ENTERAL AND PARENTERAL NUTRITION UPDATE

WITH THE NUTRITION CARE PROCESS

Suzanne Neubauer, PhD,RD,CNSCFramingham State University

Overlook Health Center, Charlton, MAJanuary 31, 2013

Objectives

Calculate basic flow rates for enteral nutrition considering interruption factors and fluid needs.

Calculate parenteral nutrition formulas, including basic electrolyte considerations.

Practice the nutrition care process for enteral/parenteral cases, focusing on new nutrition diagnosis and intervention standardized language.

Critical Illness Guidelines 2012: Blood Glucose Control promote blood glucose control between

140 to 180 mg per dL in critically ill adult patients Tight blood glucose control (80 to 110

mg per dL) and moderate control < 140 mg per dL is not associated with reduced hospital length of stay

Grade II (fair)days on mechanical ventilation

Grade II (fair)http://www.adaevidencelibrary.com/topic.cfm?cat=1035

Tight blood glucose control (80 to 110 mg per dL) is not associated with infectious complications in surgical (primarily cardiac) patients

Grade II (fair)cost of medical care

Grade III (limited Tight blood glucose control (80 to 110

mg per dL) increases risk of hypoglycemia

Glucose level >180 mg per dL is associated with increased mortalityGrade II (fair)

Critical Illness Guidelines 2012: Blood Glucose Control

http://www.adaevidencelibrary.com/topic.cfm?cat=1035

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Composition of Solution

3-in-1 Total nutrient admixture (TNA) 2-in-1

Lipids infused separately Favorable when patients have high

protein or minimal fluid needs and can maintain euglycemia with addition of modest insulin dose

Must use laminar-airflow hood to decrease the risk of contamination

Clinimix

http://www.clinimix.com/home Clinimix

Sulfite-free (Amino Acid in Dextrose) injections

Clinimix E Sulfite-free (Amino Acid with

electrolytes in Dextrose with calcium) injections

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Protein: Crystalline Amino Acids

Stock solutions range from 8.5% to 20% Usually expressed at final concentration

after dilution vs initial concentration How many g protein in 8.5% AA

solution? 8.5% = 8.5 g = x

100 ml 1000 ml 85 g/L

How many calories in 8.5% AA? 4 kcal/g 85 g/L x 4 = 340 kcal

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Carbohydrate: Dextrose Monohydrate

Stock solutions range from 5.0% to 70% Calories

Anhydrous glucose: 4 kcal/g Hydrous in IV solution: 3.4 kcal/g

CPN Limits Average adult requires 1 mg/kg/min or 100

g/d 5 mg/kg/min 4 mg/kg/min in critically ill and 7 mg/kg/min

in hospitalized patients (Supp Line 2005;27:6)

patients on ventilators: 4 mg/kg/min patients with diabetes: 2-2.5 mg/kg/min

How many g carbohydrate in 25% dextrose solution? 25% = 25 g = x

100 ml 1000 ml 250 g/L

How many calories in 25% dextrose solution? 3.4 kcal/g 250 g/L x 3.4 = 850 kcal

Carbohydrate: Dextrose Monohydrate

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Glucose Tolerance: Mg/Kg/Min

Max: 5 mg/kg/min Solve for g Dextrose:5 mg x 70 kg x (60 minutes x 24 hr)

= 504 g 1000 mg/g

Solve for mg/kg/min:504 g x 1000 mg/g = 5 mg/kg/min

70 kg x 1440 min

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CHO in Peripheral Parenteral Nutrition

PPN: Maximum of 10%; 5% most

common Osmolality

Maximum = 900 mOsm(10 x g pro) + (6 x g CHO) + (.3 x ml

fat)total L

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Lipids: Administration

Slow and continuous 24-hour infusion can improve hepatic reticuloendothelial function As opposed to short, < 10 hrs,

infusion Usually infused over 12 hrs. if

infused separately IVFE infusion rate

NOT > 0.11 g/kg/h

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Calculation Rules for Lipid

Maximum lipid: 60% of total kcal 2.5 g/kg body weight

2 – 4% of total kcal as linoleic acid to prevent EFAD 10% of total kcal as fat meets EFA

Maximum of 30% lipid for septic patients

May use > 30% with hyperglycemic or pulmonary compromised patients

Usually begin with 1 g lipid/kg/day

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Calculation Rules for Lipid Cont’d

Intralipid 10%: 1.1 kcal/ml; 11 kcal/g Total volume of lipid x .1 = g fat

Intralipid 20%: 2.0 kcal/ml; 10 kcal/g Total volume of lipid x .2 = g fat

Intralipid 30%: 3.0 kcal/ml; 10 kcal/g Total volume of lipid x .3 = g fat

Lipid available as 250 ml or 500 ml

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Diprivan (Propofol)

Administered intravenously to intubated/ mechanically ventilated adult ICU patients Provides continuous sedation Controls stress responses Usually infused at 10 mg/mL

IsotonicCheck rate and total volume infused daily

18Supp Line. 2009; 31(6):12-19.

Propofol Calculations

Supp Line. 2009; 31(6):12-19.

Calculate 3-in-1 solution/2200 mL Pt weight @ 55 kg

requires 2200 kcal; 93 g protein; 2200 ml fluid Protein: 93 g x 4 kcal/g = 372 kcal

2200 kcal – 372 kcal = 1828 kcal remaining for fat & CHO

Lipid: use 1 g/kg/day to start 55 g x 1 g/kg = 55 g fat

55 g fat x 10 kcal/g = 550 kcal 1828 kcal – 550 = 1278 kcal remaining for

CHO

CHO: 1278 kcal = 376 g dextrose3.4 kcal/g dextrose

Check maximum CHO 5 mg x 55 kg x (60 x 24 hr) = 5 mg x 55 kg x 1440 min/day 1000 mg/g .005 g x 55 kg x 1440 min/day = 396 g

CHO

Calculate 3-in-1 solution/2000 mL

PN Order Divide g of each substrate by total

volume of fluid. Multiply x 100 for percent.

93 g protein x 100 = 4.2% AA 2200 ml 55 g lipid x 100 = 2.5% lipid 2200 ml 376 g CHO x 100 = 17% CHO 2200 ml

PN Order 93 g protein = 1 L 10% AA 55 g lipid = 250 ml 20% lipid 376 g CHO = 1 L 30% dextrose Total fluid = 2250 ml Kcal: 100 g protein; 400 kcal (21%) 250 ml lipid; 500 kcal (26%) 300 g CHO; 1020 kcal (53%) Total kcal: 1920

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Daily Electrolyte Requirements

The ASPEN Adult Nutrition Support Core Curriculum, 2nd, 2012:248

The ASPEN Adult Nutrition Support Core Curriculum, 2nd, 2012:248

Electrolytes: Initial Dose

Generally aim for the middle of the normal range

Individualize based on renal function, GI losses, acid-base balance and medications

Can use multiple-electrolytes or several single entity electrolyte solutions

Dependent on the compatibility of each electrolyte with the other components in the PN admixture

Electrolytes: Sodium

Generally use approximately equal amounts of chloride and acetate (1:1 ratio)

Acetate and chloride also found in AA solution

In metabolic acidosis use maximum acetate and minimum chlorideAcetate is metabolized as bicarbonate

In metabolic alkalosis use maximum chloride and minimum acetate

Sodium Goal: 1 – 2 mEq/kg Use 1.5 mEq/kg

1.5 x 70 kg reference man = 105 mEq/day

2 L (not including IVFE) so 105/2 = 53 mEq/lSodium Chloride: 53 mEqSodium Acetate: 53 mEq

Electrolytes: Sodium

Electrolytes: Potassium & Phosphorus Potassium available in chloride, acetate, and

phosphate salts K: maintenance @ 1 mEq/kg = 70 mEq

2 L (not including IVFE) so 70/2 = 35 mEq/l If serum K is low correct with a separate

infusion of K

Phosphorus available as the sodium or potassium salt

Phosphorus: 25 mmol/day 25 mmol Potassium Phosphate (37 mEq K) Remainder of K as KCl: 33 mEq

Electrolytes: Calcium

Ca available as gluconate (preferred form) or chloride salt Gluconate preferred b/c more

stable in solutionLess likely to dissociate and precipitate with Phosphorus

dose within accepted solubility range and amino acid pH and concentration

standard dose: 12 mEq/day

Electrolytes: Magnesium

Mg available as sulfate or chloride salt

Mg Sulfate is preferred form Mg 8 – 20 mEq/day

Supp Line 2005;27:13-22

(140)

Supp Line 2005;27:13-22

References

Kingley J. Fluid and electrolyte management in parenteral nutrition. Supp Line. 2005;27(6):13-22.

Whitmire SJ. Nutrition-focused evaluation and management of dysnatremias. Nutr Clin Pract. 2008;23:108-121.

Schmidt GL. Techniques and Procedures: Guidelines for Managing Electrolytes in Total Parenteral Nutrition Solutions. Nutr Clin Pract 2001 16: 226

Baumgartner TG. Enteral and Parenteral Electrolyte Therapeutics. Nutr Clin Pract. 2001;16:226-235.