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 < 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?cat=1035

4.  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 >180 mg per dL is associated with increased mortality Grade II (fair) Critical Illness Guidelines 2012: Blood Glucose Control http://www.adaevidencelibrary.com/topic.cfm?cat=1035

5. 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 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 6

9. 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. 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 2005;27:6)  patients on ventilators: 4 mg/kg/min  patients with diabetes: 2-2.5 mg/kg/min

11.  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 Carbohydrate: Dextrose Monohydrate

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

15. 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 > 30% with hyperglycemic or pulmonary compromised patients  Usually begin with 1 g lipid/kg/day

16. 16 Calculation Rules for Lipid Cont’d  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. 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. 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 @ 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.  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 Calculate 3-in-1 solution/2000 mL

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. 24 Daily Electrolyte Requirements The ASPEN Adult Nutrition Support Core Curriculum, 2 nd, 2012:248

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 (1:1 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.  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 Electrolytes: Sodium

29. Electrolytes: Potassium & Phosphorus  Potassium available in chloride, acetate, and phosphate salts  K: maintenance @ 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. Supp Line 2005;27:13-22 (140)

33. Supp Line 2005;27:13-22

34. References  Kingley J. Fluid and electrolyte management in parenteral nutrition. Supp Line. 2005;27(6):13-22.  Whitmire SJ. Nutrition-focused evaluation and management of dysnatremias. Nutr Clin Pract. 2008;23:108-121.  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. 2001;16:226-235.