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Nutrition Basics Michael Sprang M.D. Loyola University Medical Center.

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1 Nutrition Basics Michael Sprang M.D. Loyola University Medical Center

2 Why Nutrition Malnutrition is presents in 30-55% of all inpatients on numerous studies Malnutrition is presents in 30-55% of all inpatients on numerous studies Increased length of stay & increased readmission (esp. elderly) Slower healing, impaired wound healing, suboptimal surgical outcomes Increased length of stay & increased readmission (esp. elderly) Slower healing, impaired wound healing, suboptimal surgical outcomes More complications including infection and readmission More complications including infection and readmission Increased morbidity & mortality Increased morbidity & mortality

3 Obvious malnutrition

4 Who is malnourished? Diagnosis of malnutrition is not a lab value Diagnosis of malnutrition is not a lab value Albumin and pre-albumin are acute-phase proteins that are altered by stress and are not sensitive markers of nutritional status. Albumin and pre-albumin are acute-phase proteins that are altered by stress and are not sensitive markers of nutritional status. How to best determine nutritional status, History and Physical Exam How to best determine nutritional status, History and Physical Exam

5 Subjective Assessment Unintentional wt loss (>10% significant) Unintentional wt loss (>10% significant) Dietary intake Dietary intake types of food eaten,reduced intake and duration of change types of food eaten,reduced intake and duration of change GI symptoms: anorexia, n/v/diarrhea GI symptoms: anorexia, n/v/diarrhea Dysphagia Dysphagia Functional capacity Dysfunction duration Employment change Activity level Ambulatory or bedridden Metabolic demands from underlying disease states

6 Medical History Acute or chronic illnesses Acute or chronic illnesses Including physical impediments to eating Including physical impediments to eating Difficulty with mastication or swallowing Difficulty with mastication or swallowing Recent diet changes and reasons. Recent diet changes and reasons. Change in appetite, loss of taste Change in appetite, loss of taste Unusual stress or trauma (surgery, infection) Unusual stress or trauma (surgery, infection) Medications and prescriptions Medications and prescriptions Steroids, anticonvulsants, Herbals, etc.. Steroids, anticonvulsants, Herbals, etc.. Substance abuse Substance abuse Food intake 24hr,7day recall. Food intake 24hr,7day recall. Fad diets, special dietary restrictions Fad diets, special dietary restrictions

7 Subjective Global Assessment (SGA) - Exam Loss of SQ fat Loss of SQ fat triceps and mid-axillary line at lower ribs triceps and mid-axillary line at lower ribs Muscle wasting in quadriceps & deltoids Muscle wasting in quadriceps & deltoids Presence of edema in ankle/sacral region Presence of edema in ankle/sacral region Presence of ascites Presence of ascites Skin, hair, eye, tongue and mouth Skin, hair, eye, tongue and mouth vitamin and mineral deficiencies vitamin and mineral deficiencies

8 Temporal wasting

9 Triceps Skin fold

10 Supraclavicular Wasting

11 Somatic muscle store depletion

12 Tongue Atrophy

13 Nails- Vertical Ridging

14 When do you feed? Controversy on how soon is soon enough. Controversy on how soon is soon enough. In healthy individuals as long as 7 days In healthy individuals as long as 7 days Malnourished pts benefit from earlier support Malnourished pts benefit from earlier support Surgery guidelines < 72 hours Surgery guidelines < 72 hours

15 Patient needs Calories Calories Protein Protein Fluid Fluid

16 Caloric needs Harris-Benedict Equation Harris-Benedict Equation Basal Energy Expenditure – BEE Basal Energy Expenditure – BEE Works for metabolically active tissue Works for metabolically active tissue If > 125% IBW, ~25% of additional weight is metabolically active If > 125% IBW, ~25% of additional weight is metabolically active Female Female (9.6 x wt(kg)) + (1.7 x ht(cm)) – (4.7 x age) (9.6 x wt(kg)) + (1.7 x ht(cm)) – (4.7 x age) Male Male 66 + (13.7 x wt(kg)) + (5 x ht(cm)) – (6.8 x age) 66 + (13.7 x wt(kg)) + (5 x ht(cm)) – (6.8 x age)

17 BEE modifiers 1.1 = afebrile, paralyzed, sedated 1.1 = afebrile, paralyzed, sedated 1.2 = afebrile, mild to mod stress, minor surgery, intubated 1.2 = afebrile, mild to mod stress, minor surgery, intubated 1.3 = frequent fever, fulminant sepsis, major surgery 1.3 = frequent fever, fulminant sepsis, major surgery 1.4 = frequent fever with constant motion, agitation, surgical complications 1.4 = frequent fever with constant motion, agitation, surgical complications 1.5+ = CHI, trauma, Burns 1.5+ = CHI, trauma, Burns Metabolic Cart Metabolic Cart

18 Protein Average daily needs g/kg Average daily needs g/kg Increased to g/kg in sepsis, trauma, burns Increased to g/kg in sepsis, trauma, burns Reduced to g/kg in renal failure/hepatic failure Reduced to g/kg in renal failure/hepatic failure Once on dialysis, no longer protein restrict Once on dialysis, no longer protein restrict

19 Fluid needs Service dependant Service dependant 4 cc/hr/kg for first 10kg 4 cc/hr/kg for first 10kg 2 cc/hr/kg for the next 10 kg 2 cc/hr/kg for the next 10 kg 1 cc/hr/kg for any additional weight >20kg 1 cc/hr/kg for any additional weight >20kg Simplified formula Simplified formula 30 cc/kg/day 30 cc/kg/day

20 How do you feed Three means of feeding Three means of feeding Oral Oral Enteral/tube feeding Enteral/tube feeding Parenteral nutrition Parenteral nutrition Golden rule- If the gut works use it Golden rule- If the gut works use it Intestinal function, cost, translocation Intestinal function, cost, translocation

21 Oral diet adequacy Eating logistics Eating logistics Mental status Mental status Coordination Coordination Swallow evaluation- If in doubt, check it out Swallow evaluation- If in doubt, check it out Intubation, CVA, dysphagia is common Intubation, CVA, dysphagia is common Calorie Count Calorie Count Assess how much nutrition they are getting Assess how much nutrition they are getting

22 Calculating an oral diet No calculations involved, the food services have standard meal plans for specific orders No calculations involved, the food services have standard meal plans for specific orders Clear liquids are not adequate Clear liquids are not adequate Any diet above Full liquids is considered adequate po nutrition. Any diet above Full liquids is considered adequate po nutrition.

23 Tube Feeding Indications Pts unable to tolerate po with intact GI system Pts unable to tolerate po with intact GI system

24 Access NG and small bore feeding tubes initially NG and small bore feeding tubes initially Semi rigid NG only short term/decompression Semi rigid NG only short term/decompression PEG/PEJ indicated if >4 weeks PEG/PEJ indicated if >4 weeks Endoscopically placed Endoscopically placed G and J tubes are surgically placed, G and J tubes are surgically placed, Other surgery, endoscopic difficulty Other surgery, endoscopic difficulty

25 Tube Placement Pre-pyloric vs. post-pyloric placement Pre-pyloric vs. post-pyloric placement Pre-pyloric (preferred) allows intermittent feeding (more physiologic), does not require a pump and there is more information about drug absorption with gastric delivery Pre-pyloric (preferred) allows intermittent feeding (more physiologic), does not require a pump and there is more information about drug absorption with gastric delivery Post-pyloric feedings should be considered if tube feeding related aspiration, elevation of head of bed >30 contraindicated or GI dysmotility intolerant of gastric feeding. Post-pyloric feedings should be considered if tube feeding related aspiration, elevation of head of bed >30 contraindicated or GI dysmotility intolerant of gastric feeding. All post-pyloric tubes must use continuous feeding program All post-pyloric tubes must use continuous feeding program

26 Formula Dietiticians are very helpful Dietiticians are very helpful Get a formulary card Get a formulary card Formulas are frequently changing Formulas are frequently changing Osmolite 1 Cal- standard formula Osmolite 1 Cal- standard formula Replete/Nutren- higher protein, lower CHO Replete/Nutren- higher protein, lower CHO Supplena- low protein, low volume- renal formula Supplena- low protein, low volume- renal formula Nepro/Nutren renal- normal protein, low volume- dialysis Nepro/Nutren renal- normal protein, low volume- dialysis Nutrihep- branched chain AA for hepatic encephalopathy Nutrihep- branched chain AA for hepatic encephalopathy Peptamen- semi-elemental formula for malabsorption Peptamen- semi-elemental formula for malabsorption

27 Example 66-year-old male unable to eat because of dysphagia after a acute recent stroke. GI tract functioning. Non-ICU patient. Height: 168cm, Weight: 60kg, BMI 21

28 Questions? Harris Benedict Equation? Harris Benedict Equation? Protein Goal? Protein Goal? Estimated Fluid Requirement? Estimated Fluid Requirement?

29 Caloric Needs HB (male) = (60) + 5(168) - 6.8(66) so BEE = 1280 kcal/day HB (male) = (60) + 5(168) - 6.8(66) so BEE = 1280 kcal/day Calorie goal: BEE x 1.2 ~1500 kcal/day Calorie goal: BEE x 1.2 ~1500 kcal/day

30 Protein Requirements Protein goal: 1 g/kg/day = 60g/day Protein goal: 1 g/kg/day = 60g/day No complicating factors in this patient No complicating factors in this patient

31 Fluid Requirements? Estimated fluid requirement: 30mL/kg/day x 60kg = 1800mL/day Estimated fluid requirement: 30mL/kg/day x 60kg = 1800mL/day

32 Formula Check the formulary for the closest match Check the formulary for the closest match We needed 1500 kcal, 60g protein, 1800 cc H20 We needed 1500 kcal, 60g protein, 1800 cc H20 Osmolite standard formula has 1.0 kcal/mL and 44g protein/L Osmolite standard formula has 1.0 kcal/mL and 44g protein/L 1500mL/day will provide 1500 kcal/day, 66g protein, 1260 cc free water 1500mL/day will provide 1500 kcal/day, 66g protein, 1260 cc free water 1800mL – 1260mL in tube feeding formula = 540mL/day fluid still required 1800mL – 1260mL in tube feeding formula = 540mL/day fluid still required Remainder as free h20 flushes Remainder as free h20 flushes

33 Tube feeding precautions Be aware of drugs… Be aware of drugs… with high osmolality or sorbitol content like KCl, acetaminophen, theophylline can cause diarrhea with high osmolality or sorbitol content like KCl, acetaminophen, theophylline can cause diarrhea that clog tubes such as psyllium, ciprofloxacin suspension, sevelamer and KCl (do not use KCl tablets; use liquid or powder form) that clog tubes such as psyllium, ciprofloxacin suspension, sevelamer and KCl (do not use KCl tablets; use liquid or powder form) whose absorption is interfered with by tube feeds such as phenytoin whose absorption is interfered with by tube feeds such as phenytoin

34 Parenteral nutrition Indications for Parenteral nutrition Indications for Parenteral nutrition SBO, ileus, ischemic bowel, high output proximal fistula, severe pancreatitis, active Gi bleed, intestinal GVHD, Intractable vomiting/diarrhea SBO, ileus, ischemic bowel, high output proximal fistula, severe pancreatitis, active Gi bleed, intestinal GVHD, Intractable vomiting/diarrhea

35 Access and delivery Peripheral parenteral nutrition can be given through any IV. Peripheral parenteral nutrition can be given through any IV. Limited concentrations- Amino acids 2.75% and Dextrose 10% Limited concentrations- Amino acids 2.75% and Dextrose 10% Total parenteral nutrition requires central access Total parenteral nutrition requires central access Central line, port, PICC Central line, port, PICC Lipid emulsion can go through any IV Lipid emulsion can go through any IV

36 Prescribing Recall that a 10% solution = 10g/dL = 100g/L; i.e., 10% dextrose = 100g/L (3.4 kcal/g dextrose); Recall that a 10% solution = 10g/dL = 100g/L; i.e., 10% dextrose = 100g/L (3.4 kcal/g dextrose); 5% amino acid = 50g/L (4 kcal/g protein); 5% amino acid = 50g/L (4 kcal/g protein); 10% fat emulsion = 1.1 kcal/mL, 20% fat emulsion = 2 kcal/mL 10% fat emulsion = 1.1 kcal/mL, 20% fat emulsion = 2 kcal/mL Determine estimated need for calories, protein and fluid Determine estimated need for calories, protein and fluid We include protein in caloric estimate since amino acids are oxidized and provide energy. We include protein in caloric estimate since amino acids are oxidized and provide energy. Fats should be 25-35% of total calories Fats should be 25-35% of total calories

37 Practice TPN Same patient needs as before 1500 kcal, 60g protein, 1.5 Liters Same patient needs as before 1500 kcal, 60g protein, 1.5 Liters Protein 60g = 240 kcal Protein 60g = 240 kcal 750 kcal from CHO=(750/3.4)=220 g/CHO 750 kcal from CHO=(750/3.4)=220 g/CHO Give 25-35% calories as fat Give 25-35% calories as fat Lipid 20% x 250cc= 500 calories Lipid 20% x 250cc= 500 calories 220g/1.5 L= D15, 60g protein/1.5L= AA 4% 220g/1.5 L= D15, 60g protein/1.5L= AA 4% 1.5L/24hours= 62 cc/hr Get a TPN card for electrolytes and additives Get a TPN card for electrolytes and additives

38 Transition from TPN to TF Transition from TPN when contraindications to enteral feeding resolve Transition from TPN when contraindications to enteral feeding resolve Start pt on TF for tolerance and wean TPN Start pt on TF for tolerance and wean TPN Once TF is 35-50% of TF then taper down TPN to 1/2 Once TF is 35-50% of TF then taper down TPN to 1/2 Once TF > 75% needs, stop TPN Once TF > 75% needs, stop TPN

39 Nutrition support complications Aspiration Aspiration Diarrhea Diarrhea Abdominal distension/pain Abdominal distension/pain Refeeding syndrome Refeeding syndrome

40 Complications Aspiration Aspiration Elevate the head of the bed 30 to 45° during feeding Elevate the head of the bed 30 to 45° during feeding Check residual volumes q 6 hours if continuous or before feedings if intermittent. > cc is significant. Check residual volumes q 6 hours if continuous or before feedings if intermittent. > cc is significant. Consider post-pyloric placement Consider post-pyloric placement Recheck tube placement by x-ray after placement or manipulation Recheck tube placement by x-ray after placement or manipulation

41 Complications Diarrhea; common problem but might not be caused by tube feeding Diarrhea; common problem but might not be caused by tube feeding Review medications for sorbitol (in liquid medicines), magnesium, and osmolality Review medications for sorbitol (in liquid medicines), magnesium, and osmolality Consider infectious etiology (especially C. difficile) Consider infectious etiology (especially C. difficile) Rule-out infusion of full strength hyperosmolar formula or medications into jejunum Rule-out infusion of full strength hyperosmolar formula or medications into jejunum Can try fiber containing formula and, if no infection, loperamide or tincture of opium Can try fiber containing formula and, if no infection, loperamide or tincture of opium

42 Complications Abdominal distention or pain Abdominal distention or pain Assess for ileus, obstruction or other abdominal pathology Assess for ileus, obstruction or other abdominal pathology Stop the tube feeding until problem resolved then restart slowly Stop the tube feeding until problem resolved then restart slowly Constipation Constipation Be certain fluid (including water program) is adequate Be certain fluid (including water program) is adequate Commonly medication induced, need counter agents Commonly medication induced, need counter agents Can use fiber-containing formula (may worsen) Can use fiber-containing formula (may worsen)

43 Complications Refeeding Syndrome Refeeding Syndrome Repletion of severe malnourished state Repletion of severe malnourished state Low K, Phos, Magnesium Low K, Phos, Magnesium Fluid shifts Fluid shifts Arrhythmia and death Arrhythmia and death Key is recognition in high risk patients and prevention Key is recognition in high risk patients and prevention Replace electrolytes before advancing nutrition Replace electrolytes before advancing nutrition Monitor labs Monitor labs

44 Common Calls NG/SBFT is out NG/SBFT is out PEG, g-tube or j-tube is out PEG, g-tube or j-tube is out High residuals High residuals Elevated glucose Elevated glucose Weekend TPN Weekend TPN No formula, attending wants to feed No formula, attending wants to feed

45 Questions?


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