You are on page 1of 14

Nutrition Support

August 15, 2007

Maria Brown, RD, CNSD


Nutrition Support Dietitian
Mount Sinai Hospital

Objectives
Participants will be able to:

Estimate calorie and protein needs for preand posttransplant patients


State 4 questions which can assist in
enteral formula selection
List 3 possible etiologies of Parental
Nutrition Associated Liver Disease
(PNALD)

Overview
How much?
When?
Where?
What?
And What now?

of Enteral and Parenteral Nutrition

Pretransplant goals &


requirements

Maintain or improve nutritional status


Maintain normal electrolyte levels based upon organ
failure

Pretransplant needs

Dietary restrictions of Na, K, PO4, fluid

Energy: maintenance 30kcals/kg

Protein: maintenance 0.8 to 1.2 gms/kg

35-40kcals/kg for weight gain


A deficit of 500 kcals/day for weight loss
1.3 to 2 gms/kg for repletion
Hemodialysis :1.2 to 1.5 gms/kg est. dry weight
Peritoneal dialysis: 1.5gms/kg

Posttransplant Requirements

Posttransplant Needs:

Energy: 30-35kcals/kg or 1.3-1.5 x basal


energy expenditure
Protein: 1.5-2 gms/kg immediate posttransplant (if renal function is normal)
1gm protein/kg chronic post-transplant

Indications for enteral nutrition


Enteral nutrition provides a more physiologic

route of nutrient administration than parenteral


nutrition.
Indications for enteral nutrition:

Malnourished patient with a functioning GI tract,


with inadequate po intake for >5-7 days

Following severe trauma or burns


Patients with a functioning GI tract who are orally
intubated
Trophic effects/Gut integrity

Contributing factors: poor appetite or dysphagia

Enteral Access Devices


NGT, OGT, Naso-enteric-

short-term (4-6 weeks)

PEG percutaneous endoscopic gastrostomy


PEG-J (may be for both gastric

decompression and feeding) percutaneous


endoscopic gastrostomy with jejunal extension

DPEJ-

direct percutaneous endoscopic jejunostomy

Surgical gastrostomy and jejunostomy

Enteral tube materials

Polyurethane used for short-term tubes


stiff give a larger inner diameter with thin
wall
Silicone for longevity and comfort for longtern use
Rubber tubes (Foley) should not be used
due to the rapid deterioration of the
material and the lack of an external
retaining device

Types of Enteral Formulations


Standard- Polymeric

contains intact proteins


Used for patients with normally functioning GI tracts.
May have additional protein added or be fluid
concentrated

Semi-Elemental/Partially Hydrolyzed

Contains Peptides and/or amino acids


For use when function of the GI tract is questionable

Disease Specific

Renal Electrolyte restricted, volume restricted


Diabetic- low CHO- may be elevated in PUFAs,
necessity for this is controversial

4 QUESTIONS WHEN
CHOOSING AN ENTERAL
FORMULA:
Is the functionality of the GI tract

compromised?
Is a semi-elemental formula needed?
Is there a need for a high protein
formula?
Is there a need for a water restriction?
Is there a need for a low electrolyte
formula?

When GI functionality Is
Impaired
Small peptides in the di & tri form may have

better absorption than amino acids

Improved nitrogen balance and absorption in


patients fed a partially hydrolyzed protein diet vs.
an amino acid diet
(Meguid et al)
Comparable results found in primates (Albina et al)

Protein Composition
Standard

Intact whole proteins

Examples: soy protein isolate


Requires the most digestion

Semi-elemental

Hydrolyzed whole proteins to 2- 5 chained peptides

Partially hydrolyzed whey


Whey protein hydrolysate
Hydrolyzed casein

Elemental

Crystalline amino acids

Fat Composition

Fat provided a calorie-dense energy source that serves as a vehicle for


fat-soluble vitamins and provides essential fatty acids

Most semi-elemental formulas are lower in fat and high in mediumchained triglycerides (MCTs), to improved compromised absorption.

Common sources of fat in enteral formulas:

Soybean oil
Canola oil
Safflower oil
Corn and fish oils
Lecithin

Fat content may range from <10% to >50% of total calories in a formula

Fat Composition
Many of the semi-elemental formulas contain MCTs
MCTs are:

more water-soluble,
absorbed without bile emulsification and lipase for
micelle packaging
bypass the lymphatic system

Hence, MCTs may be beneficial in states of pancreatic

insufficiency, chylous ascites, or biliary disorders


After absorption, MCTs do not require lipoprotein lipase
or carnitine for mitochondrial absorption
(required by LCT for hydrolysis at the cell surface)

Water Content
Water concentrations of formulas range from

85%- 69% allowing for varying fluid needs

If the patient does not require a fluid restriction,


likely the amount of water in the formula will be
inadequate to meet needs, and water boluses
would be necessary

Osmolality often increases with concentration.

Sometimes a more concentrated formula may


exacerbate delayed gastric emptying.

Disease- Specific Formulas

Renal Formulas

Diabetic Formulas

Renal Formulas
Lower in electrolytes and volume

concentrated

Need to ensure this composition is


consistent with other treatments

Diabetic Formulas
Often lower in carbohydrate 34-40% of kcals, however,

contain fiber and are higher in fat

This may be detrimental in a patient with


gastroparesis,
Recommended CHO content of diets for patients with
diabetes or glucose intolerance is 45-65% total kcals.
Slightly better glucose control (not statistically
significant) has been exhibited with use of lower CHO
formulas
The American Diabetes Association suggests either a
standard formula or a lower carbohydrate formula
may be used
Need to determine which formula is most beneficial
for the patient.

Managing Complications of
Enteral Nutrition
Impaired Gastric Emptying
Diarrhea
Electrolyte Imbalances
Feeding Tube Occlusion

Impaired Gastric Emptying


Possible causes:
Sepsis, hypotension
Post-op state
Medications such as opiate analgesics and
anticholinergics
Surgical vagotomies
Diabetic gastroparesis.
High fat and fiber formulas could delay
emptying.
Infusion of very cold formulas (rare)

Impaired Gastric Emptying


Treatment:
Elevate HOB 30-45 degrees
Provide prokinetic agents
Review current medications (opiates, Propofol)
Change to a lower fat and fiber-free formula
Administer at room temp
If distended or nauseated, check gastric residuals
every 4 hours during a continuous feeding. If low,
consider an anti-emetic medication
Diagnostic work-up for distension, if abd girth
increases by > 8-10cm with feeding initiation
Consider feeding into the small bowel

Checking Gastric Residuals


Checking gastric residuals is usually recommended,

however, there is reasonable doubt about the validity of


this practice and the amount at which action should be
taken.
Frequently 2, consistent episodes of a residual >200ml
or 250ml is recommended before decreasing enteral
feeding rate
" Little data exist to support a correlation of gastric

residual volume with gastric emptying, volume of gastric


contents or changes in infusion of enteral tube feeding.
Gastric residual volumes do not correlate to regurgitation

or aspiration and their use cannot be relied on to protect


patients against aspiration pneumonia. (McClave)

More on Gastric Residuals


Average daily secretions, 1500ml of saliva, 3000ml

gastric juices, would equal about 188ml/hr with 35-55% of


gastric contents being emptied per hour. - McClave,
2002.
A physical exam checking for bloating, distension,

nausea and vomiting may indicate patients with impaired


gastric emptying.
Checking residuals from a small bowel feeding is

inappropriate as the contents of the small bowel


continuously move and do not pool. Gastric residuals
may be checked

Diarrhea
Normal stool content 250-500ml/day. Diarrhea
has been defined as > 500ml every 8 hours or
>3 stools per day for at least 2 consecutive
days
Potential causes:

medications
GI disorders or dysfunction
malabsorption
fecal impaction
malnutrition
composition of feeding, rate of delivery
opportunistic infections

Diarrhea
Medication induced:

Antibiotics can reduce the numbers of colonic


bacteria resulting in less gases and shortchained fatty acids that normally aid in
absorption of electrolytes and water. Also
associated with C diff
Hyperosmolar liquid forms of medicines,
including sorbitol-containing elixirs can induce
diarrhea.
Prokinetic agents, Phos and Mg containing
meds, stool softeners, lactulose and laxatives,
antineoplastic agents

Diarrhea
Malnutrition:

decreased enzymatic secretion from the stomach,


pancreas and brush border and decreased proliferation,
height and maturity of intestinal villi.

Hypertonic feeding formula?

Unless infused at a very high rate, or bolused into the


SB, hypertonicity usually does not cause diarrhea.
Originates from "home brew" diets with 1200mOsm/kg
via 500ml boluses
118 hospitalized patients were randomized to receive
either a 430 mOsm/kg enteral formula, the same diet but
with dilution so that the osmolality increased over 4 days
from 145-430 and a 296 mOsm/kg formula.

Their conclusion: Diluting formulas does not improve


tolerance, but rather leads to suboptimal nutrient
delivery. (Keohane et al)

Treatment of Diarrhea
Check for C diff or other infectious causes. Medical

assessment to rule out inflammatory causes, fecal


impaction, etc.
Reduce or change possible offending medications.
Change from elixir form, if possible.
Add an antidiarrheal agent once C Diff has been ruled out
If GI function is impaired due to disease state
Change to a peptide-based or elemental formula
A formula containing a large percentage of provided
fat in the form of MCT in addition to pancreatic
enzyme replacement may be needed with pancreatic
insufficiency
If fluid and electrolyte losses remain excessive, decrease
rate to the last tolerated level. Begin parenteral nutrition
but continue enteral nutrition for gut stimulation

Enteral Feeding Tube


Occlusion
Potential causes:
congealing or clumping of protein of formula w/
meds
gastric secretions mixed with formula in the tube
from withdrawal of residuals
microbial growth and colonization of the tube
Prevention:
flush whenever feeds are stopped
before and after residuals
before and after meds
Overall, flush with enough water to clear the tube.

Treatment of an Enteral
Feeding Tube Occlusion
Warm water flushing
Flush with a mixture of pancreatic enzymes and

bicarbonate

one table Viokase, one 324mg tablet of sodium


bicarb mixed with 5ml water, clamp for 5 min and
flush

Special declogging devices


should only be used by someone who has been
trained in its use
Never use soda or juices as they may result in

dried residues that further clog the tube

History of Parenteral Nutrition


History of TPN :

1967 - Cannulation of the subclavian vein -Mogil &


others
1968 - Growth in beagle puppies receiving IV nutrition
1969 - An infant girl received parenteral nutrition
1970s - Crystalline amino acids were synthesized from
soybeans and replaced protein hydrolysates.
1975 - American Medical Association published
recommendations for standard amounts of parenteral
vitamins
1976 - Lipids were re-introduced in the US
1979 - AMA published recommendations for standard
amounts of parenteral minerals
1983 - FDA approved TNAs

10

Indications for Parenteral


Nutrition
Enteral nutrition is contraindicated or the GI tract has

diminished function or is inaccessible, specifically:


Short Bowel Syndrome
Intestinal obstruction and Paralytic Ileus
Mesenteric ischemia
Diffuse peritonitis
Massive GI Bleed
Proven intolerance to Enteral Nutrition
GI fistula, except when enteral access can be placed
distally or volume of output is <250ml/day
Cancer patients in whom treatment is expected to
cause gastrointestinal disturbances > one week

Components of Parenteral
Nutrition
Dextrose
Amino Acids
Lipid
Electrolytes, vitamins, trace elements

Dextrose
The optimal amount is that which is

adequate to spare protein from


catabolism for energy, without causing
hyperglycemia

Dextrose provides 3.4kcals/g


Available concentrations range from 2.5%70%

11

Amino Acids

Amino acid concentrations yield 4

kcals/gm,
Available in 3%- 20% concentrations

Lipid
Lipid provides essential fatty acids and a calorically-

dense nutrient source


Parenteral lipid emulsions provide 10 kcals/gm
Most commercial preparations are made of LCT from

soybean oil or a mixture of soybean and safflower oils


Egg yolk phospholid is present as an emulsifier

Patients with egg allergies may have a reaction


Contains approximately 6mmol of phosphorus/L

At least 2% to 4% of total calories should be provided

from linoleic acid to prevent EFAD

PPN
A maximum of 900 mOsm/L is recommended

for peripheral parenteral nutrition administration

Amino acids are the major contributor to osmolarity


Frequently calorie and protein provision is
inadequate
Osmolarity can be reduced with an increase in
volume, therefore, peripheral parenteral nutrition is
not recommended for patients requiring fluid
restrictions

Maximum recommended time for peripheral

parenteral nutrition is 12-14 days, however,


depends upon patient tolerance and amount of
nutritional needs being met

12

Complications of Parenteral
Nutrition
Catheter-related Complications
Hepatic Complications
Metabolic Bone Disease (Long

term )
Electrolyte abnormalities

Hepatic Abnormalities- Theories of


cause; precise etiology unknown
Overfeeding of overall calories from all

nutrient sources
Essential Fatty Acid, choline or carnitine

deficiency
Bacterial overgrowth (exhibited in rats)
Elevated Manganese levels
An absence of intraluminal nutrients to

stimulate bile secretion (cholestasis)


Phytosterol components of lipid solutions?

Metabolic Bone Disease


Abnormal bone metabolism, associated with long-term

TPN, which may lead to osteoporosis or osteomalacia.


Characterized by hypercalciuria and hypercalcemia
Possible causes of MBD

Chronic hypercalciuria

chronic acidosis
Al toxicity due to contamination
more common in patients with SBS and IBD

Chronic diarrhea and Vit D malabsorption


Inflammatory process and cytokine activity
Medications: corticosteroids, cyclosporine, heparin,
warfarin, phenytoin and tacrolimus
Lack of exercise and smoking

13

Metabolic Bone Disease


Prevention/Treatment
Evaluate all patients receiving TPN of >1 year for
physical signs: bone pain, loss of height, back pain
Provide adequate amounts of Ca, Phos and Mg in
TPN for bone remodeling
Avoid excessive protein (>1.5 gm/kg, if nutritionally
stable)
Minimize acidosis treat with acetate in TPN
Minimize steroid use
Obtain DEXA scan if low bone mineral density
Promote routine low-impact exercise
Encourage cessation of smoking

Electrolyte Abnormalities
Sodium

Correction based upon etiology of high or low Na; often


correct with free water or water restriction.
Assess volume and Na content of IV fluids
Sodium needs 1-2 mEq/kg

Potassium

Potassium needs 1-2 mEq/kg


Increase or decrease based upon value and factors that
may be contributing to the imbalance

Adjust Mg and PO4 as needed

Remember low K and Ca can be refractory to a low Mg


Replete low electrolytes to normal; before initiating
enteral or parenteral nutrition

References
1.
2.
3.
4.

5.
6.
7.
8.

9.
10.

Gottschlich, MM. The ASPEN Nutrition Support Core Curriculum. A Case- Based
Approach. Silver Spring, MD: ASPEN; 2007
Shikora, S, Martindale R, Schwaitzberg S. Nutritional Consideration in the Intensive
Care Unit. Dubuque, IA: ASPEN; 2002
Merritt R. The ASPEN Nutrition Support Practice Manual. 2nd ed. Silver Spring, MD:
ASPEN; 2005
Meguid MM, Landel AM, TerzJJ, Akrabawi SS. Effect of Elemental Diet on Albumin
and Urea Synthesis: Comparison with Partially Hydrolyzed Protein Diet. J Surg Res
1984; 37 (1):16-24
Albina, J et al: Nitrogen Utilization from Elemental Diets. JPEN 1985; 9(2):189-95
McClave SA, et al. Poor Validity of Residual Volume as a Marker for Risk of
Aspiration in Critically Ill Patients. CCM 2005; 33:324-30
McClave SA, Snider HA. Clinical Use of Gastric Residual Volume as a Monitor for
Patients on Enteral Tube Feeding. JPEN 2002;26(6):S43-48
Keohane PP, Attrill H, Love M, et al.: Relation Between Osmolality of Diet and
Gastroiintestinal Side Effects in Enteral Nutrition. BMJ (Clin Res Ed) 1984:288:67880
Raman M, et al. Metabolic Bone Disease in Patients Receiving Home Parenteral
Nutrition: A Canadian Study and Review JPEN 2006; 30(6):492-6.
Gottschlich MM. The Science and Practice of Nutrition Support. A Core-Based
Curriculm. Silver Sprong, MD:ASPEN; 2001

14

You might also like