adult nutrition support handbook

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  • University of Kentucky Chandler Medical Center


    (Revised 4/11)

  • PERSONNEL: Nutrition Support Service Core Team Members: DDeebboohhaahh RR.. FFlloommeennhhoofftt,, MMDD AAssssiissttaanntt PPrrooffeessssoorr ooff PPeeddiiaattrriiccss DDiivviissiioonn ooff DDiiggeessttiivvee DDiisseeaassee aanndd NNuuttrriittiioonn MMeeddiiccaall DDiirreeccttoorr,, NNuuttrriittiioonn SSuuppppoorrtt SSeerrvviiccee WWiilllleemm DDee VViilllliieerrss JJSS,, MMDD,, PPhhDD PPrrooffeessssoorr ooff MMeeddiicciinnee CChhaaiirr,, DDiivviissiioonn ooff DDiiggeessttiivvee DDiisseeaasseess aanndd NNuuttrriittiioonn AAnnddrreeww BBeerrnnaarrdd,, MMDD PPhhiilllliipp CChhaanngg,, MMDD AAssssiissttaanntt PPrrooffeessssoorrss ooff SSuurrggeerryy SSeeccttiioonn ooff TTrraauummaa aanndd CCrriittiiccaall CCaarree AAtttteennddiinngg:: NNuuttrriittiioonn SSuuppppoorrtt SSeerrvviiccee

    Barbara Magnuson, PharmD , BCNSP Coordinator, Clinical Pharmacist Adjunct Associate Professor, College of Pharmacy Pager #330-4324 Amy Peppard, RD, LD, CNSD, MHA Clinical Dietitian Pager # 330-6375 Meghan Jewell, RD, LD, CNSD Clinical Dietitian Pager # 330-6376 Bud Nave, RT Respiratory Therapist

    Attending Physicians Bernard Boulanger, M.D. Paul Kearney, M.D. .

    TABLE OF CONTENTS Page General Overview 1 Nutrition Support Service Consult Procedure 1 Estimating Nutritional Needs 1 Nutrients 2 Acute Renal Failure 3 Liver Failure 4 Burns Enteral Nutrition Support 4 How to Choose an Enteral Product 5 Initiating Enteral Nutrition 6 Guidelines: Drug Administration via Feeding Tubes 6 Complications of Enteral Feedings 6 Guidelines for Appropriate Adult TPN Indications 9 Ordering Adult TPN 9 Standard UKMC Parenteral Solutions 10 Initiating TPN 10 Discontinuing TPN 10 Glycemic Control 11 Sample TPN Calculations 11 Complication of TPN 11 Home Parenteral Nutrition 11 GGuuiiddeelliinneess ffoorr tthhee PPrroovviissiioonn aanndd AAsssseessssmmeenntt ooff NNuuttrriittiioonn SSuuppppoorrtt 1122 TThheerraappyy iinn tthhee AAdduulltt CCrriittiiccaallllyy IIllll PPaattiieenntt GENERAL OVERVIEW

    Because of the prevalence of malnutrition in hospitalized patients and the relationship between malnutrition and morbidity and mortality, the University of Kentucky Hospital established the Nutrition Support Service (NSS) in 1988. The purpose of the NSS is to provide consultation to primary medical and surgical services regarding the delivery of parenteral and enteral nutrition support to

  • patients who are actually or potentially nutritionally compromised due to disease or injury. The NSS participates in development of hospital guidelines regarding preparation, administration, and monitoring of nutritional therapies. NUTRITION SUPPORT SERVICE CONSULT PROCEDURE: Consultation is provided for all adult patients in the TICU, NSICU, Burn Unit, SICU & MICU. Patients will receive a consult within 48-72 hours of ICU admission. NSS consultations are also available upon a request basis. Phone # 257-5386 Consults for other units Phone # 323-6987 ESTIMATING NUTRITIONAL NEEDS: 1. Ideal Body Weight: (IBW)

    Women: 100 lbs for the first 5 feet; add 5 pounds for each inch above 5 feet. Men: 106 lbs for the first 5 feet; add 6 pounds for each inch above 5 feet.

    Obesity: Patients above 125% of IBW, calculate an adjusted body weight:

    *Adjusted Body Weight = (Actual weight - IBW) 0.25 + IBW

    Less than 5 feet tall: 100 lbs then subtract 2.5 pounds for each inch below 5 feet

    Miflin St. Jeor (MSJ) Formulas: BEE Basal Energy Expenditure Males: BEE= 10 x weight (kg) + 6.25 X height (cm) 5 x age (y) +5 Females: BEE= 10 x weight (kg) + 6.25 X height (cm) 5 x age (y) 161

    Harris-Benedict Equations:

    BEE Men = 66 + (13.7 x Wt kg) + (5.0 x Ht cm) (6.8 x Age yrs) BEE Women = 655 + (9.6 x Wt kg) + (1.7 x Ht cm ) (4.7 x Age yrs)

    2. Estimating caloric requirements: Kcal/Kg , MSJ, HBE

    KKCCAALL//KKgg NNoott lliikkeellyy vvaalliidd iiff BBMMII >>3300 ((ccoonnssiiddeerr uussiinngg IIddeeaall bbooddyy wweeiigghhtt oorr aaddjjuusstteedd BBWW)) WWoouunndd HHeeaalliinngg:: 3300--3355 kkccaall//kkgg,, iinnccrreeaassee ttoo 3355--4400 kkccaall//kkgg iiff tthhee pptt iiss uunnddeerrwweeiigghhtt oorr lloossiinngg wweeiigghhtt.. SSeeppssiiss aanndd IInnffeeccttiioonn:: 2200--3300 kkccaall//kkgg TTrraauummaa:: 2255--3300 kkccaall//kkgg AAccuuttee SSppiinnaall CCoorrdd IInnjjuurryy ((SSCCII)) 2233kkccaall//kkgg oorr HHBBEE ww//oo ssttrreessss ffaaccttoorr CChhrroonniicc SSCCII:: 2200--2233kkccaall//kkgg ddeeppeennddiinngg oonn aaccttiivviittyy SSttrrookkee:: 1199--2200kkccaall//kkgg oorr ((HHBBEE xx ..9955--11..1155)) CCOOPPDD:: 2255--3300 kkccaall//kkgg AARRFF:: 2255--3355 kkccaall//kkgg HHeeppaattiittiiss:: 2255--3355 kkccaall//kkgg iiff wweellll--nnoouurriisshheedd ((@@ 3300kkccaall//kkgg)),, 3300--4400 kkccaall//kkgg iiff mmaallnnoouurriisshheedd CCiirrrrhhoossiiss wwiitthhoouutt eenncceepphhaallooppaatthhyy:: 2255--3355 kkccaall//kkgg CCiirrrrhhoossiiss wwiitthh eenncceepphhaallooppaatthhyy:: 3355 kkccaall//kkgg SSeevveerree AAccuuttee PPaannccrreeaattiittiiss:: 3355 kkccaall//kkgg OOrrggaann TTrraannssppllaanntt:: 3300--3355 kkccaall//kkgg CCaanncceerr:: SSeeddeennttaarryy//nnoorrmmaall wwtt == 2255--3300 kkccaall.. HHyyppeerrmmeettaabboolliicc,, nneeeedd ttoo ggaaiinn wweeiigghhtt,, oorr aannaabboolliicc == 3300--3355 kkccaall//kkgg..

    HHyyppeerrmmeettaabboolliicc,, mmaallaabbssoorrppttiioonn,, sseevveerree ssttrreessss:: >> 3355 kkccaall//kkgg.. OObbeessee == 2211--2255 kkccaall//kkgg Multiply the MSJ by the appropriate "injury factor" which corresponds to the degree of stress and/or the disease. Estimated Calorie Needs: HBE or MSJ x Injury factor

    Injury Factors: Surgery: Major Elective 1.2 - 1.3 Traumatic Brain Injury (CHI) HBE x 1.4 Major Non-elective 1.3 - 1.5 Multiple trauma & CHI HBE x 1.4 1.6

    Minor Elective 1.2 Pentobarbital coma HBE x 1.0 1.2 Minor Non-elective 1.2 - 1.3 Stroke and SAH HBE x 1.0- 1.2 Infection w/temp 1.2 - 1.3 Pneumonia (or ARDS) HBE x 1.2 - 1.3 Neuromuscular Blockade HBE x 1 Burns: 10% TBSA - 1.2, 20%TBSA - 1.5, 30% TBSA 1.7, 40% TBA - 1.8, >50% TBSA 2.0

    IInn tthhee ccrriittiiccaallllyy iillll oobbeessee ppaattiieenntt,, ppeerrmmiissssiivvee uunnddeerrffeeeeddiinngg oorr hhyyppooccaalloorriicc ffeeeeddiinngg wwiitthh EENN iiss rreeccoommmmeennddeedd.. oo BBMMII :: 3300--3355 -- 22222255 kkccaall//kkgg iiddeeaall bbooddyy wweeiigghhtt//ddaayy

  • oo BBMMII :: >>3355,, tthhee ggooaall ooff tthhee EENN rreeggiimmeenn sshhoouulldd nnoott eexxcceeeedd 6600%% ttoo 7700%% ooff ttaarrggeett eenneerrggyy rreeqquuiirreemmeennttss oorr 11111144 kkccaall//kkgg aaccttuuaall bbooddyy wweeiigghhtt//ddaayy ((oorr 22222255 kkccaall//kkgg iiddeeaall bbooddyy wweeiigghhtt//ddaayy))..

    4. Estimated Daily Protein Needs : Maintenance, Unstressed 0.8 - 1.0 g/kg/BW* Infection, Major Surgery, Cancer 1.3 - 1.6 g/kg BW* Mild stress 1.0 - 1.2 g/kg/ BW* Multiple trauma or CHI 1.4 - 1.6 g/kg BW* Anabolism, Mod. stress 1.2 - 1.5 g/kg BW* Major Trauma with CHI, Burns 1.5- 2.0 g/kg BW* Burns 2.0 - 3.0 g/kg BW*

    *BW - Use actual body weight unless above 125% of IBW, otherwise use ADJUSTED body wt. (Assumes normal renal and hepatic function)

    IInn tthhee ccrriittiiccaallllyy iillll oobbeessee ppaattiieenntt ((BBMMII>>3300)) pprrootteeiinn sshhoouulldd bbee pprroovviiddeedd iinn aa rraannggee 11..55--22..00 gg// IIBBWW kkgg

    5. Estimated fat needs: 25-30% of total kcal/day ** Maximum 55% of kcal/day **

    ** May need to increase lipid to decrease glucose intake in patients with hyperglycemia 6. Measuring Energy Expenditure: Indirect Calorimetry (Metabolic Cart Study)

    Most accurate measurement of caloric needs Weir Formula applied to calculate caloric expenditure using the oxygen consumed and carbon dioxide produced

    from the oxidation of carbohydrate, fat, or protein. All critically ill mechanically ventilated patients receiving EN or TPN are eligible to have an oxygen consumption study Metabolic carts are typically performed every 10 days or more frequently as needed.

    Weir Formula: Kcal/day = (3.94 x VO2L/d)+(1.11 x VCO2L/d)-(2.17gm urine N2/d): VO2 = oxygen consumed, VCO2 = carbon dioxide produced

    Respiratory quotient (RQ) is the ratio of CO2 produced to O2 consumed. RQ = CO2

    O2 RQ provides an index of substrate utilization, values and explanations below

    1.0 1.3 Lipogenesis (overfeeding), Hyperventilation, or system leak 0.9 1.0 Primary carbohydrate oxidation, Metabolic acidosis

    0.82- 0.85 Normal, "mixed" substrate oxidation 0.80 Primary protein oxidation 0.70 Primary fat oxidation, SIRS with progressive, Decompensation, Increased Branched Chain Amino acid

    oxidation, Metabolic alkalosis, or Ethanol oxidation 1.3 Outside range question tests validity

    Ideal RQ is 0.82-0.85, but consider the patient's cond


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