Guidelines for the Use of Parenteral and Enteral Nutrition JPEN, Oct 2001

1
Guidelines for the Use of Parenteral and Enteral
NutritionJPEN, Oct 2001
2
Specific Guidelines for Disease -Adults

• Cardiac Disease
• Pulmonary Disease
• Liver Disease
• Pancreatitis
• Short-Bowel Syndrome
• Inflammatory Bowel Disease
• Solid Organ Transplantation
• Renal Disease

3
Specific Guidelines for Disease -Adults

• Gastrointestinal Fistulae
• Neurologic Impairment
• Cancer Hematoepoetic Cell Transplantation
• HIV/Acquired Immuno-Deficiency Syndrome
• Critical Care Burns
• Critical Care Critical Illness
• Psychiatric Disorders Eating Disorders
• Hyperemesis Gravidarium

4
Cardiac Disease

• Cardiac cachexia
• Severe malnutrition
• Associated with CHF
• Post open heart surgery patients
• 5 cardiopulmonary bypass pts PN
• EN should be deferred until hemodynamically
  stable

5
Pulmonary Disease

• Malnutrition common in COPD
• Malnutrition affects pulmonary function
• Overfeeding can result in excess CO2 production
• Phosphate balance critical for function of
  respiratory muscles (ATP)
• ARDS patients may benefit from a modified enteral
  formula with n-3 fatty acids (less time on vent.,
  less time in ICU and less organ failure.

• 19-74

6
Liver Disease

• PCM common in liver disease
• Amino acid metabolism is altered (low levels of
  BCAA and elevated AAA and methionine)
• Limit use modified AA formulations to
  encephalopathic patient unresponsive to
  pharmacotherapy
• Deficiencies of fat soluble vitamins (A,D,E and
  K) and zinc are common
• Patients benefit from 4-6 meals per day
• Protein restriction should be implemented for
  patients with hepatic encephalopathy
• Do not restrict protein chronically in patients
  with liver disease

7
Pancreatitis

• Specialized nutrition support (SNS) is not
  considered primary therapy
• Bowel rest limits pain but does not decrease
  morbidity or mortality
• Feeding with elemental enteral nutrition (EN)
  with low triglycerides is cheaper and safer than
  PN
• When parenteral nutrition (PN) is used, IV fat
  emulsions are save if triglycerides remain below
  400mg/dl.

8
Short-Bowel Syndrome

• Loss of bowel due to resection limits absorption
  of fluid, lytes, macronutrients, minerals and
  vitamins
• Occurs most commonly after surgery for Crohns
  disease
• Most patients require PN for 1 or more months
  following massive intestinal resection
• Patients with lt100cm of SB require PN for an
  indefinite period of time
• 50 cm of SB may suffice for oral nutrition
  following adaptation
• Deficiencies of fat-soluble vitamins (A,D,K,E)
• Absorption of Ca, Mg and Zn is impaired
• Vitamin B12 supplementation may needed

9
Inflammatory Bowel Disease

• Chrons disease (CD) and ulcerative colitis (UC)
• Malnutrition is more common in CD
• 65-78 of patients
• Malnutrition in UC 18-62
• Bowel rest with PN does not improve remission
  not primary therapy
• Most patients with CD requiring SNS can be fed
  with EN
• PN reserved for
• IBD patients who dont tolerate EN
• CD with fistulae

10
Solid Organ Transplantation

• Protein requirements in the perioperative
  transplant period are 1.5 to 2.0 gm/kg
• Energy requirements are similar to other
  perioperative patients
• (35 kcal/kg)
• Avoid hyperglycemia due to impaired wound healing
  and risk of infection

11
Gastrointestinal Fistulae

• Diversion of intestinal contents to the skin,
  bladder, vagina etc
• May result from Crohns disease, abscess,
  surgery, trauma, radiation
• TPN and bowel rest has not been shown to increase
  the incidence of spontaneous fistula closure
• Nutrition support is not considered primary
  therapy supportive therapy

12
Renal Disease

• Chronic renal failure (CRF) associated with
  anorexia and catabolism
• Renal replacement therapy increases losses of
  protein, amino acids and albumin
• Protein calorie malnutrition (PCM) in CRF is a
  strong predictor of MM
• Patients with ARF should receive a balanced
  formula with both EAA and NEAA
• CRF patients not on dialysis should receive
  0.6-0.8g/kg per day of protein
• CRF patients on HD or PD should receive 1.2-1.3 g
  of protein/day
• Hypervitaminosis A is common in end stage renal
  disease (ESRD)

13
Neurologic Impairment

• Traumatic brain injury (TBI) is associated with
  elevated nitrogen losses (20 g/d)
• PN may be required to meet the TBI patients
  nutritional requirements
• Cerebral vascular accidents (CVAs) are often
  associated with dysphagia
• Dysphagia of CVAs is one of the most common
  indications for EN

14
Cancer

• Cancer cachexia
• Progressive, involuntary weight loss
• 50 of patients
• Causes include anorexia, cytokine response, side
  effects of chemo, radiation therapy or surgery
• SNS should not be used routinely in cancer
  patients undergoing surgery or chemotherapy
• SNS is appropriate in patients who are
  malnourished and will have prolonged impaired
  intake
• Preoperative nutrition (7-14 days) has been shown
  to be of benefit in malnourished patients
• Palliative use of SNS is highly controversial

15
Cancer Hematoepoetic Cell Transplantation

• HCT uses high-dose chemo with or without
  irradiation intensive therapy
• PN is often required due to toxicity of treatment
• Patients should receive EN when GI function
  returns

16
HIV/Acquired Immuno-Deficiency Syndrome

• PCN is common in in HIV- infected patients
• Aids wasting syndrome (AWS)
• Involuntary weight loss gt 10 baseline body wt.
  plus chronic diarrhea
• Causes include reduced intake, impaired
  absorption and increased metabolism
• SNS has a limited role in AWS

17
Critical Care Burns

• Burn patients have elevated energy requirements
  that are best assessed by indirect calorimetry
• Severely burned patients have increased protein
  requirements
• EN is preferred and should be initiated ASAP
• PN has been associated with complications and
  increased MM
• PN should be limited to patients in whom EN is
  contraindicated or is unlikely to meet
  requirements within 4-5 days

18
Critical Care Critical Illness

• Represents a wide spectrum of life-threatening
  medical or surgical conditions which require ICU
  level care
• EN is the preferred route of feeding
• PN should be reserved for cases where EN is not
  possible

19
Psychiatric Disorders Eating Disorders

• Includes anorexia nervosa, bulimia, and binge
  eating disorder
• Incidence of malnutrition in anorexia nervosa is
  100
• Patients may seem genuinely cooperative in
  voluntarily correcting deficiencies but often
  fail
• In severe cases (gt30 recent wt loss or lt 65
  IBW) SNS should be initiated
• Due to risk of refeeding syndrome, feeding should
  be initiated at no more than 70 of REE
• Fluid, lytes and acid base monitoring is required
• EN is generally preferred and PN is rarely
  required

20
Hyperemesis Gravidarium

• Severe NV seen in about 1 of pregnancies
• SNS is indicated when noninvasive measures fail
  (antiemetics, diet modification) to achieve
  appropriate wt gain
• EN with a small bore feeding tube, using an
  isotionic EN formula minimizes NV
• PN has been used when EN is not tolerated
• Monitor for refeeding

21
Perioperative Nutrtion Support

• Preoperative SNS (7-14 days) should be
  administered to malnourished patients if the
  operation can be safely postponed
• PN should not routinely be given PN
• Postoperative SHS should be given to pts who sill
  be unable to meet requirements orally for a
  period of 7-10 days