Lecture on en and PN

8/3/2019 Lecture on en and PN

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Enteral

andParenteral

NutritionDiane Mendoza, RND, MSCN



Enteral and Parenteral Nutrition

OUTLI

NE:Introduction

Enteral Nutrition:

DefinitionIndications and Contraindications

Feeding Routes

Formula SelectionAdministration

Considerations

Monitoring




Parenteral Nutrition:Definition

Indications and Contraindications

Feeding AccessComponents of PN

Complications

MonitoringTransitional feeding and Discontinuation



³ The Skeleton in theHospital Closet´

Body Height not recorded in56%

Body Weight not Recordedin 23%

61% of those with recorded

weigh

t loss > 6 kg 37% had albumin < 3.0 gm/dl

Butterworth, CE, Nutr, Today 1974, April 4-8

Introduction:



Prevalence of Malnutrition

30 ± 50% of Hospitalized Patients worldwide

> In the US 30 ± 50 %

> In Britain 20 ± 48 %

> In Brazil 46 %

In the Philippines

> Private Hospital (SLMC) 48 %

>Gov¶t. Hospital (Amang Rodriguez)52%

Introduction:



NORMAL Starvation:

Lean bodymass

Gluconeo-genesis

ProteinCatabolism

NegativeN2 Balance

Water & MineralDepletion

Adjustment toNew Metabolic

State

Introduction:




FOODS

GIT

CELLS

LIVER

NORMAL PHYSIOLOGIC ROUTE OF FOOD







PROPER NUTRITION INTERVENTION

WHAT CAN WE DO?...




From: Dr. Jeff inciong



Enteral Nutrition

Supplementation or total nutrition feeding directlyinto the GIT using a feeding tube.

Beneficial effect on maintenance of intestinalstructure and function.

Enhanced utilization of nutrients, ease and safetyof administration and cost efficiency.



Enteral Nutrition

From: Dr. Jeff inciong




If the gut isWORKING;

USE IT!



Indication for Use:

ASPEN GUIDELINES FOR USE OF ENTERAL TUBE FEEDINGS

patients with PEM with inadequate oral intake for the previous5 days;

With < 50% of required needs for the previous 7 to 10 days

Severe dysphagia

Major full thickness burns

Short gut

Psychiatric/eating disorders Impaired swallowing

Increased nut¶l losses (sepsis)



ASPEN GUIDELINES FOR USE OF ENTERAL TUBE FEEDINGS:

LIMITED OR UNLIMITED VALUE

Px receiving intensive therapy;

Px with acute enteritis secondary to radiation, acute infectionor active inflammatory bowel disease;

Px with <10% remaining small intestines

Indication for Use:



ASPEN GUIDELINES FOR USE OF ENTERAL TUBE FEEDINGS:

CONTRAINDICATED

Px with complete or small bowel obstruction;

Px with ileus or intestinal hypomotility

Px with severe diarrhea resistant to pharmocologic tx

Severe pancreatitis

Shock

Gastrointestinal bleeding

Legal matters

Contraindications:



FEEDING ROUTES

NASOENTERIC FEEDING

Feeding Routes:



Feeding Routes:

ENTEROSTOMYFEEDING



Summary of Enteral Access Sites:

SITE INDICATIONS ADVANTAGES DISADVANTAGES

NASOGASTRIC normal GI function uses and stimulate GI aspiration

flexibility in administration discomfort

medications can be placed nasal irritation

tube insertion at bedside tube displacement

NASODUODENAL normal small intestine tube insertion at bedside discomfort

need to bypass stomach tube displacement

NASOJEJUNAL normal small intestine tube insertion at bedside discomfortneed to bypass stomach tube displacement

GASTROSTOMY normal GI funx. Long term feeding access surgical procedurebypass the upper GI reduced risk of displacement irritation

allows bolus feeding infection on sitePEG normal GI outpatient procedure irritation and infection

bypass the upper GI long term feeding access for insertion siteless expensive; reduced riskfor tube displacement

JEJUNOSTOMY normal GI function increased tolerance for early surgical procedurebut need to bypass initiation of EN risk for irritationcomponents of GI tract and infection, risk of

clogging may be greater



Formula Selection:



Formula Selection: Substrate Sources

POLYMERIC FORMULA composed of intact proteins, disaccharides and

polysaccharides variable amounts of fat, residue and lactose. osmolality of polymeric

formulas is usually lower thanthe osmolality of ³elemental´formulas.

In general, these formulasrequire a functioning

gastrointestinal tract fordigestion and absorption of nutrients.




PREDIGESTED

FORMULA

composed of low molecular

weight nutrients minimal residue are thought to

lead to less stimulation of pancreatic and gastrointestinalsecretions

less allergenic th

an oth

erformula.




MODULAR PRODUCTS

individual micronutrient

modules such as glucosepolymers, protein, orlipids are available asadditives to food andenteral formulas to

ch

ange overall fuelcomposition.




SPECIAL DISEASE-SPECIFIC

FORMULASthese products are designed

for patients who have specific

medical conditions that may

require nutrient modification.




DIETARY FIBER

Fiber-containing enteral formulas are most viscous

and may require a larger diameter feeding tube foradequate flow.



Formula Selection: Osmolality

Measure of the oncotic pressure exerted by a solution;

What determines osmolality?Number and

Size of : electrolytes, CHO; minerals; CHONFactors that can increase osmolality?

Concentration of formulas; (energy:volume)Addition of modular products

Formulas with higher osmolality may induce the shiftof free water into the intestinal space; thus may

cause rapid transit diarrhea.



Administration:

Continuous feeding ±constant, steady rate over a 16-24hour period, Cyclic Feeding ± delivered by continuous drip method at

an increased rate over 8 to 16 hours, Intermittent feeding- can be infused at specific intervalsthroughout the day, Bolus feeding- rapid administration of feeding



Administration:

Conversion to glucose as a majorenergy source

Insulin release

Cellular Glucose Uptake, Protein synthesis

Clinical Symptoms of refeedingsyndrome

Depletion of Phosphate, K+ & Mg

Refeeding Syndrome:



Initiation and Special Considerations

INITIATION

can be started at 10-40 ml/hr, then progressuntil desired rate.

CONSIDERATIONS:Temperature

Bacterial Contamination

Prevention of aspiration

Patency

Medications



Complications: Gastrointestinal

Diarrhea

Hyperosmolar formula

Malabsorption

Bolus feeding, volume overload, rapid

administration

PEM

Hypoalbuminemia

Medications

Nausea or vomiting

Constipation



Complications:Mechanical

Mechanical Problems:

Occlusion or clogging of the tube

Misplacement of the tube

Skin irritation around ostomy site

Metabolic problems

Electrolyte and metabolic abnormalities

deh

ydration



Termination of Tube Feeding

Gradual weaning;

Increased oral intake

Decreasing the volume of the formula

can eat/drink the formula that was earlier on the

tube

Monitor oral intake.



Monitoring:

Tube placement

Daily weight

Intake and output

CBG (DM, px w/ steroids)

Gastric residuals (esp. if h

igh

risk foraspiration)

Bowel movements and consistency

Feeding tolerance

ElectrolytesBaseline and weely reassesment of nut.indeceswith appropriate adjustments

Daily feeding tube site care



How to Compute for NutritionalHow to Compute for NutritionalRequirements:Requirements:

Given Data:Given Data:

Ht 5¶4´ Ht 5¶4´

Age 54 years oldAge 54 years old

Wt 78 kgs.Wt 78 kgs.

Diet RxDiet Rx 35 kcal/ kg BW 1.2 gms CHON 60%35 kcal/ kg BW 1.2 gms CHON 60%HBV No Sources of Simple SugarsHBV No Sources of Simple SugarsLow PotassiumLow Potassium



To Compute :To Compute :

DBW= 5 x 12 = 60DBW= 5 x 12 = 6060 + 4 = 6460 + 4 = 6464 x 2.54=162.5664 x 2.54=162.56162.56162.56 ±± 100 =62.56100 =62.56-- 6.256 (10%)6.256 (10%)

= 56.31 kg DBW= 56.31 kg DBW



ExampleExample

To Assess:To Assess:

% IDW= 78 kg% IDW= 78 kg

56.31 kg56.31 kg

= 1.39 x 100 = 139 %= 1.39 x 100 = 139 %

Interpretation:Interpretation:

Patient is Obese class 1Patient is Obese class 1



To follow diet Rx:

CHON= 56.31 x1.2x=67.84 ~ 68 gm CHON68 x 4=272 kcal

TER= 35 x 56.31 = 1970.85 kcal

NPC = 1970.85 ± 272 = 1698.85

1698.85 x 0.6 = 1019.31 kcal / 4=254.83 ~ 255 gm CHO

1698.85 x 0.4 = 679.54 / 9= 75.51 ~75 gm FATS



Complete Diet RX

TER= 1970.85 kcal/ day255 gm CHO / day

68 gm CHO

N/ day75 gm Fats /day



Food Item Exchanges CHO

gm

CHON

gm

Fats

gm

Kcal

Vegetables 2 6 2 - 32

Fruit 2 20 - - 80

Milk, low

Fat 2 24 16 10 250

Rice 9 207 18 - 900

Meat/EW 4 - 32 4 164

Fats 12 - - 60 540

Total - 257 68 74 1966

Computation based on FELComputation based on FEL




Enteral Formula Scoop perCan

1 CUP 1 SCOOP

CHO PRO FAT KCAL CHO PRO FAT KCAL

Ensure 1 kg (Vanilla) 112 (1000) 72.8 19.74 17.5 1056 5.20 1.41 1.25 37.72

Nutren Fiber 49 (400) 57.85 18.3 17.4 458.25 4.45 1.41 1.34 35.25

Nutren Optimum 54 (400) 63.56 20.16 19.18 503.3 4.54 1.44 1.37 35.95

Nutren Diabetes 43 (400) 55.08 18.84 21.72 491.16 4.59 1.57 1.81 40.93

Nutren Junior 51 (400) 63.44 14.17 18.72 476.58 4.88 1.09 1.44 36.66

Peptamen 48 (400) 72.15 23.25 22.65 586.2 4.81 1.55 1.51 39.08

Peptamen Junior 51 (500) 4.97 1.08 1.37 36.09

Nutricomp Protein 100 (250) 0 59.8 6.5 245.18 0 2.3 .25 9.43

Nutricomp Caloric 90 (450) 121.5 0 0 513 4.5 0 0 19

Nutricomp Renal - 55.75 20.67 28.37 559.99 *44.8 *16.

6

*22.8 *450

Impact CHON 30 (453.7) 1.65 11.7

5

.32 53

polycose 94 - - - 5.64/tbsp _ - -

Resource 50(400) 4.9 1.25 1.25 35.7

Aminoleban EN - 31.05* 13.5*

3.5* 210*

Glucerna SR 48 (400) 62.92 23.79 17.29 477.88 4.84 1.83 1.33 36.76

Prosure 46(380) 81 27 10 502.5



Computation using Nutritional andComputation using Nutritional andmodularmodular

Diet Rx 35 kcal/ kg BW 1.2 gms CHON 60% HBV NoDiet Rx 35 kcal/ kg BW 1.2 gms CHON 60% HBV NoSources of Simple Sugars Low PotassiumSources of Simple Sugars Low Potassium

255 gmCHO

68 gmCHON

75 gmFats K,mg

Nutren Db 3.5 c -192.78 -65.94 -76.02 2184

difference 62.22 2.06 -1.08 -

Polycose 11 tbsp -62.04 - - -

NutricompProtein 0.18 2.3 - -



Computation using Nutritional and naturalComputation using Nutritional and naturalfoodsfoods

255 gmCHO

68gmCHON

75 gmFats K, mg

Nutren Db, 2 c 110.16 37.68 43.44 1248

difference 144.84 30.32 31.56 -Veg, 1 c. 6 2 95

fruit, 2 's 20 160

bread, 5's 115 10 175

Eggwhite, 4's 16 2 190oil, 6 tsp 30 138

TOTAL 251.16 65.68 75.44 2006



Enteral Nutrition



Parenteral Nutrition

WHEN ENTERAL INTAKE ISu

uIMPOSSIBLE

...IMPROBABLE uINADVISABLE

uHAZARDOUS




PARENTERAL NUTRITION ± is the provision of nutrients into the bloodstream intravenously.

para=

outsideenteron = intestine

intra = within

vena = vein



Indications:

cancer px w/ GI problems

Preoperative PN

Acute inflammatory

bowel diseaseRenal failure

Hepatic disease

Acute pancreatitis

Critical care

Short bowelsyndrome

Eating disorders





















Parenteral NutritionParenteral Nutrition


































Aggregation -

clumping of trig

particles with the

emulsion

Creaming -

accumulation of triglycerides at the

top of emulsion




Cracking ±

separation of the oil andwater components of

the emulsion

Coalescence -

fusion of small trigparticles into larger

particles













Macronutrient Concentrations in PN



Macronutrient Concentrations in PNSolutions

Macronutrient concentrations (%) = thegrams of solute/100 ml of fluid

D70 has 70 grams of dextrose per 100 ml.

10% amino acid solution has 10 gramsamino acids/100 ml of solution

20% lipids has 20 grams of lipid/100 ml of solution




Protein Content Calculations

To calculate the

grams of protein

supplied by a TPN solution, multiply the

total volume of

amino acid solution

(in ml*) supplied in aday by the amino

acid concentration.

Example Protein

Calculation

1000 ml of 8%amino acids:

1000 ml x 8 g/100

ml = 80g

Or 1000 x .08 = 80 g




Calculation of Dextrose Calories Calculate grams of dextrose:

± Multiply the total volume of dextrose soln(in ml) supplied in a day by the dextrose

concentration. This gives you grams of dextrose supplied in a day.

Multiply the grams of dextrose by 3.4 (there

are 3.4 kcal/g dextrose) to determinekcalories supplied by dextrose in a day.




Sample Dextrose Calculation

1000 ml of D50W (50% dextrose)

± 1000 ml x 50g / 100 ml = 500g dextrose

± OR 1000 ml x .50 = 500g dextrose

500g dextrose x 3.4 kcal/g = 1700 kcal




Calculation of Lipid Content

To determine kcalories supplied by lipid*,multiply the volume of 10% lipid (in ml) by1.1; multiply the volume of 20% lipid (in ml)by 2.0.

If lipids are not given daily, divide totalkcalories supplied by fat in one week by 7 toget an estimate of the average fat kcaloriesper day.

*Lipid emulsions contain glycerol, so lipid emulsion does

not have 9 kcal per gram as it would if it were pure fat.

Some use 10 kcal/gm for lipid emulsions.




500 ml of 10% lipid

± 500 ml x 1.1 kcal/ml = 550 kcal

500 ml 20% lipid

± 500 ml x 2.0 kcal/ml = 1000 kcal

Or, alternatively, 500 ml of 10% lipid = 50grams lipid x 10 kcal/g or 500 kcal




Calculation of Dextrose/AA with

Piggyback Lipids (2-in-1)

Determine patient's kcalorie, protein,and fluid needs.

Determine lipid volume and rate for"piggy back" administration. ± Determine kcals to be supplied from lipid.

(Usually 30% of total kcals).

± Divide lipid kcals by 1.1 kcal/cc if you areusing 10% lipids; divide lipid kcals by 2kcal/cc if you are using 20% lipids. This isthe total volume.

± Divide total volume of lipid by 24 hr to

determine rate in cc/hr.




Example Calculation

Nutrient Needs:

Kcals: 1800. Protein: 88 g. Fluid: 2000 cc

1800 kcal x 30% = 540 kcal from

lipidLipid (10%):

±540 kcal/1.1 (kcal/cc) = 491 cc/24 hr=

20 cc/hr 10% lipid (round to 480 ml)

Remaining fluid needs: 2000cc - 480cc= 1520cc




Determine Protein concentration

Subtract volume of lipid from total fluidrequirement to determine remainingfluid needs.

Divide protein requirement (in grams)by remaining fluid requirement andmultiply by 100. This gives you theamino acid concentration in %.

Multiply protein requirement in grams x4 to determine calories from protein




Protein Calculations

Protein: 88 g / 1520 cc x 100 =5.8% amino acid solution

88 g. x 4 kcal/gm =352 kcals fromprotein

Remaining kcal needs: 1800 ± (528 +

352)=

920 kcal




Determine dextrose concentration.

Subtract kcals of lipid + calories fromprotein from total kcals to determineremaining kcal needs.

Divide "remaining kcals" by 3.4 kcal/gto determine grams of dextrose. Divide dextrose grams by remaining

fluid needs (in protein calculations) and

multiply by 100 to determine dextroseconcentration. Determine rate of AA/dex solution by

dividing "remaining fluid needs´ by 24hr.




Dextrose Concentration

920 kcal/3.4 kcal/g = 270 g dextrose

270 g / 1520 cc x 100=

17.

7%dextrose solution Rate of Amino Acid / Dextrose: 1520 cc / 24hr = 63 cc/hrT

PN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @63 cc/hr with 10% lipids piggyback @20 cc/hr




Re-check calculations

TPN recommendation: Suggest two-in-one PN 17.7% dextrose, 5.8% a.a. @63 cc/hr with 10% lipids piggyback @

20 cc/hr63 cc/hr x 24 = 1512 ml

1512 * (.177) = 268 g D X 3.4 kcals= 911 kcals

1512 * (.058) = 88 g a.a. x 4 kcals = 352

20 cc/hr lipids*24 = 480*1.1 kcals/cc = 528




Evaluation of a PN OrderPN 15% dextrose, 4.5% A.A., 3% lipid @

100 cc/hour

Total volume = 2400

Dextrose: 15g/100 ml * 2400 ml = 360g

360 g x 3.4 kcal/gram = 1224 kcals

Lipids 3 g/100 ml x 2400 ml = 72 glipids

72 x 10 kcals/gram = 720 kcals




Evaluation of a PN Order

Amino acids: 4.5 grams/100 ml * 2400ml = 108 grams protein

108 x 4 = 432 kcals

1224 + 720 + 432 = 2376 total kcals Lipid is 30% of total calories

Dextrose is 51.5% of total calories

Protein is 18% of total calories



Monitoring for Complications

Malnourished patients at risk for refeedingsyndrome should have serum phosphorus,magnesium, potassium, and glucose levelsmonitored closely at initiation of SNS. (B)

In patients with diabetes or risk factors forglucose intolerance, SNS should be initiatedwith a low dextrose infusion rate and bloodand urine glucose monitored closely. (C)

Blood glucose should be monitored

frequently upon initiation of SNS, upon anychange in insulin dose, and untilmeasurements are stable. (B)

ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and pediatric

patients. JPEN 26;41SA, 2002

ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult andpediatric patients. JPEN 26;41SA, 2002




Serum electrolytes (sodium, potassium,chloride, and bicarbonate) should bemonitored frequently upon initiation of SNSuntil measurements are stable. (B)

Patients receiving intravenous fat emulsionsshould have serum triglyceride levelsmonitored until stable and when changes aremade in the amount of fat administered. (C)

Liver function tests should be monitoredperiodically in patients receiving PN. (A)




Acute Inpatient PN Monitoring

Parameter Daily

Frequency

3x/week Weekly

Glucose Initially ¥

Electrolytes Initially ¥

Phos, Mg,BUN, Cr, Ca

Initially ¥

TG ¥

Fluid/Is & Os ¥

Temperature ¥

Adapted from K&M, p. 549




Inpatient Monitoring PN

Parameter Daily

Frequency

Weekly PRN

Body Weight Initially ¥

Nitrogen Balance Initially ¥

HGB, HCT ¥

Catheter Site ¥ Lymphocyte Count ¥ ¥

Clinical Status




TRANSITIONAL FEEDING ANDDISCONTINUATION:

GIT-Functional?

Reduction in PN can be made as enteral ororal feedings are increased.

clumping of trig particles with the emulsion

ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult andpediatric patients. JPEN 26;41SA, 2002




Maintain full PN support until pt is tolerating1/3 of needs via enteral route

Decrease TPN by 50% and continue to taperas the enteral feeding is advanced to total

TPN can reduce appetite if >25% of calorieneeds are met via PN TPN can be tapered when pt is consuming

greater than 500 calories/d and d-c¶d whenmeeting 60% of goal

TPN can be rapidly d-c¶d if pt is receivingenteral feeding in amount great enough tomaintain blood glucose levels




Cessation of TPN

Rebound hypoglycemia is a potentialcomplication

Decrease the volume by 50% for 1-2 hoursbefore discontinuing the solution to minimizerisk

PPN can be stopped without concern for

hypoglycemia



DIANE MENDOZA, RNDgRaciAs!

Documents

Lecture on en and PN