Adult Enteral and Parenteral Nutrition Handbook

Department of Nutrition Services

Adult Enteral and Parenteral Nutrition Handbook, 5th Ed. Department of Nutrition Services University of Virginia Health System Charlottesville, Virginia Contributors: Ana Abad-Jorge, MS, RD, CNSD Le Banh, MS, RD, CNSD Cathleen Cumming, MS, RD, CNSD Chitra Dadlani, RD Pallavi Dharamsi, RD Stacey Evans, RD Lynda Fanning, MPH, RD Theresa Fessler, MS, RD, CNSC Tamara Karosanidze, MS, RD, CNSC Joseph Krenitsky, MS, RD Stacey McCray, RD Carol Parrish, RD, MS Kelly ODonnell, MS, RD, CNSC Wendy Phillips, MS, RD, CNSD Kate Robertson, RD, CNSD Sherrie Walker, RD, CNSD Kate Willcutts, MS, RD, CNSC Andrea Yoder, RD, CNSD This handbook is intended to serve as a reference or guide in the area of enteral and parenteral nutrition support for clinical dietitians, medical staff, nursing staff, dietetic interns, medical students and nursing students. Copyright 1998 University of Virginia Health System Revised 2001, 2006, 2008, 2010; 2011

ADULT NUTRITION SUPPORT HANDBOOK TABLE OF CONTENTS

ADULT NUTRITION SERVICES AT THE UVA HEALTH SCIENCES CENTER.1

Inpatient clinical nutrition services Nutrition support teams

SECTION 1. NUTRITIONAL ASSESSMENT OF ADULT PATIENTS

Introduction. .2 I Anthropometrics

Estimating ideal or desirable weight for height Height/Weight.2 Weight..2

Adjusted body weight ..3 Body mass index (BMI) (Quetlet index)....3 Weight adjustment for amputation and ascites....4

II Clinical information...4 Physical signs of nutritional deficiency (table)....5

III Nutritional intake history.6 IV Biochemical data

Factors associated with nutritional status (table)...7 Refeeding syndrome.....8-9

Subjective global assessment of nutritional status..10 V Adult nutrition requirements...11

Calorie requirements for hospitalized patients (table).11 Metabolic cart

Respiratory quotient (table).12 Protein requirements (table)...12

Energy and protein requirements for burn patients.13 Fluid requirements (tables)......13 REFERENCES.....14-15

SECTION 2. ENTERAL NUTRITION ...16 Indications for initiation of enteral tube feedings (table)..16 Enteral formula selection guidelines (table)..17 Supplemental food and drinks.17 Increasing formula protein and fiber...17

Hospital protocol for tube feeding administration.18 To order enteral nutrition..18 Enteral nutrition delivery: Routes of administration (table).19 Indications for continuous vs. intermittent vs. nocturnal feedings (table)..20

Tube feeding progression.........20 Potential complications of tube feedings..21-24 Monitoring of enteral nutrition support: Preventing complications ....25 General guidelines for administering medications with

Enteral feedings.26 REFERENCES...26

SECTION 3. ADULT PARENTERAL NUTRITION.27 Peripheral parenteral nutrition.27 Central parenteral nutrition...28

Clinical indications for parenteral nutrition.....29 Contraindications for parenteral nutrition...29 Components of parenteral nutrition .. 30

Macronutrients...30 Carbohydrate..30 Protein..30 Fat.....31 Micronutrients....32 American Medical Association and FDA recommendations for parenteral vitamin intake (table)...33 American Medical Association recommendations for parenteral trace elements intake (table)..34

Electrolytes....34 Daily electrolyte recommendations (table).....35

Additives....35 Parenteral nutrition schedules.35 Standard parenteral nutrition orders at UVA (table) ...36 Parenteral nutrition calculations..36

Complications associated with parenteral nutrition.37

Gastrointestinal complications associated with parenteral nutrition (table) ....38 REFERENCES...39

APPENDIX.....40 Selected lab values at UVA....41-45 Adult multivitamin supplements available at UVA....46 Adult vitamin supplements available at UVA....47 Adult mineral supplements available at UVA..48-49 Nutrient conversion information...50 Electrolyte/pH content of selected body fluids......51 Content of commonly used IV fluids...51 Recipe for normal saline...52 Pancreatic enzyme replacement.....52 Common conversions (dextrose, kjoules)..52 Normal lengths of bowel...53

ADULT NUTRITION SERVICES AT UVA HEALTH SYSTEM (UVA-HS) DEPARTMENT OF NUTRITION SERVICES Inpatient Clinical Nutrition Services: The clinical dietitians provide the following at the University of Virginia (UVA) Medical Center:

Assess nutritional status.

Develop and implement a nutrition care plan tailored to the individual patients needs.

Follow-up with revision of care plan as needed to improve nutritional status, as well as nutrition counseling as needed.

Each patient unit has designated dietitians who can be contacted via EPIC, the Simon Paging

System, or by calling the Nutrition Services Office at 4-2286. The clinical dietitians are available weekdays between 8:00 a.m. - 5:00 p.m. On weekends, a clinical dietitian is on site on Saturdays for oral diet/education issues and a nutrition support dietitian is on site on Sundays. Nutrition Support Teams: Medicine/Surgery: There are two nutrition support teams for adult patients at UVA HS.

1. Medicine Nutrition Support (NST-M): NST-M is a multidisciplinary consult team under the direction of the Division of Gastroenterology and Hepatology. The team may be consulted for adult patients on any Medicine service requiring enteral or parenteral nutrition support or patients with complex GI disorders affecting nutritional intake. The team can be contacted by paging PIC # 4264 and/or entering an order via EPIC.

2. Surgery Nutrition Support (NST-S): NST-S is also a multidisciplinary consult

team that is available for consultation on the nutritional management of adult patients on any surgery service requiring enteral or parenteral support. The team can be contacted by paging PIC # 4253 and/or by entering an order via EPIC.

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Section 1. NUTRITIONAL ASSESSMENT OF ADULT PATIENTS INTRODUCTION

Nutritional assessment is evaluating nutritional status and determining the presence of, or risk of developing malnutrition. Nutritional assessment does not stop with the first evaluation, but is an ongoing process to monitor the adequacy and effectiveness of nutritional support measures. The four basic components of nutritional assessment include (1):

1. Anthropometrics 2. Clinical Information 3. Nutrition Intake History

4. Biochemical Data I. ANTHROPOMETRICS

The most common anthropometrics used in the hospital setting are weight (wt), height (ht) and weight/height (wt/ht) and their comparisons to standard values (2). A. Estimating ideal body weight (IBW) or desirable wt/ht (Hamwi Method) (3):

Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%)

Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%) B. Height/Weight: Body weight is used in nutrition assessment as an overall indicator of body fat and somatic protein stores. Body weight is compared with usual body weight (UBW) and with IBW as determined by the Hamwi method. It is important to use clinical judgment and avoid using a weight that is based on a fluid overloaded state when calculating nutritional needs. In these cases, the patients euvolemic or estimated euvolemic weight should be used.

1. Weight: Weight is used to assess a patients degree of malnutrition including evaluation of current weight as a percentage of IBW, current weight as percentage of usual weight and recent weight change. The following formulas were devised by Blackburn et al (4). Clinical judgment must also be used to consider frame size and muscle mass and to adjust for any edema or excess fluid present.

A. Percentage of UBW = current weight 100 UBW

85-90% = mild malnutrition 75-84% = moderate malnutrition

Evaluation of Weight Change Time Significant Loss Severe Loss

1 week 1-2% >2% 1 month 5% >5% 3 months 7.5% >7.5% 6 months 10% >10%

2. Adjusted Body Weight (AdjBW) for Obese Patients:

The American Dietetic Association (ADA) and the American Society for Enteral and Parenteral Nutrition (ASPEN) recommend basing caloric intake on actual body weight rather than adjusted body weight and using a reduced calorie per kg level (38, 39). However, clinicians at UVA have agreed to continue using AdjBW to determine energy needs. The research for justification either way is limited, and the only research that focused on patient outcomes used an adjusted body weight assuming 25% of the excess weight was metabolically active (5). Therefore, for patients who are overweight at >130% of their IBW, the nutritional requirements for calories should be based on an adjusted body weight rather than their IBW or actual body weight. AdjBW can be calculated as follows (5):

If patient is 130% or greater AdjBW = (Actual Wt IBW) 0.25 + IBW

3. Body Mass Index (BMI) (Quetlet Index):

The Body Mass Index or the Quetlet Index accounts for differences in body composition by defining the level of adiposity according to the relationship of weight to height and eliminates dependence on frame size (6, 7). However, it does not account for muscle mass.

BMI = wt (in kilograms)/ ht (in meters)2 or wt (in pounds)/ ht (in inches)2 705

A BMI of 18.5-24.9 is associated with the least risk of early death. A BMI of > 30 may indicate obesity and increased risk of developing health

problems. A BMI of

4. Weight Adjustment for Amputation

If a patient has loss of a body part or parts, IBW should be adjusted to reflect amputation. Percentages for adjustments in body weight (2):

Type of Amputation % Total Body Weighta Foot 1.8

Below Knee Amputation 6 Above Knee Amputation 15 Entire Lower Extremity 18.5 Hand 1 Below Elbow 3 Above Elbow 5 Entire Upper Extremity 6.5 aDouble if bilateral

5. Weight Adjustment for Ascites

To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight.

Mild Ascites ~ 3 kg Moderate Ascites ~ 7-8 kg Severe/tense Ascites ~ 14-15 kg

These adjustments were approved by UVA hepatologists.

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II. CLINICAL INFORMATION

Clinical variables can potentially influence all parameters of protein and calorie status. Clinical information is derived from a variety of sources, some of which include: Medical record Physician and other health care professionals Patient or patient family interviews General observations of the patients physical appearance Evaluation of psychosocial background

This combined data provides further information for the nutrition assessment. Some physical signs of nutritional deficiency are summarized in Table 1.2

TABLE 1.2 PHYSICALS SIGNS OF NUTRITIONAL DEFICIENCY (9, 10, 11) Site Sign Possible Deficiency______________ Skin Dry and Scaling Vitamin A Petechiae, Ecchymosis Vitamin C or K Follicular hyperkeratosis Vitamin A, Vitamin C, Essential Fatty Acid

Pellagrous dermatosis Niacin, Tryptophan Flaky Paint dermatosis Protein Hair Dull, dry, thin and easily Protein and Essential Fatty Acid pluckable Eyes Eyelid lining and whites pale Anemia Bitots spots Vitamin A Corners of eyes cracked, Riboflavin and Niacin

Red or inflamed eyelids Cornea dull, milky, hazy, or Vitamin A opaque Mouth Magenta tongue, Riboflavin

Tastebuds atrophied Glossitis Niacin, Folate, Vitamin B12 Bleeding gums Vitamin C Cheilosis Riboflavin, Pyridoxine Angular stomatitis Riboflavin, Niacin, Iron, Pyridoxine, Vitamin B12 General Appearance Edema Protein Muscle wasting Protein-Calorie Decreased subcutaneous fat Malnutrition Neurologic Disorientation Thiamin, Niacin

Neuropathy Thiamin, Copper, B12 ____________________________________________________________________________________________

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III. NUTRITIONAL INTAKE HISTORY:

A history of food intake is usually obtained by one of the following:

24 hour recall 3 day food record

Data collection should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems Risk factors identified may include:

(1) Current anorexia or major changes in appetite within last 3 months (2) Diet orders that are inadequate in meeting patient nutritional requirements

NPO or clear liquid >5 days without enteral/parenteral nutrition

(3) Problems with chewing, swallowing, motor skills or mobility alert the dietitian

to investigate potential nutrient inadequacies. Nutritional intake (calorie count or 24 hr recall) data may help the dietitian assess the need for nutrition support, education, etc.

(4) Past or present need for enteral or parenteral nutrition

IV. BIOCHEMICAL DATA:

Table 1.3 summarizes selected lab values/tests that are most often used for nutritional assessment of the adult patient at UVA. Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data, and no one value should be considered as a predictor of nutritional status.

TABLE 1.3 BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS* (3,9) ________________________________________________________________________________________________________ Lab Parameter Interpretation of Values Potential causes Potential causes for for high values low values______________________ TOTAL URINARY NITROGEN ( TUN)* Calculation of N2 balance**: Growth Inadequate calorie or protein intake Measures the net Pregnancy Increased catabolism changes in the bodys 24 hr. protein intake TUN (gm) + 2 gm] Recovery from illness Trauma total protein mass** 6.25 Athletic training Surgery Poor quality protein intake Critical Illness +4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to 1: Net catabolism __________________________________________________________________________________________________________________ URINARY UREA NITROGEN (UUN)* Measures the net Calculation of N2 balance**: Growth Inadequate protein intake changes in the bodys Pregnancy Increased catabolism total protein mass 24 hr. protein intake UUN (gm) + 4 gm] Recovery from illness Trauma

6.25 Athletic training Surgery Poor quality protein intake

+4 to + 6: Net anabolism +1 to - 1: Homeostasis -2 to 1: Net catabolism *Both TUN and UUN are used at UVA, however, TUN is preferred. When UUN is used to estimate nitrogen balance, it does not take into account 2 g for the dermal and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine). TUN measures all the protein in the urine, so a factor of 2 grams can be used instead of 4. The above equation may not be appropriate in certain circumstances. For example, the unmeasured nitrogen losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance. **Note: Do not do a Nitrogen Balance Study if unable to collect the full amount of urine, if the patient is anuric due to renal failure, or if the nutrition provision has changed in the past 2-3 days.

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Hepatic Proteins

Albumin, Prealbumin and Transferrin are not listed in the previous section as research has shown that these hepatic proteins are not reliable indicators of nutritional status and are negative acute phase reactants. Synthesis is impaired due to alterations in protein metabolism that occurs during metabolic stress. Albumin, prealbumin, and transferrin should not be used as indicators of nutritional status in hospitalized patients due to the effects of stress and inflammation on these parameters (12). REFEEDING SYNDROME:

Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and

mortality in the malnourished patient (13). Complications resulting from refeeding syndrome include electrolyte abnormalities (low serum values of potassium, phosphorus, magnesium), glucose and fluid shifts, cardiac dysfunction, and impaired release of oxygen from oxy-hemoglobin. The degree of symptoms exhibited depends upon the extent of malnutrition, electrolyte supplementation prior to nutrition support initiation, and calorie and fluid load initiated (14, 15).

Table 1.4 Patients at Risk for Refeeding Syndrome (16-19) Anorexia nervosa Chronic alcoholism Oncology patients Post-operative patients Residents admitted from skilled nursing facilities or nursing homes Depression in the elderly Uncontrolled diabetes mellitus (diabetic ketoacidosis) Chronic malnutrition:

Marasmus Kwashiorkor Prolonged hypocaloric feeding Morbid obesity with profound weight loss Prolonged fasting (including patients with non-nutritional IV fluids) High-stress patient not fed for >7 days Hunger strikers Victims of famine

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Table 1.5 Summary Guidelines to Prevent Complications of the Refeeding Syndrome (20)

1) Anticipate patients at risk for refeeding syndrome. 2) Check baseline electrolytes before initiating nutrition support and replace

any low levels promptly however, do not withhold nutrition support until serum levels are corrected, rather replete electrolytes concurrently with the nutrition support provided.

3) Initiate nutrition support, including total calories and fluids, slowly this does not mean that the enteral or parenteral nutrition has to progress slowly to meet the refeeding level that has been predetermined. Example: If a refeeding level of 20 kcal/kg is appropriate (which equates to a continuous tube feeding rate of 45 ml/hour of a 1 kcal/ml product), there is no need to also start enteral nutrition slower than this, as the amount of refeeding calories the patient is to receive in 24 hours has already been accounted for.

4) Consider additional sources of calories, such as dextrose in IV fluids, glucose or lipid calories from medications, etc. and include these in total calories.

5) Unless hemodynamically unstable, keep sodium-containing fluids to ~ 1 liter/day initially.

6) Monitor electrolytes daily for at least 3 days and replace any low levels as needed. Be wary of the malnourished patient in renal failure with elevated serum electrolytes secondary to decreased clearance, as they may be a late refeeder.

7) Be prepared for accelerated refeeding and the need for aggressive electrolyte replacement in the hyperglycemic patient while glucose control is improved.

8) Routinely administer vitamins to malnourished patients, especially thiamin; consider a loading dose prior to initiation of nutrition support.

9) Increase calories cautiously in a stepwise manner. Continue to monitor electrolytes as calories are increased.

10) Outline a plan for nutrition advancement (especially if patient is to be discharged) to prevent the patient from remaining on refeeding levels longer than necessary, thereby delaying improvements in nutritional status over time.

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Subjective Global Assessment (SGA) of Nutritional Status

The nutritional status of hospitalized patients can be assessed by a variety of methods as discussed earlier. The widely applied traditional methods rely on objective anthropometric measurements and laboratory test results. Nutritional assessment can also be based on clinical criteria-that is findings of a routine history and physical examination. Detsky et al (21) demonstrated a good correlation between the subjective and objective measurements. Some of the advantages of SGA are:

Quick, easily taught, inexpensive Adds structure to technical judgment Postoperative infections can be predicted to a degree that is equal to or better than with objective

measurements. Reproducible results

Table 1.6 Features of Subjective Global Assessment (SGA)

A. History 1. Weight Change

Overall loss in past 6 months: amount=______kg; %loss+______ (10% = definitely significant) Change in past 2 weeks: ______increase ______ no change ______ decrease (Pattern of weight loss: Patients who continue to lose weight are more likely to be malnourished, than those who have recently gained some weight)

2. Dietary intake change (relative to normal)

_____ no change _____ change _____duration #_____weeks _____ type: _____suboptimal diet, _____full liquid diet _____hypocaloric liquids _____starvation

3. Gastrointestinal symptoms (that persisted for > 2 weeks)

____none ____nausea ____vomiting ____diarrhea ____anorexia

4. Functional capacity _____No dysfunction (e.g., full capacity) _____Dysfunction ____duration = # ____weeks ____type ____working suboptimally ____ambulatory ____bedridden

5. Disease and its relation to nutritional requirements

Primary diagnosis (specify) _____ Metabolic demand (stress): _____ no stress, low stress _____ moderate stress, high stress

B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe)

# ______loss of subcutaneous fat (triceps, chest) # ______muscle wasting (quadriceps, deltoids) # ______ankle edema # ______sacral edema # ______ascites With the information obtained in parts A and B, the clinician subjectively assesses nutritional status. The most important factor is weight change over time.

C. SGA rating (select one) _____A = Well nourished _____ B = Moderately (or suspected of being) malnourished _____C = Severely malnourished

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V. ADULT NUTRITIONAL REQUIREMENTS:

Nutritional requirements for adults should be estimated on an individual basis. The nutritional requirements of each patient will depend upon a number of factors including:

Age Activity level Current nutritional status Current metabolic and disease states Individualized goals

The following section will provide a brief overview of the determination of nutritional requirements including calories, protein and fluid for the hospitalized patient.

Calorie Requirements: Estimating energy expenditure in hospitalized adult patients is challenging. If available,

indirect calorimetry can be used to measure energy expenditure using gas exchange (see following section). Frequent measurements are required to appropriately identify a patients energy expenditure (22). When indirect calorimetry is not possible, there are many possible predictive equations (see ADAs Evidence Analysis Library at www.adaevidencelibrary.com) (38). Most of these predictive equations are based on a single indirect calorimetry study per patient. The high degree of variability of an acutely ill patients energy needs from day to day limits the ability to make strong conclusions regarding the superiority of any prediction equation over another. More importantly, whichever method (indirect calorimetry or predictive equation) is used, the optimal energy provision for hospitalized patients has yet to be determined (22). Significantly underfeeding or overfeeding is harmful; (23, 24) however, there is no evidence that feeding a patient the calories they are burning based on indirect calorimetry (or based on any predictive equation) will improve outcome. Acutely ill patients remain catabolic despite meeting or exceeding full calorie expenditure (25, 26). In fact, there is evidence that feeding critically ill patients 100% of predicted energy needs may be harmful (27). For a discussion regarding permissive underfeeding of obese patients, please refer to the guidelines published in 2009 for the provision and assessment of nutrition support therapy by ASPEN and the Society for Critical Care Medicine (SCCM) (39).

At UVAHS, the calories per kilogram method is most often used to estimate a patients caloric needs to simplify calculations:

TABLE 1.7 CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

Patients at risk for refeeding* 15-20 kcal/kg *See page 8-9 Adults (18-65) 20-30 kcal/kg Elderly (65+) 25 kcal/kg Obese or Super obese 15-20 kcal/kg AdjWt

*Calorie requirements may vary based on degree of stress and need for

repletion Other factors:

Pregnancy: Add 300 kcal/day Lactation: Add 500 kcal/day

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Clinical judgment should be used to individualize each patients estimated needs, and frequent monitoring and evaluation of nutrition interventions should occur to make adjustments as needed based on patient response. 3. Metabolic cart (28, 29):

Indirect calorimetry using a metabolic cart measures actual energy expenditure by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide (VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated. The RQ for carbohydrate, protein, and fat differs and reflects net substrate utilization at the time of measurement.

Note: Patient has to be intubated for the test to be performed, FIO2 60%, no air leak or chest tube leak.

TABLE 1.8 RESPIRATORY QUOTIENT INTERPRETATION SUBSTRATE/MEASUREMENT CONDITION R.Q. _______________________________________________________________________

Lipogenesis (overfeeding) 1.001.20 Carbohydrate oxidation 1.00 Mixed substrate oxidation (appropriate feeding) 0.85 Protein oxidation 0.82 Fat oxidation (underfeeding) 0.71 Ketosis 0.670.70

PROTEIN GUIDELINES (30, 31) TABLE 1.9 SUGGESTED PROTEIN GUIDELINES IN ADULT HOSPITALIZED PATIENTS

Clinical condition Protein requirement Mild stress 1.0 1.2 g/kg Moderate stress (most ICU patients) 1.5-2.0 g/kg Severe Obesity 1.5 g / kg AdjWt 2.0 g/kg IBW Severe stress, catabolic, burns 2.0 2.5 g/kg Chronic renal failure, no dialysis 0.8-1.3 g/kg * Hemodialysis 1.2 1.4 g/kg Continuous Ambulatory Peritoneal Dialysis (CAPD) 1.2 1.5 g/kg

*Protein needs may be higher if the patient is critically ill

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4. Nutrition requirements for burn patients (32-35):

There are more than 30 predictive equations to estimate energy needs for burn patients. At UVA, patients with >20% TBSA burn are provided kcals and protein based on the guidelines below: Energy Requirements = 30-35 kcal/kg Protein requirements = 2.0-2.5g protein/kg Note: once grafting has taken place, calorie and protein requirements will decrease Additional Needs (35): Vitamin C = 500 mg BID Zinc Sulfate = 220 mg (limit to 2 3 weeks) Beta Carotene = 25,000 IU x 5 days Therapeutic Multivitamin/Mineral

IV selenium, copper and zinc - awaiting further research to determine specific amounts.

FLUID REQUIREMENTS:

Fluid requirements will vary among patients and may increase or decrease from normal needs under a number of conditions including the following:

TABLE 1.10 Potential Source of Fluid Excess or Loss in Hospitalized Patients (20) Intake Output Maintenance IV fluids Medications given via IV drip Water flushes given with crushed

medications Water flushes to keep tubes

patent Water contained in tube feedings

or PN

Chest tubes Percutaneous drains Biliary /Pancreatic

Wound drainage Ostomies/Stool/Urine Naso/oro gastric tube suction Excessive drooling/Sialorrhea

(cerebral palsy, Downs syndrome, undetermined neuromuscular disorders or those following a head injury or stroke

Fistulas Insensible losses Increased insensible losses including: Burns Tracheostomies Fever Kinair beds

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TABLE 1.11 ESTIMATING ADULT FLUID REQUIREMENTS 1. By caloric intake (36): 1ml/calorie Ex: 1800 calorie diet = 1800 calories x 1ml = 1800ml Calorie 2. By body weight and age (37): Age Fluid requirements 16-55 years 35 ml/kg/day 56-65 years 30 ml/kg/day > 65 years 25 ml/kg/day

Ex: 62 year old, weighs 58kg = 30ml x 58kg = 1740ml/day

When determining total fluid intake of the tube fed patient, the amount of free water in the

tube feeding formula and intravenous fluids needs to be considered. Intake and output records should be monitored as well as weight. A rapid weight gain or loss of 1 kg may be the result of a fluid gain or loss of 1 liter. References 1. Hooley RA. Clinical nutritional assessment; A perspective. JADA. 1980; 77:682-685. 2. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized

Patients. WB Saunders Co; 1986. 3. Hamwi GJ. Therapy: changing dietary concepts. In: Danowski TS, ed. Diabetes Mellitus:

Diagnosis and Treatment. New York, NY:American Diabetes Association; 1964:7378. 4. Blackburn GL, Bistrian BR, Maini BS. Nutritional and metabolic assessment of the hospitalized

patient. JPEN. 1977;1:11-22. 5. Krenitsky J. Adjusted body weight, pro: evidence to support the use of adjusted body weight in

calculating calorie requirements. Nutr Clin Pract. 2005;20:468-73. 6. Bray G. Pathophysiology of obesity. Am J Clin Nutr. 1992;55:488S-494S. 7. Bray GA, Gray DS. Obesity: 1. Pathogenesis 2. Treatment. West J Med. 1988;149:429-555. 8. WHO. Physical status: the use and interpretation of anthropometry. Report of the WHO Expert

Committee. WHO Technical Report Series 854. Geneva: World Health Organization, 1995. Available at: http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf. Accessed 8/22/08.

9. Grant A, DeHoog S. Nutritional Assessment and Support. Northgate Station, Seattle, WA: Grant and DeHoog; 1985.

10. Williams SR. Nutrition and Diet Therapy. Times/Mirror, Mosby. 1985; 485-502. 11. Rombeau J, Richter GC, Forlaw L. Practical aspects of nutritional

assessment. Pract Gastroenterol. 1984;8:43. 12. Banh L. Serum Proteins as a Marker of Nutrition: What Are We Treating? Practical

Gastroenterology 2006; XXX(10): 46-64. Available at: http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/resources.cfm

13. McCray S, Walker S, Parrish CR. Much Ado About Refeeding. Practical Gastroenterology. 2005;23:26-44.

14. Zeman FJ. Clinical Nutrition and Dietetics. New York: MacMillan, 1991;80. 15. Boylan H. Virginia Dietetic Association Meeting: Presentation on Refeeding Syndrome. 1998. 16. Marinella MA. The refeeding syndrome and hypophosphatemia. Nutr Rev 2003;61(9):320-323.

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17. Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001;17:632-637.

18. Matz R. Precipitation of refeeding-associated electrolyte abnormalities with intravenous hydration. [Letter to editor] Am J Med 1999;107:302.

19. Mallet M. Refeeding Syndrome. Age & Aging 2002;31:65-66. 20. University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR,

Krenitsky J, McCray S). University of Virginia Health System Nutrition Support Traineeship, 2003.

21. Detsky AS et al. What is the subjective global assessment on nutritional status? JPEN. 1987;11:8-13.

22. Reid CL. Poor agreement between continuous measurements. The use of energy expenditure and routinely used prediction equations in intensive care unit patients. Clin Nutr. 2007;26(5):649-57.

23. Talpers SS, Romberger DJ, Bunce SB and Pingleton SK. Nutritionally associated increased carbon dioxide production. Excess total calories vs high proportion of carbohydrate calories. Chest 1992;102(2):551-5.

24. Casper K, Matthews DE and Heymsfield SB. Overfeeding: cardiovascular and metabolic response during continuous formula infusion in adult humans. Am J Clin Nutr 1990;52(4):602-9

25. Frankenfield DC, Smith JS and Cooney RN. Accelerated nitrogen loss after traumatic injury is not attenuated by achievement of energy balance. JPEN J Parenter Enteral Nutr 1997;21(6):324-9.

26. Streat SJ, Beddoe AH and Hill GL. Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. J Trauma 1987;27(3):262-6.

27. Krishnan JA, Parce PB, Martinez A, Diette GB, and Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest. 2003;124: 297305.

28. Hester DD, Lawson K. Suggested guidelines for use by dietitians in the interpretation of indirect calorimetry data. JADA. 1989;89:100-101.

29. French SN. Nutritional assessment via indirect calorimetry. Tech Notes. Medical Graphics Corporation; 1987;1-12.

Harris JS, Benedict FG. A Biometric Study of Basal Metabolism in Man. Carnegie Institute of Washington, 1919.

30. Long CL, Schaeffel N, Geiger JW, et al. Metabolic response to injury and illness: Estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN. 1979;3:452.

31. Weinser RG et al. Handbook of Clinical Nutrition. St. Louis, MO:CV Mosby Co; 1989;130-179. 32. Herndon D, Tompkins R. Support of the Metabolic Response to Burn Injury. Lancet.

2004;363:1895-1902. 33. Lefton J. Specialized Nutrition Support for Adult Burn Patients. Support Line. 2003;25: 19-24. 34. Dickerson, R. Estimating energy and protein requirements of thermally injured patients: Art or

Science? Nutrition. 2002; 18:439-442. 35. Berger, MM, et al. Trace element supplementation after major burns modulates antioxidant status

and clinical course by way of increased tissue trace element concentrations. Am J Clin Nutr 2007;85:1293-1300.

36. Randall HT. Fluid electrolyte and acid base balance. Surg Clin North Amer. 1976;56:1019. 37. Water requirements in enteral support. Support Line. Dietitians in Nutrition Support: A Dietetic

Practice Group of the ADA; 1989;11. 38. American Dietetic Association Evidence Analysis Library. Available at

www.adaevidencelibrary.com. Updated 1/4/11. Accessed 3/3/11. 39. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009; 33: 277. Available at http://pen.sagepub.com/content/33/3.toc. Accessed 3/3/11.

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SECTION 2. ENTERAL NUTRITION (EN) INTRODUCTION

The gastrointestinal tract (GI) is the most effective way to feed the patient. If the patient has at least a partially functioning gut, but is unable to meet his nutritional needs via the oral (po) route, then enteral nutrition therapy via tube feeding should be considered. Enteral nutrition (EN) promotes the usual physiologic integrity of the GI tract, has less risk of harm (line infections, sepsis) and is more economical than parenteral nutrition. Table 2.1 Benefits of Enteral Nutrition (compared with Parenteral Nutrition) (1)

Stimulates immune barrier function Physiologic presentation of nutrients Maintains gut mucosa Attenuates hypermetabolic response Simplifies fluid/electrolyte management More complete nutrition than parenteral nutrition

o iron, fiber, glutamine, phytochemicals, etc. are not provided. Less infectious complications (and costs associated with these complications) ? Stimulates return of bowel function Less expensive

TABLE 2.2 INDICATIONS FOR INITIATION OF ENTERAL NUTRITION (1)

Indication Examples Oral intake is contraindicated Dysphagia, mechanical ventilation,

mandibular fractures, head & neck surgery, neurological impairment, demyelinating diseases such as amyotrophic lateral sclerosis, muscular dystrophy, etc.

Inability to meet markedly increased nutritional needs with oral intake

Burns, trauma, radiation therapy, chemotherapy, sepsis/infection, closed head injury

Inability to meet basic nutritional needs with oral intake alone

Anorexia, cancer, head and neck tumors

Need to bypass part of the GI tract to allow enteral nutrition

Pancreatitis, gastric outlet obstruction, esophageal cancer, gastroparesis

The need for supplemental nutrition due to decreased absorption

Short bowel syndrome, inflammatory bowel disease, fat malabsorption or other malabsorptive syndromes such as cystic fibrosis

17

TABLE 2.3 UVAHS Adult Formulary Type of Formula

Kcal/mL

Protein

Special Considerations

Standard, high protein (Promote, Promote with Fiber*)

1 kcal/mL

High, intact

Used most frequently at UVAHS; high protein:calorie ratio

Calorie dense (Jevity 1.5*, TwoCal HN*, Osmolite 1.5)

1.5 or 2.0 kcal/mL

Moderate, intact

Provides high amount of calories when reduced volume is desired

Elemental /Semi-Elemental (Vivonex RTF, Perative*)

1 kcal/mL, 1.3 kcal/mL

Peptides and Amino acids

Low fat, Low cholesterol Simple carbohydrate

Low-Electrolyte/Volume Restricted (Nepro*)

1.8 kcal/mL

Low, intact

Lowest K, Magnesium, P formula, concentrated; appropriate when fluid or electrolyte restriction is needed

*contains fiber Note: All formulas are gluten-free, lactose-free and low sodium. These formulas are listed on the adult enteral formulary at UVA as of 9/2008. Subject to change. Supplemental foods and drinks

If a patient is willing to consume them, oral supplements can be provided to help achieve calorie and protein goals. These are available in a variety of drinks and puddings. Some tube feeding products are flavored and can also be provided as oral supplements. Patient acceptability may improve if these supplements are served chilled. Please refer to adult enteral formulary card for a list of current enteral products and supplements.

Increasing protein

Protein delivery can be increased using modular protein products. A packet of Beneprotein provides ~25 kcal and 6 gms of protein. Increasing fiber Fiber delivery can be increased using fiber additive products. 2 teaspoons of Benefiber provides ~15 kcals and 3 g soluble fiber. Fiber should not be the first choice for treatment of diarrhea or constipation (see Table 2.7).

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HOSPITAL PROTOCOL FOR TUBE FEEDING ADMINISTRATION

When providing enteral nutrition, a number of factors need to be considered to provide nourishment as safely and comfortably as possible. The following list can serve as a guide (2-4). 1. Elevate head of bed to decrease the risk of aspiration:

a. Intermittent feeding: 30 - 45 degrees during and for 1 hour after feeding.

b. Continuous feeding: 30 - 45 degrees regardless of rate

2. Check for gastric residuals:

a. Intermittent feeding: Check prior to each feeding and if residuals are more than 500 mL, hold tube feeding for 1 hour and contact house officer.

b. Continuous feeding: Check every 8 hours. If gastric residuals are more

than 500 mL, hold the tube feeding for 1 hour and contact the house officer. There is no need to obtain residuals from nasoduodenal, nasojejunal or jejunostomy tubes.

Irrigate the feeding tube with at least 30 mL water before and after administering tube

feeds to ensure patency. Additional water to meet fluid needs is recommended on an individual basis.

TO ORDER ENTERAL NUTRITION

1. Use EPIC for ordering all adult formulas.

2. If an additive is desired, see TF Options. .

3. Following directions, select desired formula, method of delivery, strength and rate.

4. Enter water flushes and order gastric residual checks, if appropriate. 5. Nutrition Support Team members should be consulted to assist with nutrition

assessment, appropriate formula selection and provision, ongoing monitoring; and to answer questions regarding each patients nutritional needs.

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TABLE 2.4 ENTERAL NUTRITION DELIVERY: ROUTES OF ADMINISTRATION (4-7)

DELIVERY METHOD COMMON INDICATIONS PRECAUTIONS Nasogastric (NGT)*/ Orogastric

Unable or unwilling to consume adequate nutrition via oral route e.g. patient intubated, sedated Hypercatabolism in presence of at least partially functional GI tract

Tube must be secured Use CO2 detection device when placing tube. Document placement of tube with x-ray.

Nasoduodenal/ Nasojejunal

Functional GI tract with a proximal obstruction Inadequate gastric motility Esophageal reflux After upper GI surgery

Use CO2 detection device when placing tube, then confirm with x-ray. Tube must be secured Continuous feeding preferred due to high probability of dumping syndrome with bolus feeds.

Gastrostomy

Esophageal injury or obstruction Inability to swallow or consume adequate oral calories Anticipate that nutrition support will be needed for >4 weeks

Caution in patients with severe GE reflux Should be avoided in patients with intractable vomiting Caution: consider using an abdominal binder in agitated patients or those inclined to pull lines/tubes Stoma care required

Jejunostomy

Functioning GI tract with an obstruction in the proximal jejunum (long term) Upper GI stricture or fistula Inadequate gastric motility Long-term transpyloric feeding desired

Potential bowel perforation Bacterial overgrowth Stoma care required Continuous feeding preferred due to high probability of dumping syndrome with bolus feeds.

*For patient comfort and to decrease the risk of sinusitis, nasal Salem sumps used for feeding should be changed to a small-bore nasoenteric feeding tubes.

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TABLE 2.5 INDICATIONS FOR CONTINUOUS VS INTERMITTENT FEEDINGS VS NOCTURNAL FEEDINGS (5, 8)

CONTINUOUS INTERMITTENT NOCTURNAL Short term feeding Intensive Care Unit (ICU) setting May reduce risk of aspiration and/or gastric distension

Not recommended for post-pyloric feeding tubes Appropriate for long-term gastric feeding Allows time for more mobility between feedings Allows the patient to receive nutrition at meal time and socialize with others

Long-term feeding for patients who dont tolerate intermittent feedings, who have a small bowel feeding tube, or to supplement daytime po intake Allows daytime mobility Can be used during transition from tube feedings to po diet Recommend decreasing total calorie provision if increased appetite is desired.

TUBE FEEDING PROGRESSION (See EPIC Orders for Enteral Tube Feeding) Initiation:

Standard protocol for initiation of continuous feeds for non-surgical patients: Start full strength formula at 50 ml/hour x 4 hours, advance by 15 ml/hour every 4 hours until goal of _______ ml/hour is reached.

Standard protocol for initiation of bolus feeding: Give 125 ml x 1 feed, increase by 125 ml/feed until goal of ______ ml/feed is reached. Allow at least 3 hours between feedings.

Note: intermittent feeding is not for use with post-pyloric feeding tubes.

Residual Checks: Do not check residuals with post-pyloric feeding tubes. If not contraindicated, place patient on the right side before checking residuals. If residuals > 500 ml, hold feeds for 1 hour then recheck. If 500 ml, notify the physician.

Notify physician if feedings held twice in 24 hours. Return up to 250 ml gastric residuals to the patient.

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TABLE 2.6 POTENTIAL COMPLICATIONS OF TUBE FEEDINGS (2-4, 9, 10) COMPLICATIONS POSSIBLE CAUSE POSSIBLE MANAGEMENT

Delayed gastric emptying (Gastroparesis)

Elevate head of bed at least 30 during and 1 hour after tube feeding stopped Reduce infusion rate by using more calorically dense formula Consider prokinetic med

Tube dislodgment

Discontinue tube feeding Check tube placement Replace tube, if necessary

I. Mechanical Aspiration of formula

Gastroesophageal reflux

Use small bore feeding tube Keep head of bed elevated during and 1 hr after feeding Regularly check tube placement

Nasopharyngeal irritation/breakdown

Prolonged intubation with a large bore feeding tube.

Use soft, small-bore feeding tube Proper taping of tube to prevent undue pressure on nostril Consider G-tube, J-tube, PEG or PEJ for long term enteral feedings

Luminal obstruction (clogged tube)

Thickened formula residue Medication particles Inadequate flushing

Flush tube with water every 3-4 hours Flush tube with water before and after medications Use liquid or suspension form of medication if possible (caution: Liquid meds may cause diarrhea) Flush tube each time feeding is stopped Confirm appropriate medication delivery route with Pharm D Add ClogZapper (BIN#91200) or use Enteral Feeding Tube Declogger by Bionix

COMPLICATIONS POSSIBLE CAUSE POSSIBLE MANAGEMENT

Medications (sorbitol elixirs, antibiotics, Shohls solution, magnesium-containing antacids, laxatives, cathartic agents, Lactulose)

Review medications and eliminate causative agent, if possible.

C. difficile C. difficile toxin

Bacterial contamination

Refrigerate any opened cans of formula Discard all unused formula within 24 hours Ensure cleanliness during preparation and administration Place 8 hours of formula at a time in the feeding set/bag Change feeding bag and tubing every 24 hours

Improper administration

Consider reduced rate Give by continuous drip (not preferred in home patients) Check location of feeding tube tip

Fat malabsorption Determine cause Try pancreatic enzymes Select lower fat or consider changing the formula

II. Gastrointestinal Diarrhea

Lack of dietary fiber / too much fiber

Consider formula change Inadequate fluid Increase fluid intake

Inactivity

Encourage ambulation if possible

GI obstruction May require decompression and surgical intervention

Constipation

Colonic dysmotility Drug induced Post op Other

Address presumed cause

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COMPLICATION Bloating

POSSIBLE CAUSE Delayed gastric emptying

POSSIBLE MANAGEMENT Calorie dense formula Prokinetic agent Post pyloric tube

Rapid formula administration

Initiate feedings at a lower rate and gradually advance Consider post pyloric tube

Vomiting/Nausea

Delayed gastric emptying Monitor residuals Verify correct tube placement Prescribe anti-emetics/ antinauseants, prokinetics Post pyloric tube

Persistantly High Gastric Residual (>500 ml)

Delayed gastric emptying

Slower infusion Prokinetic agent Consider change to a

calorically dense formula to decrease volume

Post pyloric tube III. Metabolic Hyperglycemia Hypoglycemia

Diabetes Hypercatabolism Stress/Trauma Corticosteroids Sepsis Sudden cessation of tube

feeding or parenteral nutrition (PN) in patients on oral Hypoglycemic agent

or insulin

Monitor serum glucose Give oral hypoglycemic agents or insulin Avoid overfeeding Monitor serum glucose If tube feeding or PN must must be stopped after after insulin given, hang D10 IV fluid. Treat hypoglycemia with IV dextrose

Dehydration or Hypernatremia

Inadequate fluid intake Excessive protein intake High urine output, excessive diarrhea, ostomy output, fistula output, or NGT output

Monitor body weight Monitor fluid intake and output Monitor serum sodium, serum osmolality, BUN, creatinine (BUN-Cr ratio is usually 10:1 in patients with normal hydration) Provide additional water

23

24

COMPLICATION POSSIBLE CAUSE POSSIBLE MANAGEMENT Hyponatremia

Fluid overload Hypotonic formula Excessive production of

antidiuretic hormone (SIADH) Cerebral salt wasting

Restrict fluids (when sodium

is < 130) Provide adequate sodium

and/or supplement Give diuretics

Hyperkalemia Poor perfusion (CHF) Metabolic acidosis Excessive potassium intake Decreased excretion Renal insufficiency Potassium-sparing meds

Treat cause for poor perfusion Reduce potassium intake Monitor serum levels Give Kayexalate, glucose and/or insulin

Hypokalemia

Refeeding syndrome Diuretics Excessive losses (i.e. from diarrhea or NG drainage) Insulin therapy Volume overload Metabolic alkalosis

Reduce kcals Provide adequate potassium and/or supplement Monitor serum levels

Hyperphosphatemia

Renal insufficiency

Phosphate binder Reduce phosphorus intake Monitor propofol infusion for Phos-containing

meds (Fleet enemas contain phos)

Hypophosphatemia

Refeeding syndrome Insulin therapy Phosphate binding antacids Calcium carbonate supplements

Monitor serum levels Provide adequate phosphorus and/or supplement

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MONITORING OF ENTERAL NUTRITION SUPPORT PREVENTING COMPLICATIONS

Continued monitoring of nutritional intake is particularly important for patients receiving enteral or parenteral nutrition support in order to identify inadequacies before deficiencies develop. Recommendations for changing or supplementing nutritional support are based on accurate and timely documentation of delivery.

Patients on nutrition support also need to be closely monitored to ensure that energy needs are being met but not exceeded. Overfeeding can cause a number of complications which may prevent clinical improvement. Complications of overfeeding include (but not limited to):

1. Hyperglycemia 2. Lipogenesis 3. Fluid and fat gain rather than lean body mass gain 4. Fatty liver 5. Immunosuppression (with excessive lipid and linoleic acid intake) 6. Increased minute ventilation (VE) 7. Excessive CO2 production impairing pulmonary status/vent wean

Prolonged underfeeding may lead to loss of lean tissue, skin breakdown, inadequate

wound healing and immune dysfunction. Use of Blue Dye (11)

In the past, blue dye or food coloring was sometimes added to tube feedings as an indicator of aspiration. This practice has not been shown to be an effective method to monitor for or prevent aspiration pneumonia. In addition, studies have shown that critically ill patients may have increased gut permeability, making them susceptible to absorption of the dye into systemic circulation. When absorbed, blue food dye can act as a mitochondrial toxin causing unfavorable outcomes, up to and including death. Methylene blue can be used to help diagnosis enterocutaneous fistulas or during bedside swallow evaluations.

DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS

Medications are often administered through enteral feeding tubes. Information

concerning drug-nutrient interactions during enteral feedings is limited, particularly regarding bioavailability and absorption. Medications given by the enteral route (bypassing the usual location of absorption) may cause what appears to be formula intolerance and/or result in less than optimal drug absorption (12). General guidelines for administering medications with tube feedings are as follows (Table 2.7):

TABLE 2.7 GENERAL GUIDELINES FOR ADMINISTERING MEDICATIONS WITH ENTERAL FEEDINGS (13)

1. Stop the tube feeding prior to administration of meds.

2. Flush the feeding tube with 20-30 ml of warm water or appropriate volume before and after

giving medication through the tube.

3. If more than one medication is being given at the same time, give each medication separately and flush the tube with 5 ml of warm water between medications.

4. Use liquid preparation if possible (if patient does not have diarrhea). 5. If a tablet form must be used, be sure it is finely crushed and dispersed in warm water.

6. Do not crush enteric-coated, sublingual, or sustained-release tablets, if in doubt check with

PharmD.

7. Restart tube feeding when done giving medications.

8. Consider tube site placement. Drugs that depend on gastric secretions for breakdown/absorption may need to be substituted or given by an alternate method if tube placement is in the duodenum or jejunum.

9. Medications may be given via NG, OG, ND, PEG or J tubes. Do not give crushed medications

via small bore ( 12 French) NJ or J tube, if at all possible, to prevent clogging. 10. Check with the pharmacist if in doubt about availability of medication in liquid form or whether

tablets may be crushed and administered via feeding tubes.

UVAHS DRUG INFORMATION HELP LINE: 4-8034

References 1. University of Virginia Health System Nutrition Support Traineeship Syllabus. Parrish CR, Krenitsky J,

McCray S. University of Virginia Health System Nutrition Support Traineeship, 2003. 2. Schwartz D. Enteral therapy. In: Lang CE, ed. Nutritional Support in Critical Care. Rockville, MD: ASPEN

Publishers Inc; 1987. 3. Breach CL, Saldanha LG. Tube feeding complications. Part I: Gastrointestinal. Nutrition Support

Services. 1988;8:15. 4. Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case Based ApproachThe

Adult Patient. American Society of Parenteral and Enteral Nutrition. Silver Spring, MD, 2007. 5. Weinsier, RL, Heimberger DC, Butterworth CE. Handbook of Clinical Nutrition. St Louis: CV Mosby Co;

1989. 6. McClusky KW, Fishel L, Stover MR. Nutrition policy system: A model for patient care. JADA. 1987;87:200. 7. Page C, Andrassy R, Sandler J. Techniques in delivery of liquid diets: Short term and long term. Nutrition

in Clinical Surgery. Baltimore: Williams & Williams; 1985;60-87. 8. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized Patients. W.B.

Saunders Company, 1986. 9. Breach CL, Saldanha LG. Tube feeding complications. Part II: Mechanical. Nutrition Support Services.

1988;8:28. 10. Breach CL, Saldanha LG. Tube feeding complications. Part III: Metabolic. Nutrition Support Services.

1988;8:16. 11. Lucarelli MR, Shirk MB, Julian MW, Crouser ED. Toxicity of Food Drug and Cosmetic Blue No. 1 dye in

critically ill patients. Chest. 2004 Feb;125(2):793-5. 12. Smith MC, Brown TR. Handbook of Institutional Pharmacy Practice. Williams and Wilkins Co; 1984-5,

288-310. 13. Enteral Nutrition Handbook, Ross Laboratories, Columbus, Ohio, 1989. 26

SECTION 3. PARENTERAL NUTRITION (PN) Parenteral nutrition (PN) support is used to nourish patients who either are already malnourished or have the potential for developing malnutrition and who are not candidates for enteral support (1). Parenteral nutrition provides intravenous carbohydrates in the form of dextrose, protein in the form of amino acids, lipids in the form of triglycerides, and vitamins, minerals, trace elements and fluid. PERIPHERAL PARENTERAL NUTRITION (PPN): Peripheral Parenteral Nutrition is defined as supplementation via a peripheral vein and is a temporary route for the administration of dilute nutrient solutions. Sensitivity of peripheral veins to hypertonic solutions limits the caloric density of formulations that may be used. Solutions with an osmolality of greater than 900 mOsm generally require central access (1, 2). PPN is used only for a short time (up to 2 weeks) because (1): The lack of peripheral venous sites that can withstand long-term high

osmolality infusion May not meet patients calorie and protein needs Indications: PPN may be used in the following conditions: Partial or total nutrition support for patients who are not able to ingest

adequate calories orally or enterally, and whose therapy is likely to be less than 7 days.

When central-vein parenteral nutrition is not feasible or desirable. Contraindications: Because of the lower concentration of nutrients, PPN is not the optimal choice for feeding patients with the following conditions: Large nutrient or electrolyte needs Fluid restriction The need for prolonged intravenous nutrition support Note: Vein Protector is available and consists of: Hydrocortisone 15mg (added to the PPN bag) Heparin 1500 units (added to the PPN bag) This may increase the life of the peripheral line on average from 6 days to 15 days (3).

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CENTRAL PARENTERAL NUTRITION (CPN): Central Parenteral Nutrition is defined as delivery of nutrients via central venous access (1, 2). CPN allows for the provision of nutrients in greater concentrations and smaller fluid volumes than is possible with PPN. Short Term Access:

Short term PN may be provided centrally via the subclavian or internal jugular vein.

If PN is needed for a prolonged period, one of the central venous access devices listed below is required:

Long-term Access: Peripherally Inserted Central Catheter Line (PICC line), which is passed via

the antecubital vein, and advanced into the central venous system (5). Long-term access may be obtained using a catheter that is tunneled into the

subclavian vein subcutaneously away from the insertion site. Long term catheters that are tunneled under the skin, may reduce the

incidence of infection. Access ports may also be inserted under the skin. Examples: Groshong, Hickman, Port a cath.

Placement of long term IV access may be surgical or non surgical depending upon the type of catheter used. Implantable devices are inserted surgically, whereas percutaneous catheters do not require surgical intervention.

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CLINICAL INDICATIONS FOR PARENTERAL NUTRITION:

Table 3.1 Indications for Parenteral Nutrition (1, 4)

Parenteral nutrition is usually indicated in the following situations: Documented inability to absorb adequate nutrients via the gastrointestinal

tract; this may be due to: Massive small-bowel resection / Short bowel syndrome (at least initially)

Radiation enteritis Severe diarrhea Steatorrhea

Complete bowel obstruction, or intestinal pseudo-obstruction Severe catabolism with or without malnutrition when gastrointestinal tract is

not usable within 5-7 days Inability to obtain enteral access Inability to provide sufficient nutrients/fluids enterally Pancreatitis in the setting of intolerance to jejunal delivery of nutrients Persistent GI hemorrhage Acute abdomen/ileus Lengthy GI work-up requiring npo status for several days in a malnourished

patient High output enterocutaneous fistula and EN access cannot be obtained distal

to the site. Trauma requiring repeat surgical procedures / NPO status Parenteral nutrition may be indicated in the following situations: Enterocutaneous fistula as above Inflammatory bowel disease unresponsive to medical therapy Hyperemesis gravidarum when nausea and vomiting persist longer than 5 -7

days and enteral nutrition is not possible Partial small bowel obstruction Intensive chemotherapy / severe mucositis Major surgery/stress when enteral nutrition not expected to resume within 7-

10 days Intractable vomiting and jejunal access is not possible Chylous ascites or chylothorax when EN (with a very low fat formula) does

not adequately decrease output Contraindications for Parenteral Nutrition: Functioning gastrointestinal tract Treatment anticipated for less than 5 days in patients without severe

malnutrition Inability to obtain venous access A prognosis that does not warrant aggressive nutrition support When the risks of PN are judged to exceed the potential benefits

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COMPONENTS OF PARENTERAL NUTRITION: A. MACRONUTRIENTS:

1. CARBOHYDRATE (1,2,5,6)

Dextrose contains 3.4 kcal/g (CHO is given as a dextrose monohydrate)

Requirements: Minimum: 1 mg/kg/minute 1440 mg/kg/24hrs Maximum: 5 mg/kg/minute 7200mg/kg/24hrs OR 7 g/kg/day OR 24 dextrose kcal/kg/day. *Note: Per minute calculations are based on 24 hour infusions; not on nocturnal or cyclic infusions, where infusion rates are generally higher.

Solutions:

Commercially prepared dextrose solutions are available in concentrations ranging from 5% - 70% (D70W Used at UVA). Solutions with final concentrations greater than 10% must be administered into a central vein because of the high osmolarity. Consequences of excess CHO administration:

Hyperglycemia Glucosuria Synthesis and storage of fat Hepatic steatosis Increased carbon dioxide production impairing pulmonary status/vent

wean 2. PROTEIN (1, 2, 7)

Amino acid = 4 kcal/g Protein calories should be included when calculating total caloric

requirements. Requirements: Approximately 16% of protein or amino acids are nitrogen. The goal

should be to provide adequate protein to maintain a positive (2 to 4 g)

30

Requirements range from 0.8 g/kg/day to 2.5 g/kg/day. For specifics, see table 1.9.

Generally 15 20% of the daily caloric intake should come from protein.

Crystalline amino acids are currently the protein source for commercial formulas. Amino acids are available in concentrations of 3 15%. Amino acid solutions of 3% and 3.5% (without added electrolytes) are nearly isotonic, making them acceptable for peripheral administration. Standard amino acid solutions are usually comprised of 40 50% essential amino acids and 50 60% non-essential amino acids. At UVA: 10% Travasol amino acid solution is used and is customized according to the protein needs of patients.

2. FAT (1, 8, 9)

IV lipids are also referred to as IV fat emulsions (IVFE) Exact fat requirements are unknown.

Minimum: To prevent essential fatty acid deficiency (EFAD), 2% to 4% of the total caloric requirement should come from linoleic acid (25 to 100 mg/kg/day)

Maximum: Maximal fat dosage should not exceed 60% of calories OR 1.0 - 2.5 g/kg/day (8) For critically ill patients, IVFE should not exceed 1.0 g/kg/day (8)

Intralipid (Soybean oil) 20% lipid (2 kcal/ml) is used at UVA. Has phospholipid as the emulsifier. Use with caution in patients allergic to eggs. Lipids should be used with caution in patients with serum triglycerides

(TG) > 400mg/dl. Lipids are generally administered over a 24 hour period.

Administering lipids over a 24 hour period may avoid immunosuppression and improve clearance. However with cyclic PN ( 12 hours), most patients tolerate lipids delivered over this shorter period. Guidelines for rate of infusion are < 0.11 g / kg / hr (8).

Propofol is a lipid-based sedative (soybean oil-in-water emulsion) that contains phosphorus and provides 1.1 kcal/ml. Because propofol has rapid onset and quick recovery, it is becoming widely used in critical care units. Infusion of propofol or any other lipid-based drug must be

31

Propofol contains phosphorus-75 mEq (115mg or 37mm) / 1 L

Consequences of excess lipid administration:

Fat overload syndrome with neurologic, cardiac, pulmonary, hepatic and renal dysfunction

Thrombocyte adhesiveness Accumulation of lipid in the reticuloendothelial system (RES), leading

to RES dysfunction Impaired immune response

B. MICRONUTRIENTS:

1. VITAMINS (2)

Parenteral vitamin requirements differ from enteral requirements because of differences in efficiency of absorption and utilization of nutrients administered via the parenteral route, and physiochemical stability in the parenteral solutions. Because of instability when mixed with PN solutions, vitamins are

added just prior to administering the solution. Optimal vitamin intakes for seriously ill and septic patients are

unknown.

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TABLE 3.2 AMERICAN MEDICAL ASSOCIATION and FOOD AND DRUG ADMINISTRATION RECOMMENDATIONS FOR PARENTERAL VITAMIN

INTAKE (10-12)

Vitamin AMA Recommended

Amount

FDA Recommended

Amount

Multi-Vitamins added to standard PN solution at

UVA (MVI-ADULT, 10 ml/day)

Vitamin A 3300 IU 1 mg / 3300 units 3300 USP units

Vitamin D 200 IU 5 mcg / 200 units 200 USP units

Vitamin E 10 IU 10 mg / 10 units 10 USP units

Vitamin K - 150 mcg 150 mcg

Ascorbic acid 100 mg 200 mg 200 mg

Folic Acid 0.4 mg 600 mcg 600 mcg

Niacin 40 mg 40 mg 40 mg

Riboflavin (B2) 3.6 mg 3.6 mg 3.6 mg

Thiamin (B1) 3 mg 6 mg 6 mg

Pyridoxine (B6) 4 mg 6 mg 6 mg

Cyanocobalamin (B12)

5 mcg 5 mcg 5 mcg

Pantothenic acid 15 mg 15 mg 15 mg

Biotin 60 mcg 60 mcg 60 mcg

2. TRACE ELEMENTS (13)

Trace elements are critical to support proper function of metabolic pathways.

Additional zinc (5-10 mg daily) should be considered during periods of

excessive GI output (diarrhea, fistulas, or ostomies) or for severe wounds / burns.

Use of copper and manganese should be closely evaluated in the

setting of biliary obstruction and liver failure. Whole blood manganese levels should be monitored for any patient receiving parenteral nutrition for > 3 months. Use 0.3 mg copper per day for patients with cholestasis, and recheck levels monthly (13, 14).

33

Iron is not routinely added to parenteral nutrition solutions. Iron may be

added to 2:1 mixtures but not 3:1 mixtures. Parenteral iron therapy is indicated in patients with iron deficiency anemia associated with conditions that interfere with the ingestion or absorption of oral iron. The overall incidence of adverse reactions associated with the parenteral administration of iron is low, but the potential for an anaphylactic reaction requires that an initial test dose be given followed by careful observation (13).

Concentrated Multitrace 5 is used at UVA. See table 3.3

mg = milligrams mcg = micrograms

TABLE 3.3 Daily Parenteral Trace Element Supplementation for Adults (13) Trace Element

Previous Guidelines (AMA - 1979) 1

Recent Recommendations2

( ASPEN-2004)

Concentrated Multitrace 5

(1mL) used at UVA

Non- Concentrated

MTE- 5 (2.5mL)

Zinc 2.5-4 mg 2.5-5 mg 5 mg 2.5 mg Copper 0.5-1.5 mg 0.3-0.5 mg 1 mg 1 mg Chromium 10-15 mcg 10-15 mcg 10 mcg 10 mcg Selenium No guideline 20-60 mcg 60 mcg 50 mcg Manganese 150-800 mcg 60-100 mcg 500 mcg 250 mcg

3 ELECTROLYTES (2)

Electrolyte requirements in PN can vary widely The table on the

following page provides a guideline of standard, maintenance levels of electrolytes used at UVA for patients without significant metabolic disarray..

Calcium and phosphorus (Ca/P) compatibility in PN solution:

The combination of calcium and phosphorus salts in excessive amounts may result in crystalline precipitate and possible catheter occlusion, as well as adverse patient outcomes. The maximal amount of calcium and phosphorus that may be added to a given volume of PN is dependent on several factors including the volume of fluid, the pH of the solution ( in pH results in Ca/P solubility), and mixing procedures. At UVA a maximal combined dose of calcium and phosphorus does not exceed 52 mEq/L of PN.

At UVA, all macro and micronutrients are ordered as per day or per bag and not per L.

34

35

TABLE 3.4 DAILY ELECTROLYTE RECOMMENDATIONS (15, 16)

Electrolyte Daily

Recommendations or Requirements

Standard Additive at UVA

Sodium 70 100 mEq/day 63 mEq/day

Chloride 70 100 mEq/day Varies per day,

based on composition of other elytes in the PN

solution. Potassium 70 100 mEq/day 72 mEq/day

Calcium 10 20 mEq/day 8.1 mEq/day

Magnesium 15 20 mEq/day 18 mEq/day

Phosphorus 40-60 mEq/day 18 mMol/day

Acetate 0 60 mEq/day 53 mEq/day

Other Custom PN Additives available at UVA include: Insulin, Human Regular Vitamin K Famotidine Heparin Vitamin C Vitamin B12 Chromium Copper Manganese Zinc Selenium Iron dextran Thiamin

C. FLUIDS

Standard rate at UVA is 75 ml/hour. See section on PN calculations to calculate minimum flow rates. PN SCHEDULES: Continuous nutrient infusion Cyclic usually 12 hour infusion overnight

Improved quality of life In preparation for discharge home Run PN at half of the goal rate for the first and the last hour Monitor fluid status, blood glucose response

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TABLE 3.5 STANDARD PN ORDERS AT UVA

Central Line: CPN

Peripheral line: PPN

Provides: Macronutrients: 750 Dextrose calories/day 300 Protein calories/day 500 Fat calories/day (250 mL of 20% lipid per day)

Provides: Macronutrients: 400 Dextrose calories/day 300 Protein calories/day 500 Fat calories/day (250 mL of 20% lipid per day)

Electrolytes: See Standards on Table 3.4

Trace elements: 1mL/day (ATES-5)see page 34 Multivitamin: 10 ml/daysee page 33

Total calories: 1550/day Total protein: 75 g/day

Total calories: 1200/day Total protein: 75 g/day

The differences between standard CPN and PPN are in the dextrose and total calories and have been underlined.

PARENTERAL NUTRITION CALCULATIONS:

CUSTOM PN: Step 1 Determine protein and calorie needs Step 2 Subtract protein calories (grams protein x 4) from total calories Step 3 Subtract lipid calories* from remaining calories Step 4 remaining will be dextrose calories IV lipids UVA are 20% or 2 calories / mL. To avoid wastage of lipid and to simplify orders, order lipid by 250 ml or 500 ml bag per day. Decide whether 250 ml or 500 ml is more appropriate based on the goal for % of kcals provided by fat or by maximal amount allowed to avoid immunosuppression (~1 gm / kg body weight).

37

Minimum flow rates: Dex/50 + g Pro/215 + 5 = minimum flow rate Central: [(Dextrose kcals X 0.42) + (grams of protein X 10)] 24 = minimum hourly flow rate. Add 5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5. Peripheral: [(Dextrose kcals x 0.15) + grams of protein] 2.1 = minimum hourly flow rate. Add 5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5. COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION (1): Parenteral Nutrition can be a life-saving therapy, but complications may arise. Potential complications of PN include: Metabolic complications; hyperglycemia is the most common tight blood glucose

control is optimal. Gastrointestinal complications: steatohepatitis, cholestasis (17,18) Pharmacological complications Manganese toxicity is possible with prolonged use of PN (14) Infection / sepsis Metabolic bone disease (19)

TABLE 3.6 GASTROINTESTINAL COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION (OR LACK OF ENTERAL NUTRITION) (4)

Complication Possible Etiology Symptoms Treatment Prevention Fatty liver Delivery of

carbohydrate in excess of hepatic oxidative capacity

Overfeeding of calories and/or fat

Excess infusion of amino acids

Essential fatty acid deficiency

Carnitine deficiency

Elevation of liver enzymes within 1 to 3 weeks post PN initiation

Reduce carbohydrate delivery

Cyclic PN Rule out other

causes Begin enteral

nutrition if possible

Use mixed substrate solutions

Avoid overfeeding

Avoid glucose infusion > 5 7 mg/kg/minute

Enteral nutrition as tolerated (trophic feedings)

Cholestasis Impaired bile flow Lack of intraluminal

nutrient stimulation of hepatic bile secretion

Overfeeding Toxic tryptophan

metabolites

Progressive increases in serum total bilirubin

Elevated serum alkaline phosphatase

Avoid overfeeding Rule out other

causes

Early use of gastrointestinal tract

Gastrointestinal mucosal atrophy

Atrophy of villi Colonic hypoplasia

In vitro, presence of enteric bacteria in mesenteric lymph nodes

Development of enteric bacteremia and sepsis without clear source

Transition to enteral/oral feedings as tolerated

Early use of gastrointestinal tract

38

References 1. Madsen H, Frankel EH. The Hitchhikers Guide to Parenteral Nutrition Management for

Adult Patients. Practical Gastroenterology 2006; XXX(7):46-68. 2. Gottschlich, MM, ed. Nutrition Support Core Curriculum: A Case Based Approach. Silver

Spring, MD: American Society of Parenteral and Enteral Nutrition; 2007. 3. Tighe MJ, Wong C, Martin IG, et al: Do heparin, hydrocortisone, and glyceryl trinitrate

influence thrombophlebitis during full intravenous nutrition via a peripheral vein? JPEN 19:507-509, 1995.

4. University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR, Krenitsky J, McCray S). Parenteral Module. University of Virginia Health System Nutrition Support Traineeship Syllabus, 2003.

5. Baumgartner TG. Parenteral macronutrition. In: Baumgartner TG, ed. Clinical Guide to Parenteral Micronutrition. Fujisawa USA, Inc; 1997: 41.

6. Evans N. The role of total parenteral nutrition in critical illness: Guidelines and recommendations. AACN Clinical Issues. 1994;5:476-484.

7. Miles J, Klein J. Should protein be included in calorie calculations for a TPN prescription? Nutrition in Clinical Practice. 1996;11:204-206.

8. Hise ME, Brown JC. Lipids. In: Gottschlich, MM, ed. Nutrition Support Core Curriculum: A Case Based Approach. Silver Spring, MD: American Society of Parenteral and Enteral Nutrition; 2007:54-57.

9. Lowrey T, Dunlap A, Brown R, Dickerson R, Kudsk K. Pharmacologic influence on nutrition support therapy: Use of propofol in a patient receiving combined enteral and parenteral nutrition support. Nutrition in Clinical Practice. 1996;11:147-149.

10. Parenteral multivitamins products; drugs for human use; drug efficacy study implementation; amendment (21 CFR 5.70). Federal Register. April 20, 2000; 65:21200-21201.

11. Fuhrman MP, Hammond KA, et.al. The Science And Practiceof Nutrition Support. Dubuque, Iowa: American Society of Parenteral and Enteral Nutrition; 2001: 94.

12. M.V.I. Adult UNIT VIAL, Manufacatured by: AstraZeneca, Westborough MA; January 2004.

13. Fessler TA. Trace Element Monitoring and Therapy For Adult Patients Receiving Long Term Total Parenteral Nutrition. Practical Gastroenterology. 2005;25:44-65.

14. ODonnell K, Radigan, A. Hypermanganesemia in an Acute Care Setting. Nutrition in Clinical Practices. 2003;18:374-376.

15. Skipper A, Marian MJ. Parenteral Nutrition. In: Gottschlich MM, ed. Nutrition Support Dietetics Core Curriculum. 2nd Ed. Silver Spring, MD. American Society of Parenteral and Enteral Nutrition, 1993:111.

16. Evans JN. The role of total parenteral nutrition in critical illness: guidelines and recommendations. AACN Clincal Issues. 1994;5:476-484.

17. Lee V. Liver Dysfunction Associated with Long Term Parenteral Nutrition: What are the options? Practical Gastroenterology 2006. XXX(12):49-68.\

18. Jeejeebhoy. Management of PN induced cholestasis. Practical Gastroenterology 2005; XXIX(2):62-68.

19. Hamilton C, Seidner D. Metabolic Bone Disease in the Patient on Long-Term Parenteral Nutrition. Practical Gastroenterology 2008; XXXII(1):18-32.

39

APPENDIX

40

APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM*

Lab Parameter Normal Range Elevated with: Decreased with:

BUN

7 18.7 mg/dl Higher in elderly: 8.4 25.7 mg/dl

Dehydration Renal disease Increased protein metabolism Starvation Stress Diabetes Fever Acute myocardial infarction G I bleed Congestive heart failure Urinary obstruction

Liver failure Increased protein synthesis - Late pregnancy - Infancy Acromegaly Nephrotic syndrome Overhydration Malabsorption Low protein, high CHO diets

Creatinine

0.6 - 1.1 mg/dl

Large muscle mass Muscle disease Starvation Renal disease

CO2 (Bicarbonate)

22 29 mmol / L

Metabolic alkalosis Respiratory acidosis Emphysema Vomiting

Metabolic acidosis Respiratory alkalosis Hyperventilation Fever Lack of oxygen

*This list is not all inclusive. For example, drug effects not listed.

41

APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (Cont)*

Lab Parameter Normal Range Elevated with: Decrease with:

Serum Osmolarity Osm = serum sodium x 2 + BUN + Glucose 2.8 18

275 295 mOsm/L Calculated values are generally lower than measured values

Inadequate fluid intake Diarrhea Diabetes mellitus Diabetes insipidus Renal disease Hyperlipidemia Hyperglycemia

Excess fluid intake Adrenal disease Inappropriate ADH secretion - Hypothyroidism - Cerebral disease

Porphyria - Bronchogenic cancer

Serum Glucose * Elevated values may give falsely low serum sodium values. For every 100% elevation, serum sodium is decreased by 2 mEq/L

74 99 mg/dl

Diabetes mellitus Cushings syndrome Acromegaly Hemochromatosis Pheochromocytoma Burns, shock Acute pancreatitis Wernickes encephalopathy Dehydration Sepsis Overfeeding Corticosteroids Blood draw contaminated with PN (can confirm with a finger stick)

Liver disease Neoplasms Pancreatic disorders Adrenal insufficiency Hypothyroidism Fluid overload Severe sepsis

*This list is not all inclusive. For example, drug effects not listed.

42

APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Hematocrit (HCT) Often used to diagnose iron deficiency; not a conclusive measure

Women: 35 47% Men: 40 52%

Dehydration Polycythemia

Hemorrhage Anemia Fluid overload Advanced age Late Pregnancy

Hemoglobin (Hgb) More direct measure of iron deficiency than HCT

Women: 12 16 gm/dl Men: 14 18 gm/dl

Dehydration Polycythemia

Hemorrhage Iron deficiency anemia Malnutrition Advanced age Late pregnancy Renal failure Fluid overload

Mean Corpuscular Volume (MCV) Indicates average size of the red blood cells. Calculated MCV = HCT x 10 RBC

83 95 fL

Macrocytosis - Folate deficiency

- Vitamin B 12 deficiency - Excess alcohol intake

Hemochromatosis

Microcytosis - Advanced iron deficiency - Blood loss

Iron malabsorption Lead poisoning

**This list is not all inclusive. For example, drug effects not listed.

43

APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Sodium Body content of sodium is not always reflected in serum levels

136 145 mmol / L

Dehydration: Diabetes Insipidus Osmotic diuresis GI losses Renal disease Severe exercise

Adrenal insufficiency Extreme sweating Diuretics Diabetic acidosis Malabsorption Excessive GI losses ( diarrhea, vomiting, etc) SIADH

Potassium

3.4 4.4 mmol / L

Hemolysis Burns, shock Crush injuries Excess supplemental potassium Renal failure Diabetic ketoacidosis Dehydration Hyperglycemia Acidosis Blood draw contaminated with PN

Refeeding Syndrome Starvation Excessive GI losses (diarrhea, vomiting, etc) Hypomagnesemia Cushings syndrome Diuretics Amphotericin

Chloride

98 107 mmol / L

Dehydration Renal failure

Excessive GI losses (diarrhea, vomiting, etc) Excess urinary losses

*This list is not all inclusive. For example, drug effects not listed.

44

45

APPENDIX 1. SELECTED LAB VALUES (ADULTS) AT UVA HEALTH SYSTEM (cont.)*

Lab Parameter Normal Range Elevated with: Decreased with:

Calcium Absorption decreased by phytates, oxalates, phosphates Check ionized calcium

8.4 10.2 mg/dl

Cancer Renal disease Vitamin D intoxication Hyperparathyroidism Renal calculi Prolonged Immobilization

Hypoparathyroidism Renal disease Osteomalacia Steatorrhea Rickets Hypomagnesemia

Phosphorous

2.3 4.7 mg/dl

Hemolysis Renal disease Healing fractures Vitamin D deficiency Skeletal disease

Rickets Insulin injections Malnutrition Malabsorption Refeeding syndrome

Magnesium

1.6 2.6 mg/dl

Renal failure Diabetic acidosis Hypothyroidism Addisons disease Dehydration Overuse of magnesium supplements or antacids Hemolysis

Chronic diarrhea Alcoholism Pancreatitis Renal disease Hepatic cirrhosis Toxemia of pregnancy Hyperthyroidism Malabsorption Ulcerative colitis K- depleting diuretics Refeeding syndrome

*This list is not all inclusive. For example, drug effects not listed.

APPENDIX 2. ADULT MULTIVITAMIN SUPPLEMENTS AVAILABLE AT UVA

Product/Form

Amt. A (IU)

D (IU)

E (IU)

B1 (mg)

B2 (mg)

Niacin(mg)

B5 (mg)

B6 (mg)

B12 (mcg)

Folate (mg)

C (mg)

Ca (mg)

Fe (mg)

*Others

Therapeutic

multivitamin tablet

1 tablet

5000 400 30 1.5 1.7 20 10 2 6 0.4 60 - - -

Therapeutic high potency vitamins

with minerals

1 tablet

5000 400 60 3 3.4 20 40 6 12 0.4 90 40 - 1

Childrens Chewable Multivitamin

1 tablet

2500 400 15 1.05 1.2 13.5 - 1.05 4.5 0.3 60 - - -

Liquid multivitamin 5 ml 5000 400 - 10 10 100 21.4 4.1 5 - 200 - - -

Liquid high potency multivitamin with

minerals

15 ml 1300 400 30 1.5 1.7 20 10 2 6 - 60 - 9 2

MVI ADULT IV multivitamin

10ml 3300 200 10 6 3.6 40 15 6 5 0.6 200 - - 3

ADEKs tablets 1 tablet

4000 400 150 1.2 1.3 10 10 1.5 12 0.2 60 - - 4

Nephro vite for dialysis patients

1 tablet

- - - 1.5 1.7 20 10 10 6 0.8 60 - - 5

Materna Prenatal vitamin

1 tablet

5000 400 30 3 3.4 20 10 10 12 1 100 250 60 6

The others category: 1. Vitamin K 28 mcg, Calcium 40 mg, Phosphorus 31 mg, Potassium Chloride 7.5mg, Iodine 0.15mg, Copper 2 mg,, Biotin 30 mcg, Manganese 2 mg, Magnesium

100 mg, Zinc 15 mg, Selenium 70 mcg, Chromium 50 mcg, Molybdenum 75 mcg, Boron 150 mcg, Tin 10 mcg, Vandium 10 mcg, Nickel 5 mcg, Silica 2 mg 2. Chromium 25 mcg, Iodine 0.15 mg, Molybdenum 25 mcg, Manganese 2 mg, Zinc 3 mg, Biotin 300 mcg, Iron 9 mg (78 mg Fe gluconate) 3. Biotin 60 mcg 4. Zinc 7.5 mg, Vitamin K 150 mcg, Biotin 50 mcg, Beta carotene 3 mg, Fructose 5. Biotin 300 mcg 6. Chromium 25 mcg, Iodine 0.15 mg, Copper 2 mg, Magnesium 25 mg, Molybdenum 25 mcg, Biotin 30

mcg, Zinc 25 mg, Manganese 5 mg

46

APPENDIX 3. ADULT VITAMIN SUPPLEMENTS AVAILABLE AT UVA Vitamin

Form

Dose

Composition

Vitamin A

Capsule (as beta carotene)

Drops

Injection

1 each

1 ml

2 ml

25,000 IU

50,000 IU/ ml

100,000 IU

Vitamin D2 - Ergocalciferol

Capsule

Drops (Drisdol)

1 each

0.25 ml

50,000 IU

2000 IU

Vitamin D3 - Cholecalciferol

Tablet

1 each

400 IU and 1000 IU

Calcitriol -active form (Calcijex or Rocaltrol)

Capsule

Liquid

Injection

0.25 mcg, 2 mcg

0.25 mcg & 0.50 mcg

1 mcg/ml

1 mcg

Vitamin E

(Aquasol E)

Capsule

Drops

1 each

0.3 ml

100 IU, 400 IU, & 1000 IU

15 IU

Vitamin K

Tablet

Injection

1 each

0.5 ml 1 ml

5 mg

1 mg 10 mg

Vitamin B6

Tablet 1 each 25 mg, 50 mg, & 100mg

Vitamin B12 (Cyanocobalamin)

Tablet

Injection

1 each

1 ml

100 g

1000 g Vitamin C

(Ascorbic acid)

Tablet

Syrup

1 each

5 ml

500 mg

500 mg

47

Vitamin C (cont.) Injection 1 ml 500 mg & 1000 mg

Vitamin B Complex

Soft gel capsule

1 each 3 mg B1, 3 mg B2, 20 mg B3, 0.5 mg B6,

1 g B12, 5 mg Panthothenic acid, 60 mg Desiccated liver,

60 mg Debittered Brewers yeast

Thiamin

Thiamine HCl

Tablet

Injection

1 each 1 ml

100 mg

100 mg Niacin

Niacin ER (Niaspan)

Nicotinic Acid

Tablet

Tablet

Tablet

1 each

1 each

1 each

250 mg

500 mg

50 mg & 100 mg

Folic Acid Tablet

Injection

1 each

1 mL

1 mg

5 mg

APPENDIX 4. ADULT MINERAL SUPPLEMENTS AVAILABLE AT UVA

Vitamin

Form

Dose

Composition

Calcium Acetate

Calcium Carbonate

Calcium Oyster Shell w/ Vit. D (Oscal 250)

Calcium Oyster

Shell

Calcium Glubionate

Capsule

Liquid

Tablet

Tablet

Syrup (liquid)

1 each

2.5 ml 4 mL

1 each

1 each

5 mL

667 mg

625 mg 1 g

250 mg

500 mg

1.8 g

48

Vitamin

Form

Dose

Composition

Ferrous sulfate

Ferrous gluconate