Managing Nutrition, Hydration & Electrolytes In the Older...

Managing Nutrition, Hydration & Electrolytes In the Older Adult

Janet ReidJanet ReidJanet ReidJanet Reid----Hector, Ed.D, RDHector, Ed.D, RDHector, Ed.D, RDHector, Ed.D, RDJanuary 26January 26January 26January 26thththth, 2012, 2012, 2012, 2012

Nutrition and Hydration the ElderlyNutrition and Hydration the ElderlyNutrition and Hydration the ElderlyNutrition and Hydration the Elderly

Organ System Change Potential Outcome

Body composition ↑ Fat

↓ LBM

↓ Body water (20%)

↓ BMR

↑ Fat-soluble drug storage, w/ prolonged ½ - life

↑ Concentration of H2O -soluble drugs

Gastrointestinal ↓ Gastric acid secretion

↓ Gastric motility

↓ Lactase activity

↓ Absorption of folate, protein-bound vitamin B12

↓ Bioavailability of minerals, vitamins, protein

Avoidance of milk products, with ↓ intake of

Vit D & calcium

Hepatic ↓ Size & blood flow

↓ Activity drug-metabolizing enzymes

↓ Albumin synthesis rate

Poor or delayed metabolism of certain drugs

Immune ↓ T-cell function Anergy

↓ Resistance to infection

Neurologic Brain atrophy ↓ Cognitive function

Renal ↓ Glomerular filtration rate

↓ Renal activation of 1,25,(OH)2 D3

Reduced renal excretion of metabolites; drugs

↓ Vit D, Calcium

Sensory-perceptual ↓ Taste buds, papilla on tongue

↓ Olfactory nerve endings

Altered taste threshold, ↓ ability to detect

sweet/salt, ↑ use of salt/sugar

Altered smell threshold, ↓ palatability

causing poor food intake

Skeletal ↓ Bone density ↓ Fractures

SOURCE: Nutrition Screening Initiative. 2626 Pennsylvania Ave. NW, Suite 301, Washington, DC 20037. (2003)

Overview of Composition & Volume of

Body Fluid Components

� TBW = 60% Body Wt.

� ⅔ is ICF space, ⅓ ECF space� ECF: Interstitial, Plasma, Na+, CL-, HCOӡ-

• Na+ Correlates with ECF osmolality

• ICF: K+, Mg, PO₄-, Proteins –Osmolality correlates with conc. of K+ & Mg+

• ICF & ECF have similar osmolality ~ 285 mOsm/kg

• 360 ml fluid lost / c°°°° / fever / day

• Respiratory fluid loss ↓ with humidified air given by mask or ET tube

• Janet Reid-Hector, Ed.D, RD, CNSD

Fluid & Electrolytes Changes In the Older Adult

• Creat. clearance ↓ with age by 1 ml/min/yr after 40 years of age.

• S. Creatinine remains constant due to ↓muscle mass.

• ↓ of water intake occur in the elderly 2° ↓ sensation of thirst;

associated with a tendency to lose water with urine.

• Capacity to respond to sodium( NA) load is impaired in aged

kidneys, →ECV expansion & HTN.

• The elderly have a ↓ capacity for retaining NA making old

subjects sensitive to salt depletion & ECV contraction. • Hypernatremia (NA > 150 mmol/l) is not infrequent in the elderly

& is usually due to water deficiency and rarely to iatrogenic excess of sodium.

•



• An abrupt occurrence of severe hypernatremia ↠

neurological symptoms due to dehydration & brain

shrinking, which may lead to cerebral hemorrhage & death.

• Hyponatremia (NA < 130 mmol/l) is frequent among the

elderly ; mainly due to iatrogenic water overload.

• Hypovolemic hyponatremia occurs when salt depletion ↠

ECV contraction > 10%, & is due to water retention in an

attempt to normalize ECV.

• Hypervolemic hyponatremia is due to ADH hyper secretion

because of a ↓ in 'effective' circulating blood volume.

• 'Pseudo hyponatremia' may occur because of

hyperlipidemia or hyperproteinemia. • Janet Reid-Hector, Ed.D, RD, CNSD


• An abrupt occurrence of severe hyponatremia that → neurological

symptoms (water intoxication), 2° the edematous swelling of the

brain within the skull.

• Rapidly occurring hyponatremia may be lethal, slowly occurring

hyponatremia is usually asymptomatic.

• Rapid correction of hyponatremia may cause cerebral dehydration

& 'osmotic demyelination syndrome' ('central pontine

myelinosis').

• ↓ (e.g. by diuretics) or⇡⇡⇡⇡ (e.g. by ACE-inhibitors, NSAID, ℬ-

blockers) of serum potassium may occur in the elderly.

• Diuretics should be used with caution in elderly subjects to avoid

salt depletion, hypotension & renal function impairment• Janet Reid-Hector, Ed.D, RD, CNSD

Gender differences in Fluid Metabolism• Semin Nephrol. 1996 Jul;16(4):277-88. Abnormalities of water metabolism in the elderly. Ayus JC, Arieff AI.

• Hypernatremia (high sodium in the blood that occurs with excessive fluid loss) is a frequent problem at the extremes of age, but particularly so in elderly individuals.

• When comparing healthy elderly men to younger controls, there are differences in the response to water deprivation. In older men, there are deficits in both the intensity & threshold of the thirst response.

• The ability to concentrate the urine also declines with age. There is both a decline in GFR & an ֈ incidence of renal disease with advancing age, to impaired ability to conserve water.

• A ⇓ in % TBW of equal volumes of fluid loss in young & old individuals ⇝⇝⇝⇝ more severe dehydration in the elderly.

MDS triggers that indicate hydration may be at risk?

↠ •UTI in the past 30 days

↠ • Dehydration diagnosis

↠ •Weight +/- 3 lbs. in the last 7 days

↠ • Fluid output exceeds intake

↠ •Fever

↠ • Internal bleeding

↠ •Tube feeding in place

↠ • Certain medications

↠ •Over the last 3 days beverages offered are not consumed• Janet Reid-Hector, Ed.D, RD, CNSD

Electrolyte Balance

• Hyponatremia

• The most common electrolyte imbalance.

• Associated with kidney disease : nephrotic

syndrome & ARF

• Very young & old people affected more often

than young adults.


Electrolyte Balance

• Causes of HyponatremiaH20

retention &

renal failure

Pseudo

hyponatremia

Psychogenic

polydipsia

Hypovolemic

hyponatremia

Hypervolemic

hyponatremia

Euvolemic

hyponatremia

⇥ in a low

NA level in

the blood

too much water

is drawn into

the blood;

commonly seen

in

hypoglycemia

compulsively

drink > 4

gallons of

water/ day.

low blood

volume due

to fluid loss

► in

dehydrated

people who

rehydrate too

quickly,

thiazide

diuretics,&

S/P severe

vomiting or

diarrhea

high blood

volume due

to fluid

retention ►

in cirrhosis,

heart disease,

nephrotic

syndrome,

edema

⇓in TBW in hypothyroidism,

adrenal gland

disorder, &

disorders

that⇑ release

of ADH, such

as TB,

pneumonia, &

brain trauma.


Signs & Symptoms

HyponatremiaTreatmentGoal of treatment

Methods include:

Symptoms of hyponatremia

are related to the severity &

rate at which the conditions

develop.

The first symptoms: fatigue,

weakness, nausea, &

headache.

More severe cases: confusion,

seizure, coma, and death.

Restore electrolyte balance for

proper hydration & use of

total body fluid.

NA deficiency must be

corrected slowly because

drastic change in NA level ⇛

brain cell shrinkage and

central pontine myelinolysis

(damage to the pons region of

the brain).

Fluid & water restriction

IV saline solution of 3% NA

Salt tablets

Signs , Symptoms & Treatment of Hyponatremia


Hypernatremia

• Hypernatremia commonly affects older hospitalized people, 50% of whom have underlying diseases that, when combined with excessive NA & fluid loss, are fatal.

• Hypernatremia : occurs with excessive fluid loss; not replaced, sodium is not adequately excreted from the body.

• Causes:

• * Diabetes insipidus (caused by deficiency of or insensitivity to ADH)* Diarrhea; * Diuretic medication* Excessive salt intake* Excessive vomiting* Heavy respiration (e.g., exercise, exertion)* Severe burn* Sweating It is associated with the same symptoms as hyponatremia, and also causes the following:* Delerium* Irritability* Muscle twitching


Treating Hypernatremia

• Slowly replenish H2O loss, usually over 48

hours, through drinking or IV solution.

• In cases of DM, the imbalance is treated with

adequate water intake and NSAIDS or with

synthesized hormones (e.g., desmopressin)

that aid in fluid retention & decrease

urination.


Hypokalemia• An abnormally low level of K+ ; The adrenal gland makes

aldosterone; that signals the kidneys to excrete or conserve potassium, based on the body's needs.

• In hypokalemia, the adrenal gland retains the hormone & the kidneys conserve potassium when more is needed.

• Causes• The most common cause of K+ depletion is diuretics that ⇈ urination. Other causes include:

• * Diarrhea* Dietary deficiency* Excessive sweating* Magnesium deficiency (causes over excretion of fluid)


Signs, Symptoms & Treatment of Hypokalemia

• Symptoms of deficiency: cardiac arrhythmia, muscle pain, general discomfort or irritability, weakness, & paralysis.

• Diagnosis

• May require urinalysis & blood tests to determine the amount of K+ being excreted by the kidneys.

• Treatment

• K+ supplements, diet, IV solution.

• ***Patients on diuretics are given K+ supplements.

• Potassium is given slowly to avoid hyperkalemia.


Hyperkalemia

• An abnormally high level of potassium.

• K+ is released into the blood when cells are damaged.

• Causes include:

• * Burn* Chemotherapy* Hemolysis (RBC destruction caused by infection or burn)* Rhabdomyolysis (destruction of skeletal muscle; associated with acute tubule necrosis, or ATN)* Strenuous exercise (rarely)

• Urinary excretion of potassium can be impaired by the following:

• * Acute & Chronic Renal failure * * Impaired aldosterone release or production* Medications that ⇓ K+ excretion:o Amiloride (diuretic)o Bactrimo Cyclosporine (immunosuppressive)


Signs, Symptoms & treatment of Hyperkalemia

• Hyperkalemia affects the heart & ↠↠↠↠ EKG changes, ventricular fibrillation, & cardiac arrest.

• Other symptoms include:

• Tingling in the extremities, weakness, & numbness.

• Treatment

• IV Diuretics &calcium to promote K+ excretion.

• Insulin is given with glucose to help cell absorption of K+

• Albuterol may be added to ⇡⇡⇡⇡ absorption.

• Drugs that bind to K+ such as Kayexalate, force K+ into the intestine to be excreted.

Hydration ManagementPromotion of adequate fluid balance that prevents

complications resulting from abnormal fluid levels.

Maintaining adequate fluid balance is an essential component of

health across the life span; older adults are more vulnerable to

shifts in H20 balance, over-hydration & dehydration, 2° age-

related changes & ⇡⇡⇡⇡ medical conditions. Dehydration is the

most frequently occurring problem.

Seniors are at ⇡⇡⇡⇡ risk dehydration; they are not as sensitive as

younger adults to the sensation of thirst.

Age-related changes in the body’s ability to balance H2O & NA

sodium ⇡⇡⇡⇡ increase the danger.

Older persons with diarrhea / vomiting consume at least 1.7 L

fluid/q 24 hr. = about (7) 8 Oz. glasses of water. ****Liquid meal replacements are also recommended.

� Essential to all functions

� Affects cellular metabolism & integrity

� Catalyst in biological Rxs.

� Regulation of body temperature

� Transport of nutrients & electrolytes

� Dilution & transport of medication

� Maintain normal body waste removal


Disturbances of Volume & Concentration of Body Fluids.

• The general clinical terms for volume abnormalities are dehydration & overhydration. Both conditions are associated with a Δ in ECF volume.

� ADH secretion regulated by osmotic, volume, hormonal & neural stimuli

� Osmolarity & Osmolality are a measure of the # H2O attracting particles� Osmolarity: # osmoles of particles (solute) / kg of solvent (mosmol/kg/ H2O))))� Osmolarity: # osmoles of particles / vol. Of solvent (mosmol/L)

� Thirst = 1-2 % deficit in BW� Soduim (Na): Primary ECF cation

� Integrity of ECF determined by Na & its accompanying onions.


»FLUID BALANCE

� Obligatory: minimum required for survival

� Facultative: 500 – 1000ml – margin of safety for

� Conservatory/Excretory mechanisms of the body which use H2O.

� A wt Δ of 1 kg. unattributable to anything else = fluid loss / gain of 1L

Obligatory Input Obligatory Output

Fluids 750ml Urine 750

Metabolism 350ml Sweat 500

Facultative 1000ml

Lungs 400

Total 2800ml Feces 150

Facultative 1000

Total 2800

� **********General recommendations:

30 ml/kg / BW / day or 1 ml/kcal ingested.• Fluid intake must replace measurable losses (urine, feces,

drain tubes & insensible losses from respiration & skin.

• Recommended minimum total fluid intake is 1500-

• 2000ml, (equivalent to 6-8 250ml cups) /day from all sources including soups and beverages.

• Formula: to calculate fluid requirements for older people

• 100 ml fluid/ kg BW for the first 10 kg

• 50 ml fluid/ kg for the next 10 kg

• 15 ml fluid/ kg for each kg after 20 kg.

Dehydration – common anomaly

Dehydration is a frequent etiology of morbidity and mortality in elderly people.

It causes hospitalization of many patients & its outcome may be fatal.

Often linked to infection, & if overlooked, mortality may be over 50%.

� 1. ↓ thirst response

� 2. Kidney’s ⇩ concentrating capacity

� 3. Diuretic medications

� 4. Dementia• Janet Reid-Hector, Ed.D, RD, CNSD

Risk Factors Associated with Dehydration

Risk Factors Etiology in the

Elderly

Clinical Signs of

Dehydration?

Consequences of

dehydration

Acute or chronic

illness

Lack of sense for thirst Dizziness upon

sitting/standing Confusion—

Δ in mental status

⇓ functional ability

Medication use—

especially

laxatives, diuretics,

enemas

Aged kidney—⇓ ability

to concentrate urine

⇓ urine output

• Poor skin turgor;

dry mucous membranes

Constipation • Fever

Predisposition to falls

& Infection

Restriction of fluid ⇓muscle mass,

therefore, ⇓ total body

water

⇓ auxiliary sweating

Dry oral mucosa

Recent Δ in consciousness

Fecal impaction

•Fear of

incontinence

⇑ need for feeding

assistance

Dry oral mucosa Fluid and electrolyte

imbalance

•Dysphagia Darker urine • Death


Diagnosing Dehydration

• The most accurate test is serum osmolarity –

• A value above 295 mOsmol is diagnostic of ⇓ body water in all but

very exceptional circumstances.

• Other tests include: an ⇡⇡⇡⇡ BUN: Creatinine, ⇡⇡⇡⇡ S. Na

• ***These tests are more liable to be abnormal for reasons other

than dehydration.

• All 3 values are stable in non-ill residents of nursing homes, so a Δ

from baseline is reliable to suggest dehydration has occurred.

• Urine specific gravity: H2O balance & urine concentration


� Mucosal xerosis

� Swollen tongue

� Sunken eyeballs

� ↑ body temperature

� ↓ urine output

� Constipation

� Nausea

� Vomiting

� ↓ blood pressure

� Mental confusion

� Acute renal failure

� Altered drug effects

� Electrolyte disturbance


Biochemical Signs of Dehydration*

Signs Value

Raised serum osmolarity

Raised serum sodium

Raised BUN/creatinine ratio

Urine specific gravity

*****Conditions under which the test may be performed:

Complicated UTI (pyelonephritis)

High blood sodium level (hypernatremia)

Low blood sodium level (hyponatremia)

Excessive urination

Above 295 mOsmol

Above 145 mmol/L

Above 50 (urea in mmol/L

1.002 to 1.030.


Dehydration

• 3 types of dehydration:– Isotonic; Hypotonic ; Hypertonic

• Proportional balance of Na & H2O losses

• Dehydration can be measured as % of BW loss.

• Effects– Increases resting rate

– Susceptibility to development of UTI

– Pneumonia

– Pressure ulcers

– Confusion, disorientation, dementia

•• Janet Reid-Hector, Ed.D, RD, CNSD

� Hypertonic Dehydration

� Body H20 losses > NA Losses

� Reduced Oral Intake

� Excessive loss from sweating or prolonged fever

� NA concentration ↑ in the ECF

� ↑ Bun/ Creatinine in absence of renal failure


� Body Na+ loss exceeds H2O loss

� Na+ depletion or hyponatremia

� Diuretics, diarrhea / vomiting

� Renal wasting syndrome

� Lab Tests: � abnormally low serum Nat Levels

� Reduced ECF

� Tx: H2O/ Electrolytes solutions to rehydrate


• Body loses equal amounts of Nat & H2O

• Extreme diarrhea/vomiting

• Food borne Illnesses/severe bleeding

• S. NA, Osmolality & specific gravity are WNL

• Patients do not sense thirst/need for fluid

• Both fluid & NA are required to rehydrate


Lab Test Hypertonic Isotonic Hypotonic

Osmolality, serum >Normal WNL <Normal

Sodium, serum >Normal WNL <Normal

Hemoglobin >Normal >Normal >Normal

Hematocrit >Normal >Normal >Normal

Albumin, serum >Normal >Normal >Normal

BUN >Normal >Normal >Normal

Urine specific Gravity

>Normal >Normal <Normal

Laboratory Screening For Dehydration


OverHydration• ↑ in ECF volume

• Fluid shifts from ECF→ IFC → edema

• ↑ capillary hydrostatic pressure (CHF)

• ↓ colloid osmotic pressure (hypoalbuminemia)

• ↑ capillary permeability (inflammation)

• Lymphatic obstruction (following surgery)

• Liver / Kidney failure

• Physical inactivity

• CHF, Low BP

• Tx. Edema – Loop Diuretics


Laboratory Screening For Overhydration by TypeLab Test Hypotonic Isotonic Hypertonic

Osmolality, serum <normal WNL >normal

Sodium, serum <normal WNL >normal

Albumin <normal WNL or slightly low

<normal

H/H <normal WNL or slightly low

<normal

Blood Urea Nitrogen

<normal WNL or slightly low

<normal

Dehydration

Fluid Balance/ Homeostasis

� ICF Deficit ECF Loss Excess

� Tx: Hyponatremia� H2O restriction (w) 150gm CHO orally or 25%

dextrose slowly.

� True Na+ Deficit

� 100-150mg NaCL as 3% or 5% NaCL slowly IV

followed by strict fluid restriction.

� Hyponatremia

� Isotonic dilute saline solution IV.

■ ICF loss & dehydration due to H20 loss.

■ with higher osmotically active fluids.

Eg. Non- Ketotic hyperosmolar

syndrome.

■ Tx: Hypotonic Fluid

If BP is ↓ due to ECF deficit,

Tx with isotonic fluid.

ICF Excess■ H2O intoxication

Inappropriate ADH secretion.

■ Hyponatremia – (< 135 ) dilutional

or artifactual.

■ Hyperglycemia

■ Hyperlipemia

■ G.J. hemorrhage

Addisonian crisis

■ Renal DS. (w) Na+

wasting

■ NG Suction

■ Vomiting, diarrhea

■ Diuretic Tx.

■ Edema

■ Heart Failure

■ Ascites

■ Excessive infusion of

hypotonic fluid.


Calculating Water Deficit (Liters0.6 x BW (1- 140)

[Na]

S.Na+↑3mEq/L for each liter of H2O deficit

Bun ↑3mg/100ml

Reverse for Over hydration

Calculating Fluid Deficit

70 kg male, S. Na+ = 170 mEq/L

H2O Deficit: = 0.6 (70) (1-140 / Na)

= 42 – 34.6 = 7.4 L Deficit

• Calculating Excess H20 to be Excreted to

Correct HyponatremiaSerum Osmolality

Glucose (mg/dl) Bun (mg/dl)

mosm/kg/ H2O = 2 x Na + 18 + 2.8

Normal = 285 – 290 mOsmol/kg/h₂₂₂₂0

Chloride Deficit

mEq Cl = 0.2 x BW (kg) x (103 – S.CL-)

Bicarbonate Deficit (HCOӡӡӡӡ))))mEq HCO3 = (24 - PHCOӡӡӡӡ) ) ) ) x 0.4 x BW (kg)

PHCOPHCOPHCOPHCOӡӡӡӡ = Arterial Blood Gas

E.g. 70kg male, 60% BW, Serum Na+ Conc.

= 120 mEq/L

70 x 0.6 = 42 L TBW

120 mEq/L (PT) x 42L =36L

140 mEq/L (normal)

42 – 36 = 6L excess fluid

• Hyperglycemia → ↑ ECF Osmolality

• H2O moves from ICF → ECF → Nutriuresis

• Theory = ↓ for q 100mg/dl ↑ in Gluc → 2.8 meq/L↓ in Serum Na+ conc.

• Actual = 1.6 meg / ↓ in S. Nat Conc.

E.g. Patient with Serum Glu = 800mg/dl

Serum Na+ expected to ↓ 129 meq/L

(140 - 1.6 x 7)

Any Variation Suggests:

• Superimposed dehydration or salt loss.

• Mannitol infusions.


Fluid Balance / Homeostasis

• No edema Present

• No Jugular Vein

distension

• Adequate urine output

• Normal S. electrolytes &

arterial pH.


Nutritional Interventions for Dehydration

• Rehydrate slowly

– Guidelines

• Provide 1/4 to 1/3 overall fluid deficit

• Use water of 5% glucose solution

• Thickened liquids count as fluid

• Offering fluids hourly and with medication – achieve higher levels of hydration


Strategies to maintain / increase fluid intake

� Ensure all staff are adequately trained in the importance of hydration.

� Regularly offer fluids – e.g. every 1 ½ hours by day

� Offer fluids at specific routine events

� before / after showering or washing

� after toileting

� before / after physiotherapy or other activity program

� medication rounds

� Regular hydration cart rounds

� Offer residents their preferred drinks

� Prompt residents to drink at meal times

� Ensure fluid is within residents’ reachEducate families / visitors to offer fluids when visiting

� Encourage “wet” foods such as jelly, custard, yogurt, ice cream, soup, pureed fruit

� Have a social hour where fluids are offered

� Keep a fluid intake chart especially for at risk residents

� Use a symbol such as a drop of water on trays of residents who need to drink more, to prompt staff.

� Measure urine specific gravity monthly

� Measure osmolarity, NA /BUN /creatinineratio

.

� Identify at risk residents and pay more attention to them – e.g. confused, refusing fluids, febrile, on diuretics


Alternative to IV Hydration in the elderly

• Hyaluronidase, an enzyme obtained from bull testes, has been used to enhance fluid absorption from subcutaneous tissue.

• Temporarily lyses normal interstitial barrier, which consists mainly of hyaluronic acid, a polysaccharide found in the intercellular ground substance of connective tissue.

• Hyaluronidase⇩ the viscosity of the connective tissue, thus ⇑diffusion of the fluid administered subcutaneously for about 24 to 48 hours

• One method : add 150 U/ L to a fluid infusion bag & inject 75 U of into each clysis site through the tubing near the needle.

• Some physicians have used 10X this dose for hypodermoclysis by priming the needle and infusion set with Hyaluronidase(1,500 U) & 1 - 2 mL of lidocaine.

• This dosage can cause discomfort / local reaction.


Alternative to IV Hydration in

the elderly

• Hypodermoclysis has been an alternative option to the traditional IV route for ≫ 50 years.

• This method involves the insertion of a 21 or 23 gauge butterfly cannula under aseptic conditions into subcutaneous tissue

• As subcutaneous tissue tends to diminish peripherally and increase in central areas as part of the ageing process, the abdomen, scapula or thighs are all prime sites for administration of subcutaneous fluids.

• Once the cannula is inserted, it is attached to a giving set and connected to a bag of parenteral fluids, commonly infused at a rate of 2L over a 24 h period.

.

• As the use of electrolyte-free and hypotonic solutions has been associated with cardiovascular collapse and shock, it is now standard practice to use either 5% dextrose or 0.9% saline solutions.

• Up to 34 mmol of potassium can be given safely with each litre of fluid

• Up to 2 litres of dextrose-saline solution can be safely administered every 24 hours using this route; but physician supervision and close patient monitoring is essential


Maintaining Hydration in Gastroenteritis

► Dehydration can occur very rapidly – within hours with vomiting and diarrhea ֈ fluid los.

► Electrolytes are also being lost

►Prevention of dehydration should be combined with electrolyte replacement.

� The use of glucose & salt in rehydrating solutions ensures the most rapid absorption of H2O & electrolytes from the bowel.

� Fluids too high in sugars will not be absorbed as rapidly & replacement fluids with no sugar or electrolytes can actually ֈ gut loss of fluid.

� It is essential that rehydration fluids are used early – from the beginning of an episode of gastroenteritis – & frequently.

� Examples of rehydrating fluids, include:: Hydralyte & Gastrolyte ⇩ the high risk of dehydration.

� It is recommended that Hydralyte, be administered as 200ml q 30 mins .

� When oral intake remains insufficient, Hypodermoclysis can avoid transfer to hospital for dehydration.


NYHA Classification - The Stages of Heart Failure

• In order to determine the best course of therapy, physicians often assess the stage of heart failure

according to the New York Heart Association (NYHA) functional classification system. This system

relates symptoms to everyday activities and the patient's quality of life.

Class Class I (Mild) Class II (Mild) Class III

(Moderate)

Class IV (Severe)

Patient

Symptoms

No limitation of

physical activity.

Ordinary physical

activity does not

cause undue

fatigue,

palpitation, or

dyspnea

(shortness of

breath).

Slight limitation

of physical

activity.

Comfortable at

rest, but ordinary

physical activity

results in fatigue,

palpitation, or

dyspnea.

Marked

limitation of

physical activity.

Comfortable at

rest, but less

than ordinary

activity causes

fatigue,

palpitation, or

dyspnea.

Unable to carry

out any physical

activity without

discomfort.

Symptoms of

cardiac

insufficiency at

rest. If any

physical activity

is undertaken,

discomfort is

increased.


Fluid Management in Heart FailureHeart failure Consequences

Heart failure develops gradually over several

years, or move quickly S/P an MI or a disease of

the Cardiac muscle.

Rate of death is ~ 10% after 1 year. ½ die w/n 5

yr. S/P diagnosis. Advances in research are

providing more options and improving.

The pumping action of the becomes less

powerful.. blood does not move efficiently

through the circulatory system & back up, ↑

pressure in blood vessels & forcing fluid into

body tissues.

When the (ℒ )side of the starts to fail, fluid

collects in the lungs ⇝Pulmonary edema. This

extra fluid congests the lungs ,makes it more

difficult for airways to expand as you inhale.

Breathing becomes more difficult, , SOB occurs

particularly with activity or lying down.

ℛ) side of the heart starts to fail, fluid collects in

the feet and lower legs. As the upper legs swell

and abdomen collects fluid (ascites). Weight gain

is an excellent measure of how much fluid is

being retained.

Edema is a sign of (ℛ) heart failure, especially

with pitting edema. Non pitting edema is Ȉcaused by heart failure.


Fluid & Electrolyte Concepts in Heart Failure-

Raging HormonesHormones Effect Consequences

Angiotensin II

markedly ⇈

Cause renal & peripheral vasoconstriction.

GFR may initially maintained , but eventually

both RBF & GFR are inadequate

Limits the amount of Na reaching

the proximal tubules; ⇛ more Na

reabsorbed.

Angiotensin stimulates the secretion of Aldosterone from the

adrenal cortex which acts on the distal tubules

Enhances both Na & Cl-

reabsorption, & K+ and H- excretion.

ADH ⇈Enhances vasoconstriction; allows H2O & urea to be

reabsorbed into the medullary interstitium which ⇛

urine to concentrate.

Potentiates abnormal sodium and

water retention.

Edema results from dilutional

hyponatremia & H2O retention

Oliguria is a late sign of CHF resulting

from ⇩ RBF & CO output.

Nocturia may also occur.


Congestive Heart Failure Treatment

• The treatment of heart failure depends on the exact cause, but it can usually be treated effectively.

• The overall goals of treatment:

1. Correct underlying caus,

2. Relieve symptoms

3. Prevent worsening of the condition.

4. Symptoms are relieved by removing excess fluid from the body

5. Improving blood flow,

6. Improving heart muscle function,

7. Increasing delivery of O2 to the body tissues.


Recommendations for Heart failure TX.Labs , Vitals, MNT Rationale

Daily weight checks: mandatory

in persons with heart failure

B-type natriuretic peptide(BNP)

The amount of fluid retention is usually reflected by the

amount of ⇑ SOB & weight gain.

Hormone produced at ⇈ by the failing heart muscle. Levels ⇑severity of heart failure worsens.

Fluid Intake 1.4 - 1.9 L (48-64 oz.)/ day, depending on clinical symptoms

(i.e. edema, fatigue, SOB. Fluid ℟ improve clinical symptoms

& quality of life.

Sodium Intake <<<< 2000 mg (2 g) /day. Na+℟ will improve clinical

symptoms (i.e. edema, fatigue) & quality of life.

Risks/Harms of Implementing ♥ Failure

Recommendations

• Potential risk of a fluid & Na+ ℟ diet is ⇑ BUN/ Creat.

• Patients may be Hypovolemic & alterations in diuretics, fluid & Na+ intake should be considered.

• ***Consider a lower range of fluid ℟ in NYHA stage IV patients

• 2-g Na+ diet is unpalatable for some patients, a 3-g Na+ may be a more realistic target for patients with mild – mod. ♥ failure.

• For some patients, fluid ℟ are difficult to follow because of excessive thirst related to ⇓ CO.

• Avoid other dietary ℟s unless clearly indicated (e.g., a LF, low-Chol diet for hypercholesterolemia in patients with ischemic cardiomyopathy.

• Although some ♥ failure patients are obese, other patients with advanced ♥ failure experience a syndrome of chronic wasting, which can be exacerbated by unnecessary dietary ℟s.

• Frequent, small meals may combat the effect of anorexia caused by congestion of the GIT.


Effect of Pharmacological Management Of ♥♥♥♥ Failure

on Fluid & Electrolyte management

• There are 4 categories of drugs

which are used to improve cardiac

performances in CHF :

• inotropics,

• diuretics,

• vasodilators,

• and ACE inhibitor

Diuretics.

• The aim of diuretic

therapy is to reduce

pulmonary venous

pressure and to

• promote the excretion of

edema fluid.


Effect of Pharmacological Management Of ♥♥♥♥ Failure on Fluid

& Electrolyte Management

• Loop diuretics. Bumetanide(Bumex), Furosemide (Lasix), ethacrynic acid (Edecrin).

• Potent diuretics often used when pulmonary congestion must be

• ⇓ rapidly.

• Promote excretion of Na+ & H2O by blocking their reabsorption in the Loop of Henle.

• Over-vigorous Tx ⇛ to volume depletion which ⇛ to a ⇩ in CO.

•• Other adverse effects include:

hypokalemia, hyponatremia, & hyperglycemia

• Thiazide diuretics. Chlorothiazide (Diuril), Hydrochlorothiazide (Hydro Diuril).

• Widely used because they can be administered easily & are relatively inexpensive.

• Promote excretion of Na+, CL- & H2O by blocking their reabsorption in the renal tubules.

• Adverse side effects include: hypokalemia & hyperglycemia


Effect of Pharmacological Management Of ♥♥♥♥ Failure

on Fluid & Electrolyte Management

• Potassium-sparing diuretics. Spironolactone (Aldactone)

• Produces diuretic effect by inhibiting the action of Aldosterone in the distal tubule which ⇛ to Na+ & K+ potassium excretion .

• An adverse effect is hyperkalemia.

• Be aware that diuretics can produce dehydration& electrolyte depletion which can cause circulatory collapse.

• For this reason, monitor I/O, weight & serum Na+

• ACE inhibitors

• Allow kidneys to retain K+ while excreting Na+ & fluid.

• Therefore, patients receiving K+-sparing diuretics must be carefully monitored for hyperkalemia


Lymphedema

• Lymphedema is the buildup of lymph (a fluid that helps fight Infection & disease) in the fatty tissues just under the skin.

• A common complication of cancer/ cancer treatment & can result in long-term physical, psychological &social issues for patients.


Lymphedema

• Most common type of acute

Lymphedema develops very

slowly ; noticeable 18- 24

months after surgery or not

until many years after cancer

treatment.

• Patient may experience

discomfort of the skin; aching

in the neck, shoulders, spine

or hips ; or posture changes

caused by ⇑weight of arm/

leg.

• Recurrence or spread of a

tumor to the lymph nodes.

• Infection of and/or injury to

the lymphatic vessels.

• Periods of not being able to

move the limbs.

• Radiation Tx. or surgery.

• Blockage of a vein by a

blood clot


Diagnosis & Management of Lymphedema

Diagnosis Drug Therapy Dietary Management

To evaluate a patient for Lymphedema, a medical Hx & PE should be completed to include any past surgeries, and the time between surgery and the onset of symptoms of edema.

**Surgery may be required to remove excess fluid & Lipids

**A rare but fatal complication of Lymphedema is Lymphangiosarcoma, a tumor of the lymphatic vessels.

After a patient develops lymphangiosarcoma, the average survival time is a little > than 1 year.

Antibiotics may be used to treat/ prevent infections. Other types of drugs such as diuretics or anticoagulants are generally not helpful, and may make the problem worse.

***Coumarin: It was found to cause liver damage, has been banned since the 1950s; is available in several countries, but Φ approved for use in the US or Canada

Blood protein levels and weight should be monitored regularly, & patients should be encouraged to eat protein-rich foods.

Edema can make tissues less able to take in nutrients. Patients should be monitored for areas of skin breakdown, especially over areas with very little tissue between the skin & bone.


Hydration Case Study #1

• Joan is a 45kg lady with mild dementia and

urinary incontinence. She suffers with frequent

urinary tract infections and is slightly

underweight having lost 5kg in the last 12

months. She feeds herself however requires

prompting and encouragement. A fluid intake

chart shown Joan only consumed around 1L of

fluid/ day. How can we improve Joan’s

nutritional status focusing on her fluid intake?

Hydration Case Study #2Ted is a healthy weight gentleman at 80kg. He has

developed a swallowing problem after a recent stroke and is now having semi- thickened fluids & soft foods. He dislikes the semi thickened drinks and has recently been drinking very little. His urine is very dark and with a strong odor. He is feeling quite lethargic and has a dry mouth making it difficult to swallow his food. Ted is not enjoying the thickened drinks.

What would you recommend to help Ted Consume adequate fluids and nutrients?

Knowledge Check• 1. Dehydration is best described as:

• a. Input exceeds Output

• b. Output exceeds Input

• c. Input equals Output

• d. None of the above

• 2. What are some risk factors associated with dehydration? Circle the correct answer(s)

• a. Frequent diuretic, laxative, or enema use

• b. Lack of sense for thirst

• c. Increased need for feeding assistance

• d. Dysphagia

• e. All of the above

• 3. What are some of the physical changes that make the elderly more susceptible

• to dehydration? Circle the correct answer(s)

• a. Increased bladder capacity

• b. Acute illness

• c. Increased body water

• d. Inability

• 4. The nursing staff are the only ones responsible for ensuring patients /residents

• receive adequate fluids.

• True or False

• 5. What are possible effects of dehydration? Circle the correct answer(s)

• a. Decreased functional ability

• b. Fluid and electrolyte imbalance

• c. Fecal impaction

• d. All of the above

• 6. Besides mealtime, when might fluids be offered? Circle the correct answer(s)

• a. Medication Pass

• b. Activities

• c. At family visits

• d. Snack time

• e. All of the above

Nutrition Support in Older AdultsJanet Reid- Hector Ed. D, RD

1/26/11

PN is increasingly used in the elderly. Aging is accompanied by metabolic changes that can alter substrate utilization :

In the fasting state, REE was significantly higher in the elderly patients than in the middle-aged patients

In the elderly, TPN is associated with significantly higher lipid oxidation & lower glucose oxidation than in younger patients. TPN formulas and flow rates should therefore be adapted in the elderly.


� Insulin resistance⇝⇝⇝⇝ to a ⇓ glucose utilization &� Hyperglycemia with impairment of cardiac & renal Fxn are

the most relevant features.

� They may warrant the use of formula with ⇑lipid content –up to 50% of total energy intake.

� Deficiencies in vitamins, trace elements & minerals should be suspected in older subjects.

� In both the UK and the USA up to 40% of individuals aged ⋝65 or have an inadequate intake of one or more vitamins or minerals (ascorbate, folate, B12, B2, B1, magnesium, iron & Zn) with associated low blood concentrations.


� The effect of nutritional support on restoration of depleted body cell mass is ⇓ in older patients than in younger subjects.

� In addition, mild to severe hypophosphatemia is frequently found on admission, and commmonly develops, in older malnourished patients.

� Peripheral PN Both central and peripheral nutrition can be used in geriatric patients. Osmolarity of PPN nutrition should not be higher than 850 mOsmol/l. limited to 10-14 days

� Subcutaneous fluid administration is possible for fluid administrationn order to correct mild to moderate dehydration but not to meet other nutrient requirements.


� Functional status PN can support improvement of functional status, but the margin of improvement is lower than in younger patients.

� Active physical rehabilitation however, is essential for muscle gain.

� PN can ⇓mortality & morbidity in both older & middle-aged adults.

� Cardiac & renal functions are more likely to be impaired in older persons. Therefore fluid & Na+ intake should be limited, especially during periods of mobilization of ECF H2O that has accumulated due to inflammatory processes or during an earlier stage of refeeding


� Complications tend to be more frequent due to associated co-morbidities.

� Confusion during somatic illness is more common in geriatric patients & the syndrome of geriatric delirium may occur. During periods of confusion the tolerability of the IV catheter is ⇓.

� Due to the risk of cardiac failure, Na+ intake is often limited. With more vulnerable H2O homeostasis, & a tendency to⇑ EC & ⇩ in IC H2) both hypo- & hypervolemia are prone to occur.

� This is further complicated by ⇈ use of diuretics in this n population. These factors may also contribute to the thrombosis which is more common in the elderly on PN


� Older age was associated with a higher risk of central catheter vascular erosion.

� Hypophosphatemia plays a major role in the development of the refeeding syndrome. As PO4- is mainly IC, great losses occur in parallel with loss of muscle mass & progressive osteoporosis.

� PN (especially glucose) infusion can provoke a rapid drop in plasma PO4- level ⇒ to acute psychotic changes & Delirium.

� Glucose infusion, through the sudden increase in insulin can cause acute H2O and/or Na+ retention.


� Very low plasma levels of K+ or magnesium have also been reported, as a result of IC ion shift.

� In severely malnourished older subjects a stepwise increase of substrate intake (especially glucose) is necessary with strict monitoring of plasma electrolyte levels & timely corrections.

� Thiamine deficiency can also be evoked in the refeeding syndrome causing Wernicke’s Korsakov’s syndrome, with related features such as diplopia, confabulation, confusion & coma.


� TPN Electrolytes maintain normal cellular metabolism during TPN . Providing electrolytes in appropriate amounts prevents deficiency symptoms which otherwise would occur in their absence.

� In general, dosage usually starts at the low end of the dosing range, 2° the greater frequency of ⇓ hepatic, renal, & cardiac function, and of concomitant disease or other drug therapy.

� Na+ PO4- ions are substantially secreted by the kidney, & risk of toxic Rx may be greater in patients with impaired renal function.

� Care should be taken in dose selection, with monitoring of renal function.

� Sodium excess can cause edema & exacerbation of CHF.

� Excess potassium can cause deviations from the normal ECG . Potassium deficits can impair neuromuscular function, causing muscle weakness or frank paralysis, intestinal dilatation & ileus.

� Calcium deficits can produce neuromuscular hyper excitability ranging from paresthesias, cramps , laryngospasm, tetany & grand mal seizures.⇓ Ca+ levels can accompany administration of PN PO4- or large amounts of albumin.

� MG deficiency can precipitate neuromuscular dysfunction, hyperirritability, psychotic behavior, tachycardia & HTN. Magnesium excess can cause muscle weakness, ECG changes, sedation mental confusion.

Sodium Chloride Potassium

(K+)

Magnesium

(Mg)

Acetate

(CH3COO−)

Calcium

/The principal

EC cation; it

helps

maintain

motor nerves

, proper fluid

balance &

normal renal

metabolism

The principal

extracellular

anion which,

along with

Hco3,

maintains

proper anion

balance

The principal

IC cation;

transport

dextrose

across cell

membrane;

contributes to

normal renal

function.

Poorly

conserved by

kidney .

Mg is an

important

cofactor for

enzymatic

Rxs; maintain

normal CNS

activity & AA

utilization.

Eexcreted

solely by the

kidney at a

rate

+=plasma

conc. & GFR

Acetate

(CH3COO−)

provides

bicarbonate

(HCO3−) by

metabolic

conversion in

the liver even

in the severe

liver disease.

Muscle

contraction,

blood

coagulation ;

maintain

normal

neuromuscular

function.


� Energy

� Use of an easy calculation formula to measure

energy expenditure (REE) is strongly

recommended in the elderly. For people over 60

years old, the World Health Organization

(WHO) recommends the following:

� Males : REE= 8.8(W kg) + 1.128 (Ht m) - 1071

� Females : REE= 9.2 (W kg) + 637 (Ht m) - 302

� Adult RDA should be maintained.

� At least 0.8 g protein/ kg BW must be provided.

� The amount of protein that the elderly really receives

in relation to their BCM is higher compared with the

younger adult because cell mass is lost as people get

older, being replaced by fat mass.

� In metabolic stress: protein content ⇑ 1.5 g kg.

� More than 2 g/ kg does not improve N2 balance & serum urea could ⇑.


Weight Status & Anabolism During PN

♦ ECW is lost at a more rapid rate than ICW is ↑ during adequate nutrient delivery via TPN

♦ Initial weight loss during early phase of TPN induced anabolism

♦ Up to 3.6 kg wt. Loss/ first 4-5 days of PN in severely malnourished patients.

♦ After 1 - 4 days TBW and ICW both ↑ Normal Hydration restored

♦ Weight ↑ 0.2 - 0.5 kg/dy - gains in body fat mass & LBM

Janet Reid-Hector, Ed.D, RD, CNSD

Factors To Consider For Initiating Fluid Administration

for TPN Patients

1. Correct Imbalances

2. Provide Base & Maintenance Requirements

3. Replace Ongoing Losses


Fluid Management Guidelines

1. Correct fluid, electrolyte deficits and acid balances

before initiating TPN.

2. Total fluid intake should be ↑ to achieve normal

urine output. i.e. not < 900mL/dy.

3. First sign of fluid overload : distention of IJ vein

4. Maximum acceptable central venous pressure

(cvp) → is 14.

* If Protein is < 5•0 gm/dl, hypooncontic edema

develops with cvp as low as 8 - 10 cm H2O


Electrolyte Mgt. In TPN

Goal:

Provide elements for the conservation or repletion of cell compartments while also preserving the EC Environment.

The physical, chemical, functional anatomy of all body compartments must be considered in planning & delivering nutrition by vein.

Janet Reid-Hector, Ed.D, RD, CNS

Three Phases of Electrolyte/Mineral Requirement

Occurs during the first 3-5 days of IV Nutrition Support

Frequent changes in solution composition are necessaryFirst 24-48 hours Phase –2 Total Body Deficits May Begin – Sometime

of Electrolytes/ Mins. during 1st 24 hours & Must be replaced Lasts 2 – 3 days

Phase – 3Conversion To An Anabolic State

Requirement For K+, Mg+, Po4 – IC ElectrolytesFollowed by Stable Period of Maintenance Electrolyte & Mineral

Requirement


Factors Affecting Electrolyte Requirement

• New Cell Synthesis

• Individual Variation Due to Differences In:

Total body deficits/ Excesses

Serum Concentrations

Maintenance requirements

• Ongoing Losses

♦ Third space fluid, surgery, trauma

♦ Hemorrhage into soft tissues, abdominal cavity

♦ Burns, wounds

• Renal Function


HYPOKALEMIA in PN

• Glucosuria in spite of adequate insulin release.

• IC ratio of K+ : N of 35 :1 required for optimal protein synthesis.

• For optimal metabolic conditions, serum K+ must be maintained in high – NL. range.

• The more K+ retained by the body, the greater the increase in LBM.


Treatment

Body K+ Deficits

• IV replacement, infusing ½ of calculated deficit

over 8-12 hours or up to 40 mEq/ hr via central line.

Excess

• Resin Binders, Dialysis

Emergent Cardiac Arrythmias

IV CA² , NaHCo , or ampule of

D50 with Insulin


Insulin, K+ Connection in TPN Solutions

1. Not recommended to give insulin unless K+ supplementation is

adequate and s. conc. of K+ is normal

2. Recommend limit insulin to no > 70 - 80 u/dy

♦ Excessive insulin :

• Favors Diversion of Glucose → Fat Synthesis

• Down Regulates Insulin Receptors → Insulin

Resistance


Insulin & Diabetes Mellitus

Type 1 DM: start with 100

gms dextrose/dy

Type 2 DM start with ≥ 200

gms dextrose/dy

****Cover enteral CHO with

NPH

Cover PN dextrose with IV

regular Insulin in TPN &

Sliding scale.

Insulin Sliding Scale****>400mg/dl IV drip

Capillary Glucose mg/dL

IDDM NIDDM(STRESS)

201-250 3 5

251-300 6 10

301-350 9 15

351-400 12 20


How much Insulin in TPN?

Practical Guidelines

Estimating insulin Insulin Dose =

Initial PN Kcals X Pre Hospital Insulin

BEE

***Check BS q 6 hrs; On Avg, Patients require 2X home dose of insulin

0.1 unit of insulin/gm dextrose

• Minimum dose = 10 U / bag/ ↑ Dose in 10 U increments

Avoid putting too much in TPN

Supplement with sliding scale

Add ½ of previous day’s SS to TPN


Final Dextrose concentration

• Conc. of Dextrose X Vol. of Dextrose

Total Volume

Example

D70 X 500= D14%

2450


Acetate

• Average TPN Patient Requires 50 mEq/L

• Quickly converted to HCO3 by Liver

• Most commercial AA Solutions contain acetate &

CL-

• Virtually impossible to create an acetate free TPN

solution

• CL- - acetate Imbalance Hyperchloremic

Acidosis/Alkalosis


Sample CL-/ Acetate composition of Selected Amino

Acid Solutions (mEq/L)

Amino Acid Product CL Acetate

Travasol 8.5% 34 73

Travasol 10% 40 60

Trophamine 10% < 3 97

Novamine 15% - 151

Novamine 11.4% - 114


Hyperchloremic Metabolic Acidosis

• For each 6 mEq/kg/day drop in C02, buffering capacity is cut in 1/2

• Tx : Substitute Acetate for the CL- salts of Na+, K+

• Correct underlying cause

• HCO3 may not be added to TPN soln. Incompatible/ Precepitation


Calcium & PTH

• If serum CA² ↓↓↓↓ <10mg/100ml PTH ↑↑↑↑ .

• If ↑↑↑↑ >10mg/100ml PTH is suppressed.

• PTH ↓↓↓↓ Tubular reabsorption of PO4- & HCO3 by the kidney.

• Reabsorption of CL- →→→→ Hyperchloremic RTA.

• Excessive infusion of CA² or Vitamin D →→→→ Pancreatitis, Metabolic Bone DS.

• Should be given as Gluconate, Glucoheptonate or Glucoheptatesalt.

• Chloride salt is less soluble – should not be used. Janet Reid-Hector, Ed.D, RD, CNSD

Phosphate (Po4)

• Energy transfer & O2 transport & release

• Influence Leukocyte phagocytosis &

microbial resistance.

• Rapid Hypophosphatemia with Po4 deficient TPN soln.


Po4- Requirement in TPN soln.

NL serum Conc.

• Begin TPN day #1 with 7-9 mm Po4/1000Kcal

Low serum conc.

• Begin TPN Day #1 with additional 3-5mm Po4/1000Kcal as K+ or Na salt.

• ↑↑↑↑ as necessary to maintain normal serum concentration.

• Po4 Ions may be given either as KPo4 (3mm Po4 & 4.4 mEq/K+/ml) or

As NaPo4 (3mm Po4 & 4 mEq/ml)


Total Parenteral Nutrition Compatibility

• Calcium-Phosphate compatibility

– Factors which affect stability

• Additive concentration

• Choice of calcium salt

• Order of mixing

• Amino acid product (brand)

• Amino acid concentration

• Dextrose Concentration

• Temperature

• Storage time

• Addition of l-cysteine (neonatal)



• How to minimize calcium phosphate precipitation

• Additive concentration……..……....use lower the conc.

• Choice of Ca salt.…..…...use Ca Gluconate, not CaCl2

• Order of mixing…....add phosphate first, calcium last

• Amino acid product …Aminosyn® best, FreAmine® worst

• Amino acid concentration……….…use higher AA conc.

• Dextrose concentration………use higher Dextrose conc.

• Temperature………………………………………….…Refrigerate

• Storage time……………………....Minimized storage time

• l-cysteine (neonatal) ……..greatly increases solubility



• Normal range for serum calcium is – 8.5 to 10.5 mg/dL.

• Additional calcium is often added to TPN unnecessarily.

• 40% of calcium is protein bound.

• Only the free calcium is physiologically active.

• In hypoalbunemia the free calcium may be normal although the total serum calcium (measured value) may be low.

• How do you estimate free calcium?



–Correction of Calcium in Hypoalbunemia:

• Corrected Ca• =Observed Ca + 0.8 (Normal albumin– Observed albumin)

• =Observed Ca + 0.8 (4.0 – Observed albumin)

– Example

• Serum albumin = 2.8 ; Serum calcium = 7.9 mg/dL

• What is the corrected calcium?

• Should this patient receive additional calcium in the TPN?

• Corrected Ca = 7.9 + 0.8 (4.0 – 2.8)

• = 8.9 mg/dL

• Additional calcium not warranted.

Magnesium

• 2000 mEq in body, 60% in bone & unavailable for metabolism.

• 40% ICF

• NL Req. Pn. = 0.35 – 0.45 mEq/kg/day.

• GI losses : 30 – 40 mEq/day.

• Low serum levels, should be corrected gradually over days.

• High doses/short time = toxicity.

• In TPN, give as Mg So4. Janet Reid-Hector, Ed.D, RD, CNSD

Iron

♦ 3-5 gm in adult body

♦ Sl. > 50% in Hgb, 30-35% storage forms, tissue,

enzymes

♦ 1/2 life 60 - 120 minutes.

♦ Required for Hgb & myoglobin production,

essential metabolic enzymes. Janet Reid-Hector, Ed.D, RD, CNSD

The Paradox of Fe²+ Deficiency and Infection in PN

On one handFe²+ Deficiency: may ↑↑↑↑ susceptibility to some infections

: depress cellular immunity

: ↓↓↓↓ Leukocyte bactericidal activity

On the other handFe²+ Deficiency: →→→→ less Fe²+ available for Fe²+ dependent

microbes

result: ↑↑↑↑ host resistance to some bacterial infections


Iron & TPN

♦ Maintenance Fe not typically provided in short term TPN

♦♦♦♦ Long term TPN requires supplement with Iron Dextran

0.1mg Iron Dextran/ day for maintenance

♦♦♦♦ Anemia

1.) Iron Dextran mixed in 500-1000mL D5W via separate line

2.) IM injections

3.) Calculating amount of Iron Dextran required

mg Fe required = 0.3 (wt lb.)

x (100 - Hgb x 100)

14.8

4.) Iron Dextran will break or destabilize 3 - 1 TPN mixtures, use is not recommended




Lipids are cleared by 2 mechanisms

Plasma Lipid Concentration ↓↓↓↓as the duration of infusion lengthens

1. First order Kinetics

As the Infusion Rate↑↑↑↑Plasma concentration ↑↑↑↑Clearance Rate ↑↑↑↑

Lipid Clearance is in direct relation

to plasma level

2. Above the max. clearance capacity

Lipid is metabolized via

Zero order Kinetics

Clearance rate is constant

Plasma concentration rises


Key Points of Lipid Infusion to prevent

Complications

Lipid infused over 12 - 24 hours with 24 hrs continuously will result in rate of infusion remaining at or below max clearance capacity

Continuous Lipid Administration

Lipids are oxidized more efficiently than repeated discontinuous doses.


Adverse Reactions to IV Lipid

Administration

Rapid Infusions Acute Reactors Long Term

Cyanosis

HeadacheNausea Oily Taste in MouthPain at Injection Site PalpitationsTachypneaWheezing

Pruritic UrticariaChest/ Back painChills/ FeverVomiting

EosinophiliaFat Overload SyndromeHepatomegalyJaundice/ CholestasisLeukopeniaSplenomegalyThrombocytopeniaTransient ↑ LFT’S


Total Parenteral Nutrition

Electrolytes

Elect. Range of Daily Requirement

Standard Concentration

Na 60-150 meq 35-50 meq/L

K 40-240 meq 30-40 meq/L

Ca 3-30 meq 5 meq/L

Mg 10-45 meq 5-10 meq/L

Phos. 30-50 mM 12-15 mM/L


Electrolyte Requirement for Critically Ill TPN Patients

Electrolyte Daily Increased DecreasedRequirement Requirements Requirements

Na+ 60 - 150 mEq ♦♦♦♦ Loop Diuretics ♦♦♦♦ HTN, Fluid overload

K+ 70 - 100 mEq ♦♦♦♦ Early nutritional repletion ♦♦♦♦ Renal Failure

♦♦♦♦ Post obstruction diuresis♦♦♦♦ Diuretic Therapy

♦♦♦♦ ↑↑↑↑ GI Losses

Mg+ 10 - 20 mEq ♦♦♦♦ Early nutritional repletion ♦♦♦♦ Renal Failure

♦♦♦♦ Diuretic Therapy

♦♦♦♦ ↑↑↑↑ GI Losses

CA 5 - 20 mEq ♦♦♦♦ Multiple blood Transfusions

Po4 10 - 60 mmoL/dy ♦♦♦♦ Early nutritional repletion ♦♦♦♦ Renal Failure

CL 80 - 120 mEq ♦♦♦♦ Prolonged gastric losses

Acetate 10 - 60 mEq ♦♦♦♦ Metabolic Acidosis ♦♦♦♦ Metabolic Alkalosis

♦♦♦♦ Excessive Diarrhea

♦♦♦♦ Drug Therapy - Polybinders

Electrolytes ⇓ Requirements ⇑Requirements⇓ Requirements ⇑Requirements⇓ Requirements ⇑Requirements⇓ Requirements ⇑Requirements



Electrolytes

• Electrolyte salts commercially available

• Sodium chloride

• Sodium acetate

• Sodium phosphate

• Potassium chloride

• Potassium acetate

• Potassium phosphate

• Calcium gluconate

• Calcium chloride (not recommended)

• Magnesium sulfate

• Magnesium chloride

• Incompatible: Sodium bicarbonate


Effects of Specific Drugs on Electrolyte Balance

Electrolyte Drugs Effect

Na+ ♦ Thiazide, Loop Diuretics, Cisplatin, ♦ ↑↑↑↑ urinary Na+ Excretion

Trimethoprim - sulfamethoxzole

♦ Antipseudomonal penicillins ♦ ↑↑↑↑ Na+ load to PT

K+ ♦ Thiazide, Loop Diuretics, ♦ ↑↑↑↑ urinary K+ excretion

Amphotericin-B, steroids,

Antipseudomonal penicillins

♦ Insulin, B - Agonists ♦ ICF K+ shift

♦ spironolactone, Amiloride, Heparin ♦ ↑↑↑↑ urinary K+ excretion

Po4 ♦ Antacids, sucralfate

♦ Precepitation of dietary & ``````` secreted Po4 in the GIT

Mg ♦ Aminoglycosides, Amphotericin-B, ♦ ↑↑↑↑ urinary Mg excretion

Loop Diuretics, Cisplatin,

Cyclosporine


Trace Element Recommendations for Critically Ill

PatientsTrace Adult Daily MTE-5 *Special Requirements

Element TPN Requirements

Zinc 2.5 - 4.0 mg 5 mg * Add 2 mg/dy - Acute catabolic stress

10 - 15 mg (diarrhea, fistula, wounds

Copper 1.0 - 1.5 mg 1 mg * Reduced need /w/ biliary obstruction

Manganese 0.15 - 0.8 mg 0.5 mg * Reduced need /w/ biliary obstruction

Chromium 10 - 15 µg 10 µg * 40 µg (diarrhea, GI losses)

* Reduced need /w/ Renal Failure

Selenium 40 - 80 µg 60 µg * ↑ losses in burns, GI DS Janet Reid-Hector, Ed.D, RD, CNSD


Vitamins

• Recommendations per NAG

– Multivitamin Infusion 10 ml

– Contain all essential vitamins

– MVI-Adult (Mayne) or Infuvite (Baxter)

– Fat soluble: A, D, E, K

– Water soluble: Thiamine, Riboflavin, Niacin, Pantothenic Acid,

Pyridoxine, C, Folic Acid, B12, Biotin

– In 2004 Vitamin K added per FDA recommendations


Multivitamin Requirement for TPN Patients

Vitamin IV Dose Requirement Special Requirements

in TPN/dy

A IU 3300 IU (1mq) 5000+ IU/dy (serious infection)

D IU 200 IU (5µg)

E 200 IU (10 mg)

Biotin 60 mg

Pantothenic Acid 15 mg

Folic Acid 0.4 mg 5 mg/dy ICU Patients/Thrombocytopenia

1 mg/dy - Dialysis

Thiamin 3 mg 50 mg Alcoholics - Wernicke - Karsakoff

Riboflavin 3.6

Niacin 40 mg

Pyridoxine 4.0 - 6.0

Ascorbic Acid 100

Cyanocobalamin 5.0 µg

Vitamin K 10 mg 1 - 2 x 1 week


Osmolarity of Common PN Components

Central line blood flow = 2500mL/min Peripheral Blood Flow = 25-50mL/minPPN Solns > 600-900 m0sm/L=↑ risk of phlebitis

TPN Components

mOsmol Factor

Amino Acids 100 Per % final Conc.

Glucose 50 Per % final Conc.

lipid 1.7 Per gm

Calcium 1.4 Per mEq


Osmolarity of Common PN

Components

Electrolytes

TPN Components mOsmol Factor

Magnesium 1 Per mEq.

Potassium 2 Per mEq.

Sodium 2 Per mEq.


Selected Protocol for Determining Electrolyte/ Mineral Additives to TPN

1. Determine Total Fluid Volume.

2. Determine Macronutrients (Dextrose, AA, Lipids).

3. Determine Required Amount of Na+, K+, CL-, PO4 -, Ca�+, Mg+, Trace Elements.

4. Subtract Amount of Electrolytes in the AA Solution.

5. Add PO4 - (Na+ or K+) or Acetate Salt to Maintain NL ABB.

6. Determine Amount of CL-; Subtract Na+ Ion content in AA soln., from total CL- content, Add difference

as Na Acetate.

* Na + & CL- Ions are balanced.

7. Add remainder of required Na+ as CL salt.

* Na+ Ion is now = CL - Ion concentration.

8. Add Mg as MgSO4.

9. Add Ca as Ca Gluconate.

10. Add trace elements, vitamins, heparin, insulin as required.


Total Parenteral Nutrition Formulation

Standardization vs. Customization

• Standardization

– Meets requirements of most patients

– Assists physician in order writing

– Reduces errors (writing, transcription and order entry)

– Increases pharmacy efficiency

– Cost savings

• Customization

• Patient Specific

• Consistent with current

recommendations

– Can be accomplished with and

without automated compounded

– Should be strongly considered b in

patients requiring fluid or CHO

restriction

Golden Rule for Calculating & Balancing

Electrolytes for TPNSum Total of Anions ¯

Must Equal

Sum Total of Cations +


CONVERSION

mm K Phos -- > mEq K+

mm Na Phos --> mEq Na+

Each 3 mm Kphos = 4.4 mEq K+ Each 3 mm Na Phos = 4 mEq Na+

mm Kphos, Na Phos mEq K+ mEq Na+

5 7.3 6.7

10 14.6 13.3

15 22 20

20 29.3 26.7

25 36.6 33.3

30 44 40

35 51.3 46.7

40 58.6 53.3

45 66 60

50 73.3 66.7


CALCULATING ELECTROLYTES FOR TPN

EXAMPLE

Na+ 100

K+ 70

CL- 63___________________

(170-44=126)

Acet 63___________________

PO4 30 ___________ 44mEq+ K+ & 30 mm Po4

CA²+ 9.0

Mg+ 9.0


Steps for Balancing Electrolytes in TPN

Step 1

Na 100

CL 63

Step 2

100

- 63

37mEq of Na left to balance

use Na Acetate to Balance

Step 3

63

- 37

26mEq of AC- left to use

↓use as KAC-

Step 4

26mEq of K AC

since K+ = 70

70

- 26

Step 5 44mEq of K ↓ left to use

(balance use as KPo4 =

30)

Step 6 30mm Kphos - 44 mEq of K

Step 7 Then Ca as gluconate

↓Then Mg as sulphate

Lyn Roth, RPH

ORDERING BALANCED ELECTROLYTES

Na CL 63mEq

KCL - mEq

NA Acetate 37mEq

K Acetate 26mEq

Na Po4 - mmol

K Po4 30mmol

Ca Gluconate 9.0mEq

Mg So4 10.0mEq Janet Reid-Hector, Ed.D, RD, CNSD

Lyn Roth, RPH

Metabolic Monitoring Schedule for the Critically Ill TPN Client(1)

ParametersFluid Balance

Body Weight

Intake (po & IV)

Output

Monitor infusion rate

Infectious Complications

WBC

Vital signs

Catheter dressing change

Biochemical Measures

Serum electrolyte levels

BUN, Creat.

Ca, Mg, PO4

BS

ABB

Plasma protein

Triglyceride

LFT’s

PT, PTT

Hgb

Frequency

Daily

q 8 hr

q 8 hr

q 4 hr

Daily

As indicated

q 48 hr

Daily

Daily

Daily x 3 then 3 x/wk

Daily

As indicated

Weekly

Preinfusion and postinfusion, then weekly

Weekly

Weekly

Weekly Janet Reid-Hector, Ed.D, RD, CNSD

Complications of PN feeding in the elderly

• These fall into three groups:

• Mechanical (post-catheter pneumothorax)

• Infectious; (catheter sepsis)

• Metabolic (electrolyte disturbances,

• hyperglycemia, serum urea).

• PN-associated complications ⇑ in this population


Complications of PN feeding in the elderly

• Hyperglycemia, uremia & electrolyte disturbances

• are more frequent.

• Fluid overload associated with cardiac failure risk is always present.

• Respiratory failure & CO2 retention.

• Due to their depressed immunology response, catheter sepsis risk is prevalent.

• Although prolonged PN is rarely supplied to the

• elderly, when it is done, it should be borne in mind

• that both metabolic (mainly bone & liver diseases)

• Psychological complications will affect the elderly more deeply than the adult.


Refeeding Syndrome• The ℞ for people at high risk of developing refeeding

problems should consider:

• Starting nutrition support at a maximum of 10 kcal/kg/day, ⇑ levels slowly to meet or exceed full needs by 4–7 days.

• Using only 5 kcal/kg/day in extreme cases (for e.g.; BMI<14 kg/m2 or negligible intake for > 15 days) & monitoring cardiac rhythm continually for cardiac arrythmias

• Restoring circulatory volume, monitoring fluid balance & overall clinical status closely. Providing immediately before and during the first 10 days of feeding: oral thiamin 200–300 mg daily, vitamin B, (or daily IV vitamin B) & a balanced MVIT/TE supplement once daily


Refeeding Syndrome

• Providing K+: 2–4 mmol/kg/day)

• Phosphate: 0.3–0.6 mmol/kg/day)

• Mg : 0.4 mmol/kg/day; unless pre-

feeding plasma levels are high.

• Pre-feeding correction of low plasma

• levels is unnecessary.

PN Monitoring Protocol for the older adult

Parameter Frequency Rationale

Catheter entry site* Daily Signs of infection/inflammation

Skin over position of catheter

tip (PPN fed people)*

Daily Signs of thrombophlebitis

Temperature/BP Daily initially, then as

needed

Sign of infection/fluid balance

Drug therapy* Daily initially,⇩ to

monthly; when stable

To prevent / ⇩ DNI

Are goals being met?* Daily initially, ⇩ to

2x/week, then progress

to 3–6 mon., unless

clinical condition changes

To ensure that feeding is

appropriate to overall patient care

Sodium, potassium, urea,

creatinine

Baseline; Daily until

stable; then 1- 2 X a week

Assessment of renal function,

fluid status, & Na and K

Status; Glucose intolerance

PN Monitoring Protocol for the older adult

Parameter Frequency

Glucose Baseline; Daily until stable; Then 1 or 2 times a week

Magnesium, phosphate Baseline; 1 or 2 times a day (or more if needed) until stable

Then weekly

Temperature/BP Daily initially, then as needed

Drug therapy* Daily initially,⇩ to monthly; when stable

Are goals being met?* Daily initially, ⇩ to 2x/week, then progress to 3–6 mon., unless

clinical condition changes

Sodium, potassium, urea,

creatinine

Baseline; Daily until stable; then 1- 2 X a week


References• Landry DW, Bazari H. Approach to the patient with renal disease. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders

Elsevier; 2011:chap 116. Update Date: 8/21/2011; by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

• Nephrol Dial Transplant. 1996;11 Suppl 9:9-17. Some sodium, potassium and water changes in the elderly and their treatment. Andreucci VE, Russo D, Cianciaruso B, Andreucci M.Chair of Nephrology, Faculty of Medicine, University Federico II of Naples, Italy.

• Alvelos, M, Ferreira, A, Bettencourt P, et al. The effect of dietary sodium restriction on neurohumoral activity and renal dopaminergic response in patients with heart failure. Eur J Heart Failure. 2004; 6: 593-599.

Arcand JL, Brazel S, Joliffe C, et al, Education by a dietitian in patients with heart failure results in improved adherence with a sodium-restricted diet: A randomized trial. Am Heart J. 2005; 150: 716e1-716e5.

Damgaard M, Norsk P et al. Hemodynamic and neuroendocrine responses to changes in sodium intake in compensated heart failure, Am J Physiol Regul Integr Comp Physiol. 2006, 290: R1294-R1301.

Kuehneman T, Saulsbury D, Splett P, Chapman DB. Demonstrating the impact of nutrition intervention in a heart failure program. J Am Diet Assoc. 2002; 102: 1,790-1,794.

Ramirez EC, Martinez LC, et al. Effects of a Nutritional Intervention on Body Compositiion, Clinical Status, and Quality of Life in Patients with Heart Failure. Nutrition, 2004; 20: 890-895.

• Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J. 2001;22:1527-60.

• American College of Cardiology/American Heart Association. 2005 Guideline Update for the Diagnosis and Management for CHF in the Adult. Circulation. 2005;Sept 20:1-28.

• Heart Failure Society of America 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure.

• 2006; 12.

References• Effect of age on substrate oxidation during total parenteral nutrition.Al-Jaouni R, Schneider SM, Rampal P, Hébuterne X. Nutrition.

2002 Jan;18(1):20-5.

• Public Health Nutrition: 4(6A), 1379±1384 Guidelines for nutrition support in the elderly

• Metheny, N. (2000). Fluid and electrolyte balance. In Nursing Considerations (4th Ed., pp. 3–12, 24–26). St. Louis, MO: Lippincott, Williams, & Wilkins. Evidence Level VI: Expert Opinion.

• Lindeman, R., Tobin, J., & Shock, N. (1985). Longitudinal studies on the rate of decline in renal function with age. Journal of the American Geriatrics Society, 33, 278–285. Evidence Level IV: Nonexperimental Study.

. Kenney, W. L., & Chui, P. (2001). Influence of age on thirst and fluid intake. Medicine & Science in Sports and Exercise, 33, 1524–1532. Evidence Level V: Literature Review.

• Mentes, J. (2006). A typology of oral hydration problems exhibited by nursing-home residents. Journal of Gerontological Nursing, 23(1), 13–21. Evidence Level IV: Nonexperimental Study

• Mentes, J. C., and The Iowa Veterans Affairs Nursing Research Consortium (2004). Evidence-based protocol: Hydration management. In M. G. Titler (Series Ed.), Series on evidence-based practice for older adults. Iowa City, IA: The University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. Evidence Level I: Systematic Review.

• Ferry, M. (2005). Strategies for ensuring good hydration in the elderly. Nutrition Reviews, 63(6), S22–S29. Evidence Level V: Literature Review.

• Sullivan RJ. Fluid intake and hydration: critical indicators of nursing home quality. North Carolina Med J 2005; 66: 296-9.

•• Mentes JC. A typology of oral hydration problems exhibited by frail nursing home residents. Geront Nurs 2006; 32: 13-9.

References• Semin Nephrol. 1996 Jul;16(4):277-88. Abnormalities of water metabolism in

the elderly.

• Tullman, D. F., Mion, L. C., Fletcher, K., & Foreman, M. D. (2008). Oral hydration

management. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.).

Evidence-based geriatric nursing protocols for best Practice (3rd ed.), (pp. 337-

351). New York: Springer Publishing Company, Inc.

• J Nutr Health Aging. 2009 Feb;13(2):150-7

• Musson ND, Kincaid J, Ryan P et al. Nature, nurture, nutrition; interdisciplinary

programs to address the prevention of malnutirition and dehydration.

Dysphagia 1990; 5: 96-101.

• . Amella EJ. Feeding and hydration issues for older adults with dementia. Nurs

Clin North Am 2004; 39: 607-23.

• A comparison of intravenous and subcutaneous hydration in elderly acute

stroke patients. Postgrad Med J 1994; 70: 195-7

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