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-J orge, 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
J oseph 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.












1
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
<74% = severe malnutrition

B. Recent weight change = UBW current weight 100
UBW


2
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 <18.5 may indicate nutritional risk and increased risk of illness (8).

Table 1.1 Risk of Associated Disease According to BMI and Waist Size

BMI*

Category
Waist less than
or equal to
40 in. (men) or
35 in. (women)
Waist greater
than
40 in. (men) or
35 in. (women)
< 18.5 Underweight --- N/A
18.5 24.9 Normal --- N/A
25.0 29.9 Overweight Increased High
30.0 34.9 Obesity Class I High Very High
35.0 39.9 Obesity Class II Very High Very High
40 or greater Obesity Class III Extremely High Extremely High
*These values may underestimate the degree of malnutrition in some patients. An overweight or obese patient may be
malnourished if significant weight loss has occurred, but not fall into the category of malnutrition based on BMI alone.
Adapted from: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm. Accessed 3/3/11.
3



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 Weight
a

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
a
Double 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.






















4
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, B
12

____________________________________________________________________________________________


5
6
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 N
2
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 N
2
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.
7
8
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













9

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.
















10

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+______
(<5%= small loss, between 5 and 10%= potentially significant 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

11

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
12
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 (VO
2
) and the carbon dioxide
(VCO
2
) 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 s 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








13



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



14



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.
15
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.



16
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).









18
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.









19

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 CO
2
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 CO
2
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.



20
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 <300 ml at recheck, then
restart feeds using initial rate and progress per orders. If continues > 500 ml, notify the
physician.
- Notify physician if feedings held twice in 24 hours.
- Return up to 250 ml gastric residuals to the patient.












21
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 s 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
22
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 D
10

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














25

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 CO
2
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 (s 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).
27

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.



















28


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


29


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.

















32

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
Recommendations
2
( 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



36


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 J C. 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;
J anuary 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. 2
nd
Ed. Silver Spring, MD. American Society of Parenteral and
Enteral Nutrition, 1993:111.
16. Evans J N. 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. J eejeebhoy. 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


CO
2
(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)
B
1

(mg)
B
2

(mg)
Niacin
(mg)
B
5

(mg)
B
6

(mg)
B
12

(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, Calci um 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, Mol ybdenum 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, Mol ybdenum 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, Bioti n 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, Mol ybdenum 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 D
2
-
Ergocalciferol
Capsule


Drops (Drisdol)
1 each


0.25 ml
50,000 IU


2000 IU

Vitamin D
3
-
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 B
6

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

Vitamin B
12

(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 B
1
, 3 mg B
2
,
20 mg B
3
, 0.5 mg B
6
,
1 g B
12
,
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

Iron dextran
Tablet

Tablet

Injection
1 each

1 each

1 mL
300 mg

300 mg

50 mg
Zinc Sulfate

Zinc trace elements
Capsule

Injection
1 each

1 mL
220 mg

1 mg
Chromium Injection 10 mL 40 mcg
Phosphorus
Phos-Nak (Na,
Phos, K
+
)


Neutrophos-K (K
+
,
Phos)


Powder



Powder


1 packet



1 packet

P-250 mg/mol
Na-160 mg
K
+
-280 mg

P-250 mg
K
+
-556 mg
Magnesium
Gluconate



Magnesium Oxide




Magnesium Sulfate
Tablet

Liquid
Capsule
Tablet
Injection
1 each

5 mL

1 each

1 each

1 ml
500 mg

1000 mg

140 mg

400 mg

1 gm
Potassium Acetate

Potassium Chloride








Potassium Iodine
Injection

Capsule
Powder
Liquid

Liquid
1 mL

1 each

1 scoop

3.75, 7.5, 11.25,
22.5 mL

1 ml
2 mEq

10 mEq

20 mEq

5, 10, 15, 30 mEq



1 g








49

APPENDIX 5 CONVERSION INFORMATION

1. Converting from milliequivalents (mEq) to milligrams (mg) and vice versa:

mEq = mg
Conversion factor

Conversion Factors For Major Minerals
1 mEq Na =1 mmol Na =23 mg Na
1 g Na =43 mEq Na =43 mmol Na
1 mEq K =1 mmol K =39 mg K
1 g K =26 mEq K =26 mmol K
1 mEq Ca =0.5 mmol Ca =20 mg Ca
1 g Ca =50 mEq Ca =25 mmol Ca
1 mEq Magnesium =0.5 mmol Magnesium =12 mg Magnesium
1 g Magnesium =82 mEq Magnesium =41 mmol Magnesium
1 mmol Phos =2 mEq HPO
3
=31 mg Phos
1 mEq Cl =1 mmol Cl =35 mg Cl
1 g Cl =29 mEq Cl =29 mmol Cl

Major Mineral Content in Various Compounds and solutions
1 g NaCl =393 mg Na =17 mEq Na
1 g NaHCO
3
=273 mg Na =12 mEq Na
1000 ml saline =9 g NaCl =3.5 g Na =154 mEq Na
1000 ml lactated Ringers solution =3 g Na =130 mEq Na
1 ampule (50 ml) 7.5% NaHCO
3
=1 g Na =44 mEq Na
1 g KCl =524 mg k =13 mEq K
1 g CaCl
2
2H
2
O =273 mg Ca =13.6 mEq Ca (when weighed in hydrated forms)
1 g Ca gluconate =93 mg Ca =4.6 mEq Ca
1 g MgSO
4
7H
2
O =99 mg Mg =8.1 mEq Mg (when weighed in hydrated forms)
1 mg Mg gluconate 2H
2
O =54 mg Mg =4.4 mEq Mg (when weighed in hydrated forms)
1 g CaCO
3
=400 mg Ca =20 mEq Ca
1 g FeSO
4
7H
2
O =201mg Fe (when weighed in hydrated forms)
1 g Fe gluconate 2H
2
O =116 mg Fe (when weighed in hydrated forms)
1 ml Fe dextran (Imferon) =50 mg Fe

2. Converting sodium chloride to sodium:

NaCl (table salt) is 40% sodium and 60% chloride.
Therefore: 1gm sodium chloride =400 mg sodium
400 mg sodium =17 mEq sodium

3. Niacin equivalents:

1% available dietary protein =tryptophan
60 mg dietary tryptophan is equivalent to 1 mg niacin.

50
APPENDIX 6 Electrol yte Content and pH of Selected Body Fluids (mEq/L)
Body Fluid Approx. amount
secreted per day
(mL)
Na K HCO
3
H Cl pH
Sweat 750 30-50 5 - - 45-55
Gastric 2000 - 3000 40-65 10 - 90 100-140 1.2-3
Pancreas 2500 135-155 5 70-90 - 55-75 7-8
Ileostomy varies 120-130 10 50-70 50-60 7
Bile 500 - 750 135-155 5 35-50 - 80-110 7
Diarrhea varies 25-50 35-60 30-45 - 20-40 varies
Normal stool 200 5 10 - - 10 varies
Urine varies 30-80 30-80 - - 50-100 4.5-8
Blood n/a 138 4.5 25 - 103 7.4

Used with permission from the University of Virginia Health System Nutrition Support Traineeship
Syllabus (Parrish CR, Krenitsky J , McCray SF). University of Virginia Health System Traineeship, 2003.
Adapted from:
Willcutts K, Scarano K, Eddins CW. Ostomies and Fistulas: A Collaborative Approach. Practical
Gastroenterology 2005; XXIX(11):63-79.

Frietag & Miller (eds) Manual of Medical Thrapeutics 23rd ed, Little Brown and Co 1982.
Grant J P. Handbook of Total Parenteral Nutrition. 2nd ed. Philadelphia: W.B. Saunders Co; 1992: 174.
Pemberton, LB; Pemberton DK, and Cuddy PG. Treatment of Water, Electrolyte and Acid-base Disorders
in the Surgical Patient. McGraw-Hill, Inc. Health Professions Division, 1994.




Appendix 7 Content of Commonl y Used Intravenous (IV) Fluids
Fluid Na
(mEq)
K Glucose(gm) Tonicity
0.9 normal saline (NS) 154 0 0 Slightly Hypertonic
0.45 NS 77 0 0 Hypotonic
0.25 NS 38 0 0 Hypotonic
Lactated Ringers (LR) 130 4 0 Isotonic
D
5
W 0 0 50 Hypotonic
D
5
W 0.45 NS 77 0 50 Hypotonic

Note: 1 liter of NS contains approximately 2 teaspoons of salt
Adapted from: Corbett EC. Intravenous Fluids: Its More Than J ust Fill Er Up. Practical
Gastroenterology 2007; XXXI(7):44-60.







51
Appendix 8 Recipe for Normal Saline equivalent mixture (enteral use onl y)

Mix 1.5 teaspoons of table salt in 1 liter of warm water





Appendix 9 Pancreatic Enzyme Replacement Therapy
Pancreatic enzyme activity is measured in lipase units. The number in the product name
indicates the amount of lipase. Pancreatic enzyme medications are available in varying
strengths.
Name of Product
Creon 6,000
Creon 12,000
Creon 24,000

Guidelines for Dosing:
1,000 2,000 units of lipase / kg / meal
OR
500 4,000 units of lipase / gram of dietary fat (Becker, J ADA 2001)

Dose should not exceed 2,500 units of lipase / kg / meal (Borowitz Peds Gastro 2002)
or 10,000 units of lipase / kg / day (Pankrease info)

High doses have been associated with fibrosing colonopathy (FitzSimmons NEJ M 97)



Appendix 10 Common Conversions
Dextrose

To convert mmol / L to mg / dL, multiply by 18

To convert mg / dL to mmol / L, divide by 18 OR multiply by 0.55

Energy

1 kilocalorie =4.184 kilojoules
52










Appendix 11 Normal Lengths of Bowel

Section of Bowel Approximate Normal Length
Duodenum 10 inches (25 - 30 cm)
J ejunum 6 10 feet (200 300 cm)
Ileum 10 13 feet (300 400 cm)
Colon 5 feet (160 cm)

Note: Short gut is defined as either:
3-4 feet (100- 120 cm) of small intestine without colon, OR
60 - 75% of small bowel resected, OR
1.6 feet of small intestine with colon (preservation of at least half of the
colon is equivalent to retaining 50 cm of functional SB.)

Adapted from: Parrish CR. The Clinician's Guide to Short Bowel Syndrome. Practical Gastroenterology
2005; XXIX(9):67-106.








































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