Day 3.1: Enteral and Parenteral Nutrition Dr. Clark

When to initiate enteral nutrition?

Previously healthy patients: 7 days Severely malnourished/critically ill: 24-48 hours

Holliday-Segar Method

Used to calculate water baseline requirements: First 10kg of body weight = 100mL/kg Second 10kg of body weight= 50mL/kg Remaining kg = 20mL/kg

What are common trace elements added to Parenteral Nutrition?

Zinc Copper Chromium Manganese Selenium

Parenteral administration requires:

1) IV tubing 2) Infusion pump 3) In-line filters

Parenteral bag labeling should include:

1) Dosing weight 2) Route of administration 3) Ingredients listed in amounts/day 4) Electrolytes listed as salt form 5) Overfill volume 6) Infusion duration and rates 7) Spot for administration date/time and beyond use date

Lipid Emulsion Medications

Propofol = 1.1kcal/mL Clevidipine = 2 kcal/mL

Enteral access devices: Short-term

Up to 4 weeks Nasogastric (NG); nose to stomach Nasojejunal (NJ); nose to jejunum Nasoduodenal (ND); nose to duodenum Orogastric (OG); mouth to stomach Orojejunal (OJ); mouth to jejunum Oroduodenal (OD); mouth to duodenum

What is the average adult fluid requirements?

30-40mL/kg/day Based on body weight and age: 18-55: 35ml x body weight (kg) 56-75: 30mL x body weight (kg) > 75: 25mL x body weight (kg)

3 in 1 vs 2 in 1 Parenteral Nutrition bag

3:1- Total nutrient admixture (TNA) 1) Dextrose 2) Amino Acids 3) Lipids Advantages: less time for nurse to administer, less manipulation and contamination, less equipment needed Disadvantages: shorter stability, higher potential for bacterial growth 2:1 1) Dextrose 2) Amino acids

Administration methods

1) Continuous- delivered continuously over 24 hours via a pump (Most common) 2) Bolus- Delivered over 5-10 mins via a syringe four to six times per day 3) Intermittent- same as bolus, but administered for a longer period of time (20-60 mins for patients intolerant to bolus) 4) Cyclic- similar to continuous feeding, but <24 hours 5) Trophic- very small volume of enteral nutrition delivered (<25% of caloric requirements). Keeps GI tract stimulated.

Maintenance of feeding tubes

1) Maintain proper oral hygiene 2) Skin care around tube site 3) Zinc-based ointments and semi-permeable dressings around site

Enteral access devices: Long-term

> 4 weeks Percutaneous endoscopic gastrostomy (PEG) Percutaneous endoscopic jejunostomy (PEJ) Percutaneous endoscopic gastrojejunostomy (PEG-J)

Parenteral nutrition components

Macronutrients -Protein: provides 4 kcal/g; essential and non-essential amino acids -Carbohydrates: provides 3.4 kcal/g (hydrated form) Infusion rate should not exceed: 7mg/kg/min for stable patients 4mg/kg/min for critically ill patients -Lipids- Intravenous fat emulsion that provides essential fatty acids Electrolytes (amount added is patient specific) Micronutrients -Vitamins -Minerals -Trace elements Other (certain medications like insulin, famotidine)

Refeeding syndrome

Re-initiation of nutrition in malnourished patients Treatment: 1) Identify patients at risk 2) Replete electrolytes/minerals prior to initiation 3) Start calories low and increase slowly (multivitamin, thiamine, folate, and trace element supplementation) 4) Monitor vitals and electrolytes closely

How much energy does IVE add

-10% IVFEs provides 11 kcal/g and 1.1 kcal/mL -20% IVFEs provides 10 kcal/g and 2 kcal/mL -30% IVFEs provides 10 kcal/g and 3 kcal/mL

Calculating enteral regimen

1) Calculate patient's daily caloric requirement (kcal/day) 2) Determine how many mL/day of EN formula required (kcal/day) / (kcal/mL) 3) Determine rate of administration (mL/day) / length of administration 4) Determine the patient's fluid requirement (mL/day) 5) Determine the formula's water contribution (mL/day) Volume of EN formula to be administered (mL/day) * % of water in formula 6) Determine the total volume of additional free water (mL/day) needed Fluid requirement - volume of water

Enteral formulas

1) Carbohydrates: 4 kcal/g 2) Fat: 9 kcal/g 3) Protein: 4 kcal/g

Medications that interact with enteral nutrition

Enteral nutrition should be stopped while any medication is administered because they can interact; -Phenytoin -Warfarin -Tetracyclines -Fluoroquinolone

Lipid solubility

Creaming- Accumulation of triglycerides at the top Aggregation- Clumps of triglycerides in the emulsion Coalescence- Small particles of triglycerides that fuse to larger particles Cracking- Separation of oil and water components

Calculating glucose infusion rate (mg/kg/min)

Glucose infusion rate = (dextrose in g/kg/day) x (1000mg/1g) / ((24 hr/ day) x (60 min/ 1hr))

Parenteral Nutrition

Nutrients delivered intravenously. Used for patients without functioning or accessible GI tract. Indicated: -Contraindicated with enteral nutrition -Failed trial of enteral nutrition -Patients who are NPO for > 5-7 days -Severe acute pancreatitis

Enteral nutrition

Nutrients provided directly to gastrointestinal tract via tube or mouth Indications: Patients that cannot meet adequate caloric needs due to; neoplastic disease (cancer), GI disease (fistulas), neurologic impairment, hypermetabolic state (severe burns), anorexia, HIV C/I: Bowel obstruction, intractable vomiting/diarrhea... *Patient must have functioning GI tract* Benefits: Reduced risk of infection, more physiologic than parenteral (fewer metabolic complications, increased bile flow decreasing cholestasis and gallstones), lower cost

Peripheral parenteral nutrition (PPN) vs Central parenteral nutrition (CPN)

Peripheral parenteral nutrition (PPN) -Max osmolarity <= 900 mOsm/L or else could blow a vessel -Short term use (<=10-14 days) -Lower risk of infection Central parenteral nutrition (CPN) -Not as limited by osmolarity because larger vessel size -Preferred for patient requiring parenteral nutrition that is longer than 7-14 days. -Higher risk of infection

PICC line

Peripherally Inserted Central Catheter (PICC)

Enteral device can be placed in?

Stomach or bowel (patients that can't tolerate gastric feeding)