Enteral and Parenteral Nutrition

Diane Mendoza, RND, MSCN

Enteral and Parenteral Nutrition OUTLINE: Introduction Enteral Nutrition: Definition Indications and Contraindications Feeding Routes Formula Selection Administration Considerations Monitoring

Enteral and Parenteral Nutrition Parenteral Nutrition: Definition Indications and Contraindications Feeding Access Components of PN Complications Monitoring Transitional feeding and Discontinuation

Introduction: The Skeleton in the Hospital Closet Body Height not recorded in 56% Body Weight not Recorded in 23% 61% of those with recorded weight 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 > In Britain > In Brazil In the Philippines > Private Hospital (SLMC) 48 % >Govt. Hospital (Amang Rodriguez) 52% 30 50 % 20 48 % 46 %

Introduction:

NORMAL Starvation:
Gluconeogenesis Protein Catabolism Lean body mass Water & Mineral Depletion Adjustment to New Metabolic State Negative N2 Balance

Enteral and Parenteral Nutrition

NORMAL PHYSIOLOGIC ROUTE OF FOOD FOODS LIVER

CELLS GIT

Enteral and Parenteral Nutrition

Enteral and Parenteral Nutrition

WHAT CAN WE DO?...

PROPER NUTRITION INTERVENTION

Enteral and Parenteral Nutrition

From: Dr. Jeff inciong

Enteral Nutrition

Supplementation or total nutrition feeding directly into the GIT using a feeding tube.

Beneficial effect on maintenance of intestinal structure and function.

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

Enteral Nutrition

From: Dr. Jeff inciong

Enteral and Parenteral Nutrition

If the gut is WORKING; USE IT!

Indication for Use:

ASPEN GUIDELINES FOR USE OF ENTERAL TUBE FEEDINGS  patients with PEM with inadequate oral intake for the previous 5 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 nutl losses (sepsis)

Indication for Use:

ASPEN GUIDELINES FOR USE OF ENTERAL TUBE FEEDINGS: LIMITED OR UNLIMITED VALUE  Px receiving intensive therapy; Px with acute enteritis secondary to radiation, acute infection or active inflammatory bowel disease; Px with <10% remaining small intestines

Contraindications:
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

Feeding Routes:

FEEDING ROUTES

NASOENTERIC FEEDING

Feeding Routes:

ENTEROSTOMY FEEDING

Summary of Enteral Access Sites:

SITE NASOGASTRIC INDICATIONS normal GI function ADVANTAGES uses and stimulate GI flexibility in administration medications can be placed tube insertion at bedside NASODUODENAL NASOJEJUNAL GASTROSTOMY normal small intestine tube insertion at bedside need to bypass stomach normal small intestine tube insertion at bedside need to bypass stomach normal GI funx. Long term feeding access bypass the upper GI reduced risk of displacement allows bolus feeding normal GI outpatient procedure bypass the upper GI long term feeding access less expensive; reduced risk for tube displacement normal GI function increased tolerance for early but need to bypass initiation of EN components of GI tract DISADVANTAGES aspiration discomfort nasal irritation tube displacement discomfort tube displacement discomfort tube displacement surgical procedure irritation infection on site irritation and infection for insertion site surgical procedure risk for irritation and infection, risk of clogging may be greater

PEG

JEJUNOSTOMY

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 than the osmolality of elemental formulas. In general, these formulas require a functioning gastrointestinal tract for digestion and absorption of nutrients.

Enteral and Parenteral Nutrition

PREDIGESTED FORMULA
composed of low molecular weight nutrients minimal residue are thought to lead to less stimulation of pancreatic and gastrointestinal secretions less allergenic than other formula.

Enteral and Parenteral Nutrition

MODULAR PRODUCTS
individual micronutrient modules such as glucose polymers, protein, or lipids are available as additives to food and enteral formulas to change overall fuel composition.

Enteral and Parenteral Nutrition

SPECIAL DISEASE-SPECIFIC FORMULAS

these products are designed for patients who have specific medical conditions that may require nutrient modification.

Enteral and Parenteral Nutrition

DIETARY FIBER
Fiber-containing enteral formulas are most viscous
and may require a larger diameter feeding tube for adequate flow.

Formula Selection: Osmolality

Measure of the oncotic pressure exerted by a solution; What determines osmolality? Number and Size of : electrolytes, CHO; minerals; CHON Factors that can increase osmolality? Concentration of formulas; (energy:volume) Addition of modular products Formulas with higher osmolality may induce the shift of free water into the intestinal space; thus may cause rapid transit diarrhea.

Administration:

 Continuous feeding constant, steady rate over a 16-24 hour period,  Cyclic Feeding delivered by continuous drip method at an increased rate over 8 to 16 hours,  Intermittent feeding- can be infused at specific intervals throughout the day,  Bolus feeding- rapid administration of feeding

Administration:

Refeeding Syndrome:
Conversion to glucose as a major energy source

Insulin release

Cellular Glucose Uptake,

Protein synthesis

Depletion of Phosphate, K+ & Mg

Clinical Symptoms of refeeding syndrome

Initiation and Special Considerations

INITIATION can be started at 10-40 ml/hr, then progress until 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 dehydration

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 high risk for aspiration) Bowel movements and consistency Feeding tolerance Electrolytes Baseline and weely reassesment of nut.indeces with appropriate adjustments Daily feeding tube site care

How to Compute for Nutritional Requirements:

Given Data:

Ht 54 Age 54 years old Wt 78 kgs. Diet Rx 35 kcal/ kg BW 1.2 gms CHON 60% HBV No Sources of Simple Sugars Low Potassium

To Compute : DBW= 5 x 12 = 60 60 + 4 = 64 64 x 2.54=162.56 162.56 100 =62.56- 6.256 (10%) =62.56= 56.31 kg DBW

Example To Assess: % IDW= 78 kg 56.31 kg = 1.39 x 100 = 139 %

Interpretation: Patient is Obese class 1

To follow diet Rx: CHON= 56.31 x1.2x=67.84 ~ 68 gm CHON 68 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/ day 255 gm CHO / day 68 gm CHON/ day 75 gm Fats /day

Computation based on FEL

Food Item Exchanges CHO CHON gm gm Vegetables Fruit Milk, low Fat Rice Meat/EW Fats Total 2 2 2 9 4 12 6 20 24 207 257 2 16 18 32 68 Fats gm 10 4 60 74 Kcal 32 80 250 900 164 540 1966

Enteral and Parenteral Nutrition

Enteral Formula Scoop per Can CHO Ensure 1 kg (Vanilla) Nutren Fiber Nutren Optimum Nutren Diabetes Nutren Junior Peptamen Peptamen Junior Nutricomp Protein Nutricomp Caloric Nutricomp Renal Impact CHON polycose Resource Aminoleban EN Glucerna SR Prosure 50(400) 48 (400) 46(380) 62.92 81 23.79 27 17.29 10 477.88 502.5 112 (1000) 49 (400) 54 (400) 72.8 57.85 63.56 55.08 63.44 72.15 PRO 19.74 18.3 20.16 18.84 14.17 23.25 1 CUP FAT 17.5 17.4 19.18 21.72 18.72 22.65 KCAL 1056 458.25 503.3 491.16 476.58 586.2 CHO 5.20 4.45 4.54 4.59 4.88 4.81 4.97 0 121.5 55.75 59.8 0 20.67 6.5 0 28.37 245.18 513 559.99 0 4.5 *44.8 1.65 94 5.64/tbsp 4.9 31.05* 4.84 1 SCOOP PRO 1.41 1.41 1.44 1.57 1.09 1.55 1.08 2.3 0 *16. 6 30 (453.7) 11.7 5 _ 1.25 13.5 * 1.83 1.33 36.76 1.25 3.5* 35.7 210* .32 53 FAT 1.25 1.34 1.37 1.81 1.44 1.51 1.37 .25 0 *22.8 KCAL 37.72 35.25 35.95 40.93 36.66 39.08 36.09 9.43 19 *450

43 (400)
51 (400) 48 (400) 51 (500) 100 (250) 90 (450) -

Computation using Nutritional and modular

Diet Rx 35 kcal/ kg BW 1.2 gms CHON 60% HBV No Sources of Simple Sugars Low Potassium

255 gm CHO Nutren Db 3.5 c difference Polycose 11 tbsp Nutricomp Protein -192.78 62.22 -62.04 0.18

68 gm CHON -65.94 2.06 2.3

75 gm Fats -76.02 -1.08 -

K,mg 2184 -

Computation using Nutritional and natural foods

255 gm CHO Nutren Db, 2 c difference Veg, 1 c. fruit, 2 's bread, 5's Eggwhite, 4's oil, 6 tsp TOTAL 251.16 65.68 110.16 144.84 6 20 115 10 16 2 30 75.44 68gm CHON 37.68 30.32 2 75 gm Fats 43.44 31.56

K, mg 1248 95 160 175 190 138 2006

Enteral Nutrition

Parenteral Nutrition

WHEN ENTERAL INTAKE ISu uIMPOSSIBLE ...IMPROBABLE uINADVISABLE uHAZARDOUS

Parenteral Nutrition

PARENTERAL NUTRITION is the provision of nutrients into the bloodstream intravenously. para = outside enteron = intestine intra = within vena = vein

Indications:
cancer px w/ GI problems Preoperative PN Acute inflammatory bowel disease Renal failure Hepatic disease Acute pancreatitis Critical care Short bowel syndrome Eating disorders

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Creaming accumulation of triglycerides at the top of emulsion

Aggregation clumping of trig particles with the emulsion

Parenteral Nutrition

Cracking separation of the oil and water components of the emulsion

Coalescence fusion of small trig particles into larger particles

Parenteral Nutrition

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Macronutrient Concentrations in PN Solutions

Macronutrient concentrations (%) = the grams of solute/100 ml of fluid D70 has 70 grams of dextrose per 100 ml. 10% amino acid solution has 10 grams amino acids/100 ml of solution 20% lipids has 20 grams of lipid/100 ml of solution

Parenteral Nutrition

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 a day 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

Parenteral Nutrition

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 determine kcalories supplied by dextrose in a day.

Parenteral Nutrition

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

Parenteral Nutrition

Calculation of Lipid Content

To determine kcalories supplied by lipid*, multiply the volume of 10% lipid (in ml) by 1.1; multiply the volume of 20% lipid (in ml) by 2.0. If lipids are not given daily, divide total kcalories supplied by fat in one week by 7 to get an estimate of the average fat kcalories per 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.

Parenteral Nutrition

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 = 50 grams lipid x 10 kcal/g or 500 kcal

Parenteral Nutrition

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 are using 10% lipids; divide lipid kcals by 2 kcal/cc if you are using 20% lipids. This is the total volume. Divide total volume of lipid by 24 hr to determine rate in cc/hr.

Parenteral Nutrition

Example Calculation Nutrient Needs: Kcals: 1800. Protein: 88 g. Fluid: 2000 cc 1800 kcal x 30% = 540 kcal from lipid Lipid (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

Parenteral Nutrition

Determine Protein concentration

Subtract volume of lipid from total fluid requirement to determine remaining fluid needs. Divide protein requirement (in grams) by remaining fluid requirement and multiply by 100. This gives you the amino acid concentration in %. Multiply protein requirement in grams x 4 to determine calories from protein

Parenteral Nutrition

Protein Calculations Protein: 88 g / 1520 cc x 100 = 5.8% amino acid solution 88 g. x 4 kcal/gm =352 kcals from protein Remaining kcal needs: 1800 (528 + 352) = 920 kcal

Parenteral Nutrition

Determine dextrose concentration. Subtract kcals of lipid + calories from protein from total kcals to determine remaining kcal needs. Divide "remaining kcals" by 3.4 kcal/g to determine grams of dextrose. Divide dextrose grams by remaining fluid needs (in protein calculations) and multiply by 100 to determine dextrose concentration. Determine rate of AA/dex solution by dividing "remaining fluid needs by 24 hr.

Parenteral Nutrition

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

Parenteral Nutrition

Re-check calculations TPN recommendation: Suggest two-inone PN 17.7% dextrose, 5.8% a.a. @ 63 cc/hr with 10% lipids piggyback @ 20 cc/hr 63 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

Parenteral Nutrition

Evaluation of a PN Order PN 15% dextrose, 4.5% A.A., 3% lipid @ 100 cc/hour Total volume = 2400 Dextrose: 15g/100 ml * 2400 ml = 360 g 360 g x 3.4 kcal/gram = 1224 kcals Lipids 3 g/100 ml x 2400 ml = 72 g lipids 72 x 10 kcals/gram = 720 kcals

Parenteral Nutrition

Evaluation of a PN Order Amino acids: 4.5 grams/100 ml * 2400 ml = 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 refeeding syndrome should have serum phosphorus, magnesium, potassium, and glucose levels monitored closely at initiation of SNS. (B) In patients with diabetes or risk factors for glucose intolerance, SNS should be initiated with a low dextrose infusion rate and blood and urine glucose monitored closely. (C) Blood glucose should be monitored frequently upon initiation of SNS, upon any change in insulin dose, and until measurements are stable. (B)
ASPEN BOD. Guidelines for the use of enteral and parenteral nutrition in adult and ASPEN BOD. Guidelines for the use pediatric patients. JPEN 26;41SA, 2002 of enteral and parenteral nutrition in adult and pediatric

patients. JPEN 26;41SA, 2002

Parenteral Nutrition Serum electrolytes (sodium, potassium, chloride, and bicarbonate) should be monitored frequently upon initiation of SNS until measurements are stable. (B) Patients receiving intravenous fat emulsions should have serum triglyceride levels monitored until stable and when changes are made in the amount of fat administered. (C) Liver function tests should be monitored periodically in patients receiving PN. (A)

Parenteral Nutrition Acute Inpatient PN Monitoring

Parameter Glucose Electrolytes Phos, Mg, BUN, Cr, Ca TG Fluid/Is & Os Temperature Daily Initially Initially Frequency 3x/week Initially Weekly

Adapted from K&M, p. 549

Parenteral Nutrition Inpatient Monitoring PN

Frequency Weekly Initially

Parameter Body Weight Nitrogen Balance HGB, HCT Catheter Site Lymphocyte Count Clinical Status

Daily Initially

PRN

Parenteral Nutrition

TRANSITIONAL FEEDING AND DISCONTINUATION:

GIT-Functional? Reduction in PN can be made as enteral or oral feedings are increased.
clumping of trig particles with the emulsion

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

Parenteral Nutrition Maintain full PN support until pt is tolerating 1/3 of needs via enteral route Decrease TPN by 50% and continue to taper as the enteral feeding is advanced to total TPN can reduce appetite if >25% of calorie needs are met via PN TPN can be tapered when pt is consuming greater than 500 calories/d and d-cd when meeting 60% of goal TPN can be rapidly d-cd if pt is receiving enteral feeding in amount great enough to maintain blood glucose levels

Parenteral Nutrition Cessation of TPN Rebound hypoglycemia is a potential complication Decrease the volume by 50% for 1-2 hours before discontinuing the solution to minimize risk PPN can be stopped without concern for hypoglycemia

gRaciAs!
DIANE MENDOZA, RND