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Enteral and Parenteral Nutrition Update with the Nutrition Care Process

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ENTERAL AND PARENTERAL NUTRITION UPDATE WITH THE NUTRITION CARE PROCESS Suzanne Neubauer, PhD,RD,CNSC Framingham State University Overlook Health Center, Charlton, MA – PowerPoint PPT presentation

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Title: Enteral and Parenteral Nutrition Update with the Nutrition Care Process


1
Enteral and Parenteral Nutrition Update with the
Nutrition Care Process
  • Suzanne Neubauer, PhD,RD,CNSC
  • Framingham State University

Overlook Health Center, Charlton, MA January 31,
2013
2
Objectives
  • Calculate basic flow rates for enteral nutrition
    considering interruption factors and fluid needs.
  • Calculate parenteral nutrition formulas,
    including basic electrolyte considerations.
  • Practice the nutrition care process for
    enteral/parenteral cases, focusing on new
    nutrition diagnosis and intervention standardized
    language.

3
Critical Illness Guidelines 2012 Blood Glucose
Control
  • promote blood glucose control between 140 to 180
    mg per dL in critically ill adult patients
  • Tight blood glucose control (80 to 110 mg per dL)
    and moderate control lt 140 mg per dL is not
    associated with
  • reduced hospital length of stay
  • Grade II (fair)
  • days on mechanical ventilation
  • Grade II (fair)

http//www.adaevidencelibrary.com/topic.cfm?cat10
35
4
Critical Illness Guidelines 2012 Blood Glucose
Control
  • Tight blood glucose control (80 to 110 mg per dL)
    is not associated with
  • infectious complications in surgical (primarily
    cardiac) patients
  • Grade II (fair)
  • cost of medical care
  • Grade III (limited
  • Tight blood glucose control (80 to 110 mg per dL)
    increases risk of hypoglycemia
  • Glucose level gt180 mg per dL is associated with
    increased mortality
  • Grade II (fair)

http//www.adaevidencelibrary.com/topic.cfm?cat10
35
5
Composition of Solution
  • 3-in-1 Total nutrient admixture (TNA)
  • 2-in-1
  • Lipids infused separately
  • Favorable when patients have high protein or
    minimal fluid needs and can maintain euglycemia
    with addition of modest insulin dose
  • Must use laminar-airflow hood to decrease the
    risk of contamination

6
Clinimix
  • http//www.clinimix.com/home
  • Clinimix
  • Sulfite-free (Amino Acid in Dextrose) injections
  • Clinimix E
  • Sulfite-free (Amino Acid with electrolytes in
    Dextrose with calcium) injections

7
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8
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9
Protein Crystalline Amino Acids
  • Stock solutions range from 8.5 to 20
  • Usually expressed at final concentration after
    dilution vs initial concentration
  • How many g protein in 8.5 AA solution?
  • 8.5 8.5 g x
  • 100 ml 1000 ml
  • 85 g/L
  • How many calories in 8.5 AA?
  • 4 kcal/g
  • 85 g/L x 4 340 kcal

10
Carbohydrate Dextrose Monohydrate
  • Stock solutions range from 5.0 to 70
  • Calories
  • Anhydrous glucose 4 kcal/g
  • Hydrous in IV solution 3.4 kcal/g
  • CPN Limits
  • Average adult requires 1 mg/kg/min or 100 g/d
  • 5 mg/kg/min
  • 4 mg/kg/min in critically ill and 7 mg/kg/min in
    hospitalized patients (Supp Line 2005276)
  • patients on ventilators 4 mg/kg/min
  • patients with diabetes 2-2.5 mg/kg/min

11
Carbohydrate Dextrose Monohydrate
  • How many g carbohydrate in 25 dextrose solution?
  • 25 25 g x
  • 100 ml 1000 ml
  • 250 g/L
  • How many calories in 25 dextrose solution?
  • 3.4 kcal/g
  • 250 g/L x 3.4 850 kcal

12
Glucose Tolerance Mg/Kg/Min
  • Max 5 mg/kg/min
  • Solve for g Dextrose
  • 5 mg x 70 kg x (60 minutes x 24 hr) 504 g
  • 1000 mg/g
  • Solve for mg/kg/min
  • 504 g x 1000 mg/g 5 mg/kg/min
  • 70 kg x 1440 min

13
CHO in Peripheral Parenteral Nutrition
  • PPN
  • Maximum of 10 5 most common
  • Osmolality
  • Maximum 900 mOsm
  • (10 x g pro) (6 x g CHO) (.3 x ml fat)
  • total L

14
Lipids Administration
  • Slow and continuous 24-hour infusion can improve
    hepatic reticuloendothelial function
  • As opposed to short, lt 10 hrs, infusion
  • Usually infused over 12 hrs. if infused
    separately
  • IVFE infusion rate
  • NOT gt 0.11 g/kg/h

15
Calculation Rules for Lipid
  • Maximum lipid
  • 60 of total kcal
  • 2.5 g/kg body weight
  • 2 4 of total kcal as linoleic acid to prevent
    EFAD
  • 10 of total kcal as fat meets EFA
  • Maximum of 30 lipid for septic patients
  • May use gt 30 with hyperglycemic or pulmonary
    compromised patients
  • Usually begin with 1 g lipid/kg/day

16
Calculation Rules for Lipid Contd
  • Intralipid 10 1.1 kcal/ml 11 kcal/g
  • Total volume of lipid x .1 g fat
  • Intralipid 20 2.0 kcal/ml 10 kcal/g
  • Total volume of lipid x .2 g fat
  • Intralipid 30 3.0 kcal/ml 10 kcal/g
  • Total volume of lipid x .3 g fat
  • Lipid available as 250 ml or 500 ml

17
Diprivan (Propofol)
  • Administered intravenously to intubated/
    mechanically ventilated adult ICU patients
  • Provides continuous sedation
  • Controls stress responses
  • Usually infused at 10 mg/mL
  • Isotonic
  • Check rate and total volume infused daily

18
Supp Line. 2009 31(6)12-19.
19
Propofol Calculations
Supp Line. 2009 31(6)12-19.
20
Calculate 3-in-1 solution/2200 mL
  • Pt weight _at_ 55 kg
  • requires 2200 kcal 93 g protein 2200 ml fluid
  • Protein 93 g x 4 kcal/g 372 kcal
  • 2200 kcal 372 kcal 1828 kcal remaining for
    fat CHO
  • Lipid use 1 g/kg/day to start
  • 55 g x 1 g/kg 55 g fat
  • 55 g fat x 10 kcal/g 550 kcal
  • 1828 kcal 550 1278 kcal remaining for CHO

21
Calculate 3-in-1 solution/2000 mL
  • CHO 1278 kcal 376 g dextrose
  • 3.4 kcal/g dextrose
  • Check maximum CHO
  • 5 mg x 55 kg x (60 x 24 hr)
  • 5 mg x 55 kg x 1440 min/day
  • 1000 mg/g
  • .005 g x 55 kg x 1440 min/day 396 g CHO

22
PN Order
  • Divide g of each substrate by total volume of
    fluid. Multiply x 100 for percent.
  • 93 g protein x 100 4.2 AA
  • 2200 ml
  • 55 g lipid x 100 2.5 lipid
  • 2200 ml
  • 376 g CHO x 100 17 CHO
  • 2200 ml

23
PN Order
  • 93 g protein 1 L 10 AA
  • 55 g lipid 250 ml 20 lipid
  • 376 g CHO 1 L 30 dextrose
  • Total fluid 2250 ml
  • Kcal
  • 100 g protein 400 kcal (21)
  • 250 ml lipid 500 kcal (26)
  • 300 g CHO 1020 kcal (53)
  • Total kcal 1920

24
Daily Electrolyte Requirements
The ASPEN Adult Nutrition Support Core
Curriculum, 2nd, 2012248
25
The ASPEN Adult Nutrition Support Core
Curriculum, 2nd, 2012248
26
Electrolytes Initial Dose
  • Generally aim for the middle of the normal range
  • Individualize based on renal function, GI losses,
    acid-base balance and medications
  • Can use multiple-electrolytes or several single
    entity electrolyte solutions
  • Dependent on the compatibility of each
    electrolyte with the other components in the PN
    admixture

27
Electrolytes Sodium
  • Generally use approximately equal amounts of
    chloride and acetate (11 ratio)
  • Acetate and chloride also found in AA solution
  • In metabolic acidosis use maximum acetate and
    minimum chloride
  • Acetate is metabolized as bicarbonate
  • In metabolic alkalosis use maximum chloride and
    minimum acetate

28
Electrolytes Sodium
  • Sodium Goal 1 2 mEq/kg
  • Use 1.5 mEq/kg
  • 1.5 x 70 kg reference man 105 mEq/day
  • 2 L (not including IVFE) so 105/2 53 mEq/l
  • Sodium Chloride 53 mEq
  • Sodium Acetate 53 mEq

29
Electrolytes Potassium Phosphorus
  • Potassium available in chloride, acetate, and
    phosphate salts
  • K maintenance _at_ 1 mEq/kg 70 mEq
  • 2 L (not including IVFE) so 70/2 35 mEq/l
  • If serum K is low correct with a separate
    infusion of K
  • Phosphorus available as the sodium or potassium
    salt
  • Phosphorus 25 mmol/day
  • 25 mmol Potassium Phosphate (37 mEq K)
  • Remainder of K as KCl 33 mEq

30
Electrolytes Calcium
  • Ca available as gluconate (preferred form) or
    chloride salt
  • Gluconate preferred b/c more stable in solution
  • Less likely to dissociate and precipitate with
    Phosphorus
  • dose within accepted solubility range and amino
    acid pH and concentration
  • standard dose 12 mEq/day

31
Electrolytes Magnesium
  • Mg available as sulfate or chloride salt
  • Mg Sulfate is preferred form
  • Mg 8 20 mEq/day

32
(140)
Supp Line 20052713-22
33
Supp Line 20052713-22
34
References
  • Kingley J. Fluid and electrolyte management in
    parenteral nutrition. Supp Line.
    200527(6)13-22.
  • Whitmire SJ. Nutrition-focused evaluation and
    management of dysnatremias. Nutr Clin Pract.
    200823108-121.
  • Schmidt GL. Techniques and Procedures Guidelines
    for Managing Electrolytes in Total Parenteral
    Nutrition Solutions. Nutr Clin Pract 2001 16 226
  • Baumgartner TG. Enteral and Parenteral
    Electrolyte Therapeutics. Nutr Clin Pract.
    200116226-235.
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