifically for obese, critically ill patients). In most cases,

actual weight is used. For non-critically ill obese patients, may want to use IBW.

Or calculate protein needs as a percentage of total calories. 15% of calories is a good guideline

for normal needs.

12

o Non-protein calorie to nitrogen ratio (NPC:N)

Another way to look at protein requirements is to calculate the non-protein calorie to

nitrogen ratio (NPC:N). For normal, stable patients, the ratio should be 150:1-200:1. That is,

150-200 calories coming from non-protein sources (fat and CH0) for every gram of nitrogen

provided. For critically ill patients, the ratio should be closer to 100:1.

Practice calculation:

Patient is receiving 1800 kcals and 70 gms protein.

The first step is to determine how many calories are coming from fat and CHO.

70 gm pro x 4 = 280 kcal. 1800 – 280 = 1,520 non-protein calories.

Next is to determine the number of grams of nitrogen.

70 gms protein/6.25 = 11.2 gm nitrogen.

Divide the non-protein calories by the grams of nitrogen: 135.7 NPC:N ratio.

If this were a stable patient with relatively normal protein needs, that would be sufficient.

If they were a critically ill patient with higher protein needs, you would need to increase the

amount of protein you were providing.

If you increased the protein to 90 gms, that would provide a ratio of 105:1. Much closer to the

goal of 100:1.

• Fluids there are several methods for estimating fluid needs o Calorie intake method: 1 ml fluid/kcal consumed

o Body weight method:

Adults 18-54 years of age 30-35 ml/kg Adults 55-65 years of age 30 ml/kg Adults >65 years of age 25 ml/kg

o Body weight method 2 (more commonly used in pediatric population) 1-10 kg 100 ml/kg 11-20 kg 1,000 ml + 50 ml/kg each kg >10 kg >20 kg 1,500 ml + 20 ml/kg each kg >20 kg

13

4. Biochemical Tests

• Hepatic Transport Protein Assessment o Albumin: normal range 3.5-5.0 g/dL

Decreased: liver disease, malabsorption syndromes, protein-losing nephropathies, ascites, burns, overhydration, inflammation Increased: dehydration

o Prealbumin: normal range 15-36 mg/dL Decreased: liver disease, burns, inflammation Increased: nephrotic syndrome, chronic kidney disease, Hodgkin lymphoma Both albumin and prealbumin are negative acute-phase proteins. This means that they will decrease during the physiologic response to stress. The liver will start making acute-phase reactant proteins instead. Because of this, albumin and prealbumin have little value in the assessment or monitoring of nutritional status in the acute care setting.

• Blood Glucose Assessment o Diagnosis: diabetes may be diagnosed using fasting plasma glucose (FPG), hemoglobin A1C, or

a 2-hour Oral glucose tolerance test (OGTT).

A1C >6.5% FPG ≥126 mg/dL OGTT ≥200 mg/dL classic symptoms of diabetes and a random plasma glucose of ≥200 mg/dL

o Monitoring: A1C is considered the main target for glycemic control. The American Diabetes Association recommends the use of the term “estimated average glucose” (eAG) in reference to A1C results.

The relationship between A1C and eAG may be calculated using the following formula: 28.7 x A1C -46.7 = eAG

Correlations between A1C levels and eAG:

A1C 6% 7% 8% 9% 10% 11% 12%

eAG 126 154 183 212 240 269 298

Perform the A1C test at least 2 times/year in those who are meeting treatment goals and who have stable glycemic control. Perform the A1C test every 3 months in those whose therapy has changed or who are not meeting glycemic goals. A1C goal in general is <7%.

Goals for glycemic control vary slightly between the American Diabetes Association and the American Association of Clinical Endocrinologists.

A1C Pre-Meal Plasma Glucose Peak post-meal plasma glucose

ADA Goals <7% 80-130 mg/dL <180 mg/dL

AACE Goals ≤6.5% 110 mg/dL 140 mg/dL

14

o Diabetic Ketoacidosis (DKA) vs Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS): both are life-threatening conditions

DKA-a state of severe metabolic decompensation with the overproduction of ketone bodies and keto acids, resulting in metabolic acidosis. Characterized by severe disturbances in CHO, protein and fat metabolism. Most often seen in those with T1DM.

HHNS-metabolic derangement most often seen in those with T2DM. Usually caused by an illness or injury that leads to severe dehydration. HHNS is similar to DKA except that insulin deficiency and development of ketones are not as prevalent.

• Electrolyte Assessment

o Sodium (Normal range is 135-145 mEq/L)

Hyponatremia is the most common electrolyte disturbance seen in clinical practice. Mild hyponatremia is generally asymptomatic. Moderate hyponatremia (serum sodium 125-129 mEq/L) may show symptoms of nausea, headache, generalized malaise and confusion. Severe hyponatremia (serum sodium (125 mEq/L) may be indicated by vomiting, agitation, abnormal/deep somnolence, psychosis, seizures, coma or death. The goal of therapy is to increase serum sodium levels to the point that the patient is no longer having symptoms. The rate of correction should not exceed 8-10 mEq/L in 24 hours or 18 mEq/L in 48 hours.

Hypernatremia is defined as a serum sodium >145 mEq/L. Occurs most commonly in critically ill patients. Mild hypernatremia is generally asymptomatic, or thirst may be present. Moderate hypernatremia (serum sodium 151-160 mEq/L) may show symptoms of excessive thirst, lack of appetite, insomnia, lethargy or muscle twitching/weakness. Severe hypernatremia (serum sodium >16) may have symptoms of weakness, altered mental state, irritability, lethargy, seizures, coma. As with hyponatremia, the goal of therapy is to correct serum sodium levels to the point at which the patient is no longer having symptoms. Cerebral edema and swelling can occur if serum sodium levels are corrected too quickly.

o Potassium (Normal range is 3.5-5 mEq/L)

Hypokalemia - risk increases with age (>65 years old), history of alcohol abuse and use of diuretics are risk factors for developing hypokalemia. Medications are the most common cause of hypokalemia. Moderate hypokalemia (serum potassium 2.5-2.9 mEq/L) may show signs of nausea/vomiting, constipation, generalized weakness and cardiac arrhythmias. Severe hypokalemia (<2.5 mEq/L) may show signs of paralysis leading to respiratory compromise, cardiac arrhythmias and death. Hypokalemia is treated by the administration of either oral of IV potassium supplements. Potassium infusions should be given at 10 mEq/hr to minimize negative effects, including thrombosis in a peripheral vein.

Hyperkalemia - the mortality of patients with hyperkalemia ranges from 14-41% in hospitalized patients. Those with underlying kidney dysfunction are at greater risk for developing hyperkalemia. AKI and CKD are the most common causes but can also be a result

15

of certain medications. Most patients are asymptomatic until serum potassium levels exceed 5.5 mEq/L. Signs and symptoms include: muscle twitching, weakness, ECG changes and arrhythmias. Hyperkalemia is treated by giving medications that promote intracellular distribution of potassium or those that enhance potassium excretion. Examples include calcium gluconate, sodium bicarb, regular insulin, 50% dextrose, Lasix or sodium polystyrene sulfonate (Kayexalate).

o Calcium (Normal range is 8.6-10.2 mg/dL or 4.4-5 mg/dL for ionized calcium levels)

Hypocalcemia-hypoalbuminemia is the most common reason for low serum calcium levels. Other reasons include renal impairment, hypoparathyroidism, pancreatitis and other electrolyte abnormalities. Symptoms of hypocalcemia depend on the degree of the deficit and how quickly the deficiency occurred. Acute is considered as ≤48 hours and chronic is >48 hours. Mild to moderate acute hypocalcemia (7.5-8.5 mg/dL) may have symptoms of muscle cramps, mental status changes and hypotension. Severe acute hypocalcemia (<7.5 mg/dL) may show symptoms of tetany, acute heart failure and arrhythmias. When the serum albumin level is <4 gm/dL, an adjusted total serum calcium calculation should be done.

The formula is: Corrected calcium = (4.0 gm/dL – measured serum albumin) x 0.8 + measured serum calcium. This formula becomes less accurate when the albumin is <2.5 g/dL.

If you are concerned about a patient’s calcium status, you may want to request an ionized calcium level be checked. This will give you a more accurate picture of the patient’s calcium status.

Oral supplementation is appropriate for those with no symptoms or mild to moderate hypocalcemia (7.5-8.5 mg/dL). Intermittent IV boluses should be considered for those with symptoms or severe hypocalcemia. Symptomatic hypocalcemia is a medical emergency and should be treated with IV calcium.

Hypercalcemia-cancer is the primary cause of hypercalcemia. Other causes include immobilization, hyperparathyroidism and medications. Mild to moderate hypercalcemia is defined as 10.3-12.9 mg/dL and severe as >13 mg/dL. Those with mild to moderate hypercalcemia often do not have any symptoms. A hypercalcemia crisis is defined as a serum calcium level >15 mg/dL. Symptoms of hypercalcemia include bradycardia, hypertension, altered mental status, acute renal injury, nausea, vomiting and constipation. Therapy options include giving IV fluids, loop diuretics, calcitonin, bisphosphonates and corticosteroids.

o Phosphorous (normal phosphorus is 2.5-4.5 mg/dL)

Hypophosphatemia-occurs most frequently in diabetic ketoacidosis, sepsis, trauma, burns, renal replacement therapy, and in the postoperative period. Mild and short-term hypophosphatemia is generally without symptoms and not related to long-term complications. Acute severe hypophosphatemia can cause widespread organ dysfunction and increased mortality rates in patients with sepsis. Common symptoms of hypophosphatemia

16

include respiratory muscle dysfunction, arrhythmias, chest pain, insulin resistance, altered mental status and coma. Phosphorus replacement may be given either orally or IV.

Hyperphosphatemia-highest risk is for those with renal impairment when the body has lost the ability to regulate phosphorus balance with renal excretion. There are 3 main causes of hyperphosphatemia: increased phosphorus load, increase in renal phosphate reabsorption or a decrease in renal excretion. Symptoms of a high phosphorus level are nonspecific. These include anorexia, nausea, vomiting, muscle weakness and tachycardia. Treatment options include giving IV fluids, use of a loop diuretic, and hemodialysis for those with impaired renal function.

o Magnesium (Normal range is 1.5-2 mEq/L or 1.8-2.4 mg/dL)

Hypomagnesemia-patients with low magnesium levels have higher mortality rates than those with normal magnesium levels. GI and renal losses of magnesium are the most common causes of hypomagnesemia. It is primarily associated with other electrolyte abnormalities, including hypokalemia and hypocalcemia. Unfortunately, serum magnesium levels are poor indications of total body stores. Symptoms of low magnesium levels include tremors, muscle weakness, depression, agitation, ventricular fibrillation or tachycardia, and confusion. IV replacement is preferred to oral therapy when there is GI intolerance and symptomatic hypomagnesemia.

Hypermagnesemia-renal injury and excessive magnesium supplementation are the most common causes of hypermagnesemia. Clinical symptoms do not usually occur until serum levels are >4 mEq/L or >4.8 mg/dL. Symptoms of hypermagnesemia include loss of deep tendon reflexes, hypotension, ECG changes, apnea, paralysis and coma. For those with symptoms of high magnesium levels, therapy options are to give calcium gluconate or chloride, hemodialysis or giving Furosemide (Lasix) via IV.

• Hydration Status

o Hypo/Hypervolemia

Hypovolemia, or volume depletion, is the result of a loss of total body sodium and water, either through renal of extrarenal losses (diarrhea, vomiting, suctioning, etc.). It is diagnosed based on signs/symptoms and correlation with lab data. Signs/symptoms include dizziness, mental status changes, reduced tears, dry mucous membranes, tachycardia (HR >100 bpm), hypotension (SBP <90 mm Hg), reduced urine output (<0.5 mL/kg/hr). Lab assessment: serum sodium normal (135-145 mEq/L), random urine sodium <15 mEq/L, BUN/Cr >20:1, increased hematocrit and albumin, urine osmolality >450 mOsm/kg

Hypervolemia is volume expansion within the Extra Cellular Fluid (ECF) compartment which results from an excess of total body sodium when sodium and water intake exceed losses. Examples of causes include CKD, glomerular disease, acute kidney injury, heart failure, cirrhosis. Signs/symptoms include hypertension, peripheral edema, ascites, pulmonary rales, weight gain, chest x-ray showing pulmonary edema or pleural effusions Lab assessment: elevate BNP, urine sodium <15 mEq/L, low hematocrit and albumin, low to normal serum sodium, BUN and urine osmolality.

17

o Electrolyte concentration and osmolality of common IV Fluids

Solution Dextrose g/L Tonicity Na Cl K Mg Ca

D5W (5% dextrose) 50 hypotonic

0.225 % NaCl (1/4 normal saline) hypotonic 38.5 38.5

0.45% NaCl (1/2 normal saline) hypotonic 77 77

0.9% NaCl (normal saline) isotonic 154 154

3% NaCl (hypertonic saline) hypertonic 513 513

Lactated Ringers isotonic 130 109 4 3

Plasmalyte isotonic 140 98 5 3

Normosal-R isotonic 140 98 5 3

Hetastarch 6% Lactate isotonic 143 124 3 0.9 5

Albumin in 0.9% NaCl isotonic 154 154

Mannitol hypertonic

All electrolytes are in mEq/L

• Nutritional Anemias

Anemias are classified by their morphology. Macrocytic anemias are larger RBC (MCV >94) and with higher mean corpuscular hemoglobin concentration (MCHC >31). Hypochromic/microcytic anemias are the opposite with small cell size (MCV < 80) and with a lower MCHC of <31. Normochromic/normocytic anemias have a MCV of 82-92 and MCHC of >30.

o Iron-deficiency anemia and Anemia of chronic disease Iron-deficiency anemia is a hypochromic/microcytic form of anemia. There are several causes of iron-deficiency anemia including inadequate dietary intake, inadequate absorption resulting from diarrhea and intestinal diseases, increased iron requirement for growth of blood volume (infancy, adolescence, pregnancy/lactation), increased excretion from heavy menstrual blood flow, hemorrhage from injury, chronic blood loss from bleeding ulcer or GI diseases.

The most sensitive indicator of iron deficiency is serum ferritin (<10 mcg/dL in females and <12 mcg/dL in males). Serum iron levels will be low (<40 mcg/dL in females and <50 mcg/dL in males).

o Anemia of chronic disease occurs from inflammation, infection, or malignancy because there is decreased RBC production, possibly as a result of disordered iron metabolism. This form of anemia is normocytic and should not be confused with iron-deficiency anemia. Iron supplements should not be given. This type of anemia is characterized by normal or increase ferritin levels, which serum iron and TIBC are low. Erythropoietin therapy usually corrects this anemia.

o Megaloblastic anemias: this type of anemia is characterized by the presence of large, immature, abnormal RBC progenitors in the bone marrow. 95% of megaloblastic anemias are folic acid or vitamin B12 deficiency.

Folate-deficiency anemia may be caused by a poor diet, inadequate absorption, inadequate utilization, increased requirements, increased excretion or destruction. It is characterized by very low serum folate levels (<3 ng/ml) and RBC folate levels of <140-160 ng/ml.

18

Vitamin B12 deficiency and pernicious anemia may be caused by the same factors are folate deficiency anemia. It is a megaloblastic, macrocytic anemia caused by a deficiency of vitamin B12, most commonly from a lack of Intrinsic Factor. Anemias can be difficult to diagnose. The following table may be helpful.

H/H MCV MCH Serum

iron Transferrin

Sat % Ferritin

Serum B12

Serum folate

Macrocytic (B12 or folate deficiency) L/L High High Low Low

Microcytic, hypochromic (iron deficiency) L/L Low Low Low <16% <30

Anemia of Chronic Disease L/L normal normal Low <16% >100

Please note that how hemoglobin/hematocrit levels may be due to blood loss and are not due to a micronutrient deficiency. Anemia of chronic disease is very common in the elderly and may be in addition to another type of micro or macrocytic anemia.

• Disease-Specific Lab Tests

o Chronic Kidney Disease BUN: 7-20 mg/dL is normal range. 60-80 mg/dL is normal range for dialysis patients. Creatinine: 0.8-1.4 mg/dL is normal range. 2-15 mg/dL is normal range for dialysis patients. Patients with muscle wasting may have lower than normal creatinine levels. Calcium-phosphorus product: <55 mg/dL Calcium: <10.2 mg/dL; 8.4-9.5 mg/dL is ideal Phosphorus: 3.5-5.5 for dialysis Glomerular Filtration Rate: 30-59 indicates a moderate decrease and early chronic renal insufficiency. 15-29 indicates a severe decrease and late stage renal insufficiency. <15 indicates renal failure and end stage kidney disease. The GFR is a calculated value based on the person’s serum creatinine level, age, gender, etc. If the person’s Creatinine level is low due to a non-kidney disease issue, the calculated GFR will be falsely elevated and may lead to misinterpretation of the person’s actual kidney function.

o Refeeding Syndrome-can occur with malnourished patients, those with extreme weight loss, or have been without nutrition for 7-10 days. Labs to monitor closely include potassium, magnesium and phosphorus. There will also be an increased need for thiamin and possible sodium retention.

o Hyperlipidemia/Cardiac Lipid profile desirable levels: LDL <100 mg/dL, total cholesterol <200 mg/dL, triglycerides <150 mg/dL, HDL >60 mg/dL The most commonly performed blood tests if a myocardial infarction is suspected are troponin, CK-MB and myoglobin.

19

o Metabolic Syndrome Requires 3 of the following criteria for a diagnosis of metabolic syndrome to be made.

Risk Factor Criteria

Abdominal Obesity Men Waist circumference >102 cm (>40 inches)

Women Waist circumference >88 cm (>35 inches)

Triglycerides ≥150 mg/dL

HDL cholesterol Men <40 mg/dL

Women <50 mg/dL

Blood Pressure ≥130/≥85 mm Hg

Fasting Glucose ≥110 mg/dL

5. Nutrition Support Enteral Nutrition

• Indications and Contraindications for Use

o Indications Individuals who have a functional GI tract but have a condition in which oral intake is impossible, inadequate or unsafe.

In a patient who is well-nourished, wait 7-9 days prior to starting enteral nutrition, unless it is clear that the patient will not be able to consume adequate po intake within that time frame (for example, severe CVA).

If the patient is malnourished, wait 5-7 days unless it is clear that the patient will not be able to consume adequate po intake within that time frame.

During adaptive phase of short bowel syndrome

In critically ill patients should receive early enteral nutrition, within 48 hours of admission, as long as the patient is hemodynamically stable.

o Contraindications Inability to gain access to GI tract

Intractable vomiting and diarrhea

Aggressive nutrition therapy not warranted (patient on hospice care, etc.)

Expected need less than 5-7 days if malnourished or less than 7-9 day if adequately nourished.

Distal high-output fistula

Severe short bowel syndrome (<100 cm remaining)

Severe malabsorption or GI bleed

Non-operative mechanical GI obstruction

If patient is hemodynamically unstable (MAP <60)

20

• Feeding Routes and Access Devices

o Short term feedings (<30 days) Nasogastric Nasoduodenal Nasojejunal

o Long-term feedings (>30 days) Gastrostomy: percutaneous endoscopic gastrostomy (PEG) or surgical G-tube Jejunostomy: percutaneous endoscopic jejunostomy (PEJ) or surgical J-tube

• Delivery Methods

o Continuous: generally administered by using a feeding pump and given 24 hours a day. Can feed continuously via gravity drip, but the rate is much harder to control. Might see in home use, but not in the hospital.

o Intermittent: may be fed via a pump or gravity drip. Nocturnal feedings are an example of intermittent feedings.

o Bolus: usually given via a syringe. Would typically be for a long-term feeding patient with a g-tube. You can’t bolus feed into the duodenum or jejunum.

• Formula Selection: Types

o Polymeric: standard formulas containing intact nutrients. Casein or soy isolate as major protein source. Many contain fiber, either soluble, insoluble or a combination of both. Standard formulas contain 1.0-1.2 kcal/ml and 30-40 gm protein/L. High calorie formulas contain 1.5-2.0 kcal/ml. High protein formulas contain 48-65 gm protein/L.

o Monomeric or hydrolyzed: semi-elemental or elemental formulas for those with malabsorption issues. Semi-elemental formulas contain partially hydrolyzed caseinates, maltodextrins and a combination of oils including some MCT oil. Elemental formulas are completely broken down and contain free amino acids. Usually 1 kcal/ml, 20-30 gm protein/L and 3-10% of kcal from fat.

o Blenderized: mixture of blenderized food sources. Commercial products available or may be made at home by blending foods into a liquid thin enough to be administered via a feeding tube.

o Disease specific:

Critical Care: immune-enhancing. Contain glutamine, nucleotides and omega-3 fatty acids.

Diabetes/glucose intolerance: provide more kcals as fat (40-49%) and less CHO (34-40%) of kcals, with 10-15 gm/L of fiber.

Pulmonary: these formulas provide a higher amount of fat and lower amounts of CHO. Research has not proven effectiveness of these formulas.

Renal insufficiency/failure: calorically dense (1.8-2.0 kcal/ml) and lower in sodium, potassium and magnesium. Protein content will vary depending on stage of kidney failure. Stage 3 or 4 CKD-products contain 45 gm protein/L. Products for those being dialyzed contain 81 gm protein/L.

21

o Modular products: made of a single nutrient

Protein- powder or liquid forms. A way to increase the amount of protein the enteral formula provides without providing a lot of extra calories or volume.

Fat-MCT oil may be added to the enteral formula for those with malabsorption issues.

CHO- when more calories are needed, but not protein. Mainly used in pediatrics.

• Initiation and Progression

o Initiation: generally recommended to start at 20-50 mL/hr and increase by 10-25 mL/hr every 4-24 hours until goal rate is reached. In relatively stable patients, you will likely be able to start at a higher rate and progress more quickly. Stable patients usually tolerate a fairly rapid progression and often reach their goal rate within 24-48 hours.

If you are concerned about the patient’s ability to tolerate the feeding, or for those at risk of refeeding syndrome, you may want to start at a lower rate and progress more slowly.

• Medication administration via feeding tube

o do not add medications directly to the enteral formula. o each medication should be administered separately. o liquid medications should be used when available and if appropriate. o recommended procedure: stop enteral feeding and flush tube with 15 mL of water.

Administer medication and then flush with another 15 mL of water. Follow the same procedure for all remaining medications. Restart enteral feeding.

o immediate release oral tablets, gelatin capsules and liquid medications may be administered via the feeding tube.

o enteric coated, sublingual, buccal and sustained release medications should not be administered via the feeding tube.

• Drug-nutrient interactions with enteral formulas

o Proton pump inhibitors (PPI): these medications are destroyed by the acid in the stomach. One method to prevent this from happening is to mix the capsule contents with apple or orange juice. However, if using a small-bore feeding tube, this method can’t be used as the feeding tube would clog. If that is the case, other forms of the medication should be used.

o Phenytoin (Dilantin): commonly used anti-seizure medication. While the reasons are completely understood, there is a reaction between the enteral formulas and the medication which decreases its’ bioavailability. The absorption of the drug may decrease up to 70%, which prevents it from reaching therapeutic levels in the blood. To prevent this from happening, it is recommended to hold the enteral feedings 1-2 hours before and 1-2 hours after each dose of the medication. This only needs to be done if the patient is receiving the medication through the feeding tube, not if the medication is given IV.

o Warfarin (Coumadin): Giving Warfarin with the enteral feeding has been shown to decrease the anticoagulation effects of the medication. Options are to hold the enteral feeding before and after each Warfarin dose, increase the medication dosage, or change to another type of anticoagulation therapy.

22

o Quinolones (Ciprofloxacin, Levofloxacin): There is decreased bioavailability of these antibiotics when given with products containing calcium, magnesium, aluminum and iron, which of course enteral feedings do. It is recommended to hold feedings 1 hour before and 2 hours after each dose of these medication.

• Monitoring and Complications

Monitoring

o gastric residual volume: current guidelines (ASPEN) suggest not routinely checking GRVs. If GRV is monitored, ASPEN recommends not holding feedings if the GRV is <500ml and no other symptoms of intolerance are present. Research has shown that raising the GRV cutoff does not increase the incidence of aspiration or pneumonia.

o gastroparesis-when the stomach empties more slowly than usual. Consider giving the patient a promotility agent (Reglan).

o bowel sounds-do not need to be present in order to start enteral feeding. Check to see if patient’s abdomen is soft and nontender, and if they are passing gas.

Complications

o Mechanical: these are tube related complications such as clogging or having the tube migrate to another part of the body or GI tract.

o Aspiration: important to keep the head of bed elevated to at least 30 degrees. Consider feeding into the small bowel for patients at high risk of aspiration.

o Dehydration/Tube Feeding Syndrome: if the patient is not receiving enough free water, they could become dehydrated, or develop what is referred to as Tube Feeding Syndrome. This is having an elevated sodium, BUN, or BUN/Cr ratio.

o Biochemical: blood sugars and electrolytes should be closely monitored for changes.

o Diarrhea: there are many potential causes for diarrhea in enterally fed patients. First, determine if the patient actually has diarrhea. While there is not commonly accepted definition of diarrhea, many people consider 3+ liquid stools each day as diarrhea.

It is possible that the feeding rate is too high, so you can try decreasing the rate a bit.

A Clostridium Difficile (C Diff) infection is another fairly common cause. A patient should be tested for this and started on antibiotics if positive.

Antibiotics are a common cause as they kill off the good bacteria in the gut.

The most common cause of diarrhea are sorbitol-containing medications. Many of the liquid forms of medications contain high amounts of sorbitol, which has a direct laxative effect. You could speak to the pharmacist to see if those medications could be given in another form.

23

6. Nutrition Support Parenteral Nutrition

• Overview: Parenteral Nutrition is the hypertonic IV administration of nutrition for patients who are unable to meet needs via oral intake or enteral nutrition. The main components include dextrose, amino acids, lipids, electrolytes, vitamins, minerals, trace elements. There are two primary methods of Infusion: “3-in-1” solutions provide amino acids, dextrose, lipids and all other additives in one solution (infused up to 24 hours) and “2-in-1” solutions provide amino acids, dextrose and all other additives in a single bag (infused up to 24 hours). Lipids are administered separately (must be infused in ≤ 12 hours secondary to the risk of microbial growth).

• Indications and Contraindications for PN

o Indications

Ischemic bowel Paralytic ileus Short bowel syndrome with malabsorption Bowel Obstruction High output enterocutaneous fistula with the inability to place EN tube distal of the fistula Intractable vomiting and diarrhea Chylous effusion in which very low-fat diet/ EN not feasible or has failed Persistent EN intolerance or inability to gain EN access

o Contraindications

Functioning GI tract

Catabolic patients expected to have usable GI tract within 5 days

Well-nourished patients expected to resume EN/oral diet within 7 to 10 days

Duration of therapy expected <5 to 7 days

Aggressive nutrition support not desired by the patient

Patient’s prognosis does not warrant aggressive nutrition

• Delivery Methods

o Central Parenteral Nutrition (CPN), also referred to as Total Parenteral Nutrition (TPN)

Delivered via a central vein: superior vena cava, cephalic, femoral, jugular, basilic

Possible lines: PICC, Implanted Port, tunneled catheter (Hickman), Subclavian Vein Catheter (SVC)

Goal nutrients are able to be delivered with hypertonic and hyperosmolar solution (~1300 to 1800 mOsm/L)

Indicated when the expected length of use is > 7 to 14 days

o Peripheral Parenteral Nutrition (PPN)

Delivered via a peripheral vein

IV access needed and must be changed every 3-4 days to prevent phlebitis

Often low in nutrients and high in volume given lower osmolarity requirements (should not exceed 900 mOsm/L)

24

Indicated for short term use (usually <7 to 14 days)

Contraindicated if a patient cannot tolerate a high volume, requires high energy/electrolyte needs, poor peripheral access, significant malnutrition, severe metabolic stress, liver or renal dysfunction

• Components in PN

o Dextrose

Main carbohydrate source

Caloric contribution is 3.4 kcal/gram

Available in solutions ranging from 2.5% to 70%

Usually provide a minimum requirement of 100-150 g/day

Maximum dextrose infusion rate (GIR): 4 mg/kg/min for metabolically stressed patients; 5 mg/kg/min for non-stressed patients

o Protein

Amino acid solutions are the main protein source, contains a mix of essential and nonessential amino acids

Caloric contribution is 4 kcal/gram with nitrogen content 1 gm per 6.25-gram amino acid Available in concentrations ranging from 3% to 20%

Protein requirements of acutely ill patients can range from 1 to 2+ g protein/kg; adjust based on wounds, GI losses, obesity

o Lipid

Administered as an injectable lipid emulsion utilizing egg yolk and phospholipid and glycerol

Main oil source: soybean (primary) and safflower oil, provides a source of essential fatty acid (linoleic and linolenic acid)

Available IVFE concentrations: 10% (1.1 kcal/g) , 20% (2 kcal/ml) , 30% (3 kcal/ml) ; Note: 30% is only used to compound 3-in-1 solutions. Cannot be used with 2-in-1 solutions.

Fat emulsion in the ICU:

Lipid emulsions are omega-6 fatty acids → the standard soy oil-based lipid emulsions are proinflammatory. Be cautious when using in patients with sepsis. Although there are limitations to using these types of IV lipids, they are still commonly used in the hospital.

Septic/critically ill patients: suggest withholding soybean IVFE and/or limiting IVFE to <1 g fat/kg/day

Alternative lipid solutions available for adults

Mixed oil based (SMOFlipid): mixture of soy, MCT, olive, fish oil

May also benefit patients with PN associated liver disease while on soybean oil-based IVFE, long term PN, direct hyperbilirubinemia, short bowel syndrome

No IV fat emulsion or adjust fat requirements if patient on Propofol. Propofol is a lipid-based sedative that is commonly used in critically ill patients. Propofol contains 1.1 kcal/mL. The number of calories provided by Propofol will need to be taken into consideration when calculating a patient’s enteral or parenteral nutrition prescription.

25

o Electrolytes Electrolytes in PN are adjusted daily based on the patient’s labs If a patient is at risk of refeeding syndrome, PN should not be initiated until levels are WNL PN should be used for baseline electrolyte needs and low levels should be routinely repleted with IV repletion upon obtaining low lab value.

o Vitamins Provided as a package and not commonly individually dosed MVI-13 (10 ml) is the standard for adults. Includes Vitamin A, D, E, K, ascorbic acid, folic acid, niacin, riboflavin, thiamine, pyridoxine, cyanocobalamin, pantothenic acid and biotin.

o Trace Elements Provided as a package MTE-5 (5 ml) is the standard and includes copper, manganese, chromium, zinc, selenium. Iron is not a component of trace element formulation used in PN.

• Calculations

o Goal Parenteral Nutrition Prescription

Steps Directions Sample Calculation

1

Determine Estimated Energy Needs Kcal: 25-35 kcal/kg Protein: 1.2 to 2.0 g/kg Fluid 30-40 ml/kg Fluid needs should be discussed with MD prior to starting CPN and/or refer to the patient’s current IV fluids

60 kg patient: 30 kcal/kg/day x 60 kg = 1800 kcal/day 60 kg x 1.5 g/kg = 90 g/day 60 kg x 30 ml/kg = 1800 ml/day

2

Determine the volume of amino acid solution needed to meet protein needs AA solutions available: 8.5%, 10%, 15% or 20%

Using a 10% AA solution: 10g protein per 100 ml 90𝑔 𝑃𝑟𝑜

𝑋 =

10𝑔 𝑃𝑟𝑜

100𝑚𝑙

Solve for X to get X = 900ml of 10% AA solution

3 Determine kcal from protein Protein provides 4 kcal/g

90 g x 4 kcal/g = 360 kcal

4 Determine nonprotein calories (NPC) NPC = Total calories - protein calories

1800 kcal -360 kcal (protein) = 1440 kcal

5 Determine CHO calories Usually 65-70% of NPC

1440 kcal x 0.65 = 936 kcal

26

6 Determine grams of CHO Dextrose provides 3.4 kcal/g

936 kcal / 3.4kcal/g = 275 g dextrose

7

Determine the volume of dextrose solution needed to meet CHO needs Solutions available in 2.5% 5%, 10%, 20%, 50%, 70%

Using 70% dextrose, 275𝑔

𝑋=

70𝑔

100𝑚𝑙

Solve for X to get X = 393ml of D70

8 Determine kcal from lipid Goal kcal range 20-30% of total kcal

1800 kcal - 360 kcal (protein) - 936 kcal (CHO) = 504 kcal

9 Determine grams of lipids Lipids provide 10 kcal/g

504 kcal/ (10 kcal/g) = 50.4 gm

10

Determine the volume of IVFE solution needed to meet lipid needs Available in 10%, 20%, 30%

Using 20% IVFE 54𝑔

𝑋=

20𝑔

100𝑚𝑙

Solve for X to get X = 252 ml of 20% IVFE

For calculation of 3-in-1 solution, proceed: (for 2 in 1 solution skip steps 11-12 and proceed to 13-15)

11 Calculate rate of TPN administration Fluid is determined by total goal fluid volume/day

Infused over 24 hours 1800 ml/ 24 hrs = 75 ml/hr rate of PN

12 Write your final PN order Order using per gram basis per ASPEN

PN Goal: 90 g Amino Acids, 275g Dextrose, 54 g Lipids, total provides 1805 kcal, total fluids 1800 ml

For calculation of 2-in-1 solution, proceed:

13 Calculate rate of dextrose and amino acids Infuse amino acids and dextrose over 24 hours

900 ml (AA) + 393 ml (dextrose) = 1293 ml

1293 ml/ 24 hours = 54 ml/hr

14 Calculate rate of lipid infusion Lipids have a hang time of 12 hours

252 ml/12 hour = 21 ml/hr

15 Write your final PN order Order using per gram basis per ASPEN

54 ml/hr from 900 ml 10% AA and 393 ml of D70. Piggyback 252 ml of 20% IVFE at 21 ml/hr. Providing 1800 kcal, 90 g AA, 275 g dextrose, 50 g lipid and total fluids 1800ml.

27

o Continuous vs Cyclic Infusion

Continuous Feeding

Infused over 24 hours

Preferred method of infusion, especially for critically ill patients

Minimizes glucose, fluid and electrolyte abnormalities

Cyclic Feeding

Infused over 8 to 22 hours

Decrease infusion time gradually from continuous to cyclic feeding over several days;

Requires higher infusion rate; not all patients can tolerate it

Also requires tapering PN infusion rate up and down over 1-2 hours

Helps prevent hyper and hypoglycemia

May be used to treat or reduce the risk of hepatobiliary disorders associated with PN (steatosis, cholestasis, cholelithiasis)

Can also be considered for patients who are transitioning from hospital to home PN regimen

For calculation of cyclic infusion using 3-in-1 solution (Follow steps 1-10 on goal PN solution), then proceed to steps below:

11 Determine Infusion time and taper time Infusion time: 10 hours

1 hour to taper up and down

12 Calculate goal rate of TPN administration

Total PN volume/ Infusion time – taper time

=1800 ml / (10 hrs – 1 hr) = 200 ml/hr (Goal rate)

13 Calculate rate to taper up and down 200 ml/hr / 2 = 100 ml/hr

14 Writing Instructions Begin PN at 100 ml/hr x 1 hr, increase to goal rate of 200ml/hr x 8 hrs, and taper down to 100 ml/hr

o Formulation Considerations

Glucose Infusion Rate (GIR)

Also known as carbohydrate load

Maximum recommended dose for an adult: 5 mg/kg/min

Calculation CHO Load = total CHO in g x 1000 mg / wt [kg] / 1440 [min/day] Example: 275 g x 1000 mg / 60 kg / 1440 min = 3.18 mg/kg/min

28

Fat Load

Optimal dosing: 1 g/kg/day

Calculation Fat Load = grams of lipids / wt [kg] Example: 50 g lipids / 60 kg = 0.83 g/kg/day

Osmolarity

Definition: concentration of osmotically active particles in solution as expressed by osmoles of solute per liter of solution; mOsm/L

Common Osmolarity TPN: ~1500-2800 mOsm/L PPN: <600-900 mOsm/L Restrict final PN concentrations to 5-10% dextrose and 2.5 to 5% amino acid

Contributes to osmolarity:

Dextrose ~5 mOsm/g

Amino acids ~10 mOsm/g

Electrolytes (Ca, Mg, K, Na, Cl, acetate) ~1 mOsm/mEq

To calculate osmolarity:

Multiply grams of dextrose per liter by 5

Multiple grams of protein per liter by 10

Multiply mEq of total electrolytes per liter by 1

Add to obtain total osmolarity

• Compoundability A certain amount of fluid or volume is required to make the parenteral nutrition solution. If you are limiting the volume in a PN solution (<1ml/kcal is a good guideline), then you may want to do this calculation to make sure it’s physically possible for your PN solution to be made.

For every 10 gms of amino acids in your PN solution, it takes 100mL of fluid. So, if you are ordering 120 gm of amino acids, it would require 1,200mL of fluids.

For every 70 gms of dextrose in your PN solution, it takes 100mL. For example, 350 gms of dextrose would require 500mL of fluids

Lipids are the volume you are requesting. So, if you want 250mL of 20% lipids, that would be 250mL of fluids.

You need to allow a minimum of another 100mL for the electrolytes, vitamins, minerals, etc. So, using the examples above, you would need a minimum of 1,900mL to make this PN solution. If the patient was on a fluid restriction of <1,900mL, you wouldn’t be able to make this solution. As you can see, it is the amino acids that contribute the most fluids. If the PN solution you have calculated isn’t able to be compounded, you may need to decrease the amount of amino acids you are providing.

29

• Initiation (at about 50% of total calorie needs)

o Dextrose: Start with 150-200 g/day or 100-150 g/day for critically ill/DM/hyperglycemia o Amino acids: Start near or at goal o IVFE: Start near or at goal o Caution with TG >400 mg/dlL, or in critically ill- hold soybean oil based IVFE within the first

week of PN initiation (if concern for EFAD, provide 100g/wk, divided into 2 doses)

• Monitoring (necessary for the advancement and achievement of calorie and protein goals without metabolic complications)

o Labs Electrolytes: Na, K, Cl, CO2, BUN, Cr, Ca, Mg, Phos Serum triglycerides Serum glucose Intake and Output ALT, AST, ALP, total bilirubin

• Discontinuation o Can be considered when patient is able to tolerate an oral diet or EN support

For well-nourished individuals, PN can be stopped as soon as diet tolerance is established For patients who are at high risk of oral or EN intolerance or suboptimal intake transition weaning of PN .

o PN to oral: PN can begin to be decreased in comparable amounts as soon as patient is eating 500 kcal/day with discontinue of PN when oral or EN provide >60% of nutrition requirements.

o PN to EN: performed gradually and when EN provides >75% of nutrition requirements, PN can be discontinued.

• Common PN-Associated Complications

o Hyperglycemia

Most common complication of PN, carbohydrate associated

Control with insulin therapy, IV or subcutaneous

Initiate at 150 to 200 g within the first 24 hours or at 100 g if patient is hyperglycemic

Monitor dextrose infusion rate (< should not exceed a rate of 4 to 5 mg/kg/min)

o Hypoglycemia

Can occur from excessive insulin administration and rebound hyperglycemia (abrupt stopping of PN infusion)

o Essential fatty acid deficiency

Occurs when lipid emulsions in PN are held for greater 1 to 3 weeks

Minimally provide 100 g lipid/week

Hypertriglyceridemia

Can occur with rapid infusion rate or poor glycemic control

30

o Hypertriglyceridemia

Monitor triglyceride levels prior to initiating IVFE, with acceptable levels <400mg/dL

If TG >400 mg/dL, reduce infusion rate, limit IVFE administration, or temporary withhold

o Refeeding Syndrome

Defined as the metabolic and physiological shift in fluid and electrolytes [phosphorus, magnesium, and potassium] after introduction of nutrition in malnourished patients.

Risk factors include severely malnourished patients, severe weight loss, chronic alcoholism

Be conservative with carbohydrate administration and advance when electrolytes are within acceptable limits

Thiamine supplementation (50-100 mg/d) should be provided to patients at risk for thiamine deficiency or refeeding syndrome

o PN Associated liver disease

Consider cholestasis, cholelithiasis and hepatic steatosis if patient is on PN for > 2 weeks

Indicators: elevation in aspartate aminotransferase (AST), alanine aminotransferase (ALT) alkaline phosphatase (ALP), total bilirubin (> 2 mg/dL)

Intervention: Decrease lipids (<1 g/kg/day), cyclic infusion (10-16 hours/day), avoid overfeeding

o Azotemia

May occur with excessive protein administration

Risk factors include patients with hepatic or renal disease

7. International Dysphagia Diet Standardization Initiative (IDDSI)

New international standardized terminology and definitions to describe texture modified food and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and all cultures. Levels 0-4 for liquids and levels 3-7 for foods.

• Liquids

Level 0: Thin; flows like water

Level 1: Slightly thick; thicker than water, requires a little more effort to drink than thin

Level 2: Mildly thick; flows off a spoon, mild effort is required to drink through a straw

Level 3: Moderately thick; can be eaten with a spoon or drunk from a cup, no chewing required, moderate effort required to drink through a straw

Level 4: Extremely thick; Usually eaten with a spoon (a fork is possible), cannot be drunk from a cup because it does not flow easily, cannot be sucked through a straw, does not require chewing, can be piped, layered or molded because it retains its shape

31

• Foods

Level 3: Liquidized; same as level 3 of liquids

Level 4: Pureed; same as level 4 of liquids

Level 5: Minced and moist; can be eaten with fork or spoon, soft and moist with no separate thin liquid, small lumps that are easy to squash with tongue, minimal chewing required, no biting required

Level 6: Soft and bite-sized; can be eaten with fork or spoon, can be mashed with pressure from fork or spoon, chewing is required, no biting required

Level 7: easy to chew; normal everyday foods of soft/tender texture, requires the ability to bite, chew and orally process soft/tender foods

8. Pressure Injuries (previously referred to as pressure ulcers) Definition: localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful.

• Stage 1: non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

• Stage 2: partial-thickness skin loss with exposed dermis The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose and deeper tissues are not visible.

• Stage 3: full-thickness skin loss Full thickness loss of skin in which adipose tissue is visible and granulation tissue is often present. Slough and/or eschar may be visible. The depth of the tissue damage varies by location on the body. Undermining and tunneling may occur. Muscle, tendon, cartilage and/or bone are not exposed. If slough or eschar obscure the extent of tissue loss, this would be an unstageable pressure injury.

• Stage 4: full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, cartilage or bone in the ulcer. Undermining and/or tunneling often occur. Depth will vary by location on the body.

• Unstageable Pressure Injury: obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed.

32

• Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.

• Additional definitions:

o Medical device related pressure injury-result from the use of devices designed and applied for diagnostic and therapeutic purposes. The injury should be staged using the staging system.

o Mucosal membrane pressure injury-found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these ulcers can’t be staged.

o Slough: symptom of a necrotic wound. Tissue is characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance.

o Eschar: presents as dry, thick, leathery tissue that is often tan, brown or black.

May be softer or firmer than the tissue around it.

o General nutrition therapy recommendations:

30-35 kcal/kg, increasing up to 35-40 kcal/kg for patients who are underweight or losing weight.

1.5-2.0 gm protein/kg

If vitamin/mineral deficiencies are confirmed or suspected, provide a multivitamin/mineral supplement that contains the DRI for micronutrients needed for wound healing.

The routine use of zinc supplementation in the absence of confirmed or suspected deficiency is not recommended.

Copyright © 2020 by Sodexo, Inc. All rights reserved by Sodexo. No part of the contents of this assignment may be reproduced, adapted, translated or

transmitted in any form or by any means without the express written permission of Sodexo.

sodexo dietetic internship clinical resource guide

Documents