1

Table of Contents Page

Introduction………………………………….. 2 Clinical Nutrition Care Process……………… 3 Identify Patients at Nutrition Risk…… 4 How to Access Nutrition Assessment in Physician Web Portal……………………… 5 St. Luke’s Hospital Approved Diets…………. 6 Tube Feeding Diet Orders …………………... 16 Adjusting Diet Order: Nutrition Protocol……. 17 Nutrition Assessment of Adult Patients Anthropometrics………………………. 18 Adult Predictive Equations .…………. 19 Refeeding Syndrome ………………… 22 Biochemical Data…………………….. 25 Criteria for Identification of Nutritional Deficiencies/Malnutrition/BMI Coding ..... 27 Enteral Nutrition (EN) Indications for EN Support………….. 27 Contraindications for EN Support….. 28 Enteral Formula Selection…………… 29

Initiation of EN Support……………… 30 Monitoring of EN Support…………… 31

Parenteral Nutrition (PN) Indications for PN……………………. 34 Contraindications for PN…………….. 34

Macronutrient Calculation in PN…….. 35 Calculating a PN formulation………… 36 Monitoring of PN Support……………. 38

Contact a Dietitian …………………………… 41 References……………………………………… 40

2

Introduction

This reference provides a guide to the clinical nutrition assessment procedures and provides a description of most ordered diets offered at St. Luke’s University Hospital. St Luke's clinical nutrition staff (RDs and diet technicians) are avail to:

Develop and implement a Nutritional Care Plan,

which includes a comprehensive nutrition assessment: nutrient/Kcal requirements, potential/actual identification of malnutrition and nutritional deficiencies.

Provide medical nutrition therapy (MNT) to improve medical outcomes, reduce hospital LOS, reduce morbidity/mortality and improve overall health.

As a nutrition resource to be the nutrition expert to the health care team, patients and families.

When to request a Nutrition Consult: When considering initiation of nutrition support of

enteral/parenteral feedings When patient/family needs nutrition education for

diet modifications/restrictions. A 24 hour notice requested. (Outpatient nutrition counseling is available at all campuses)

When patient appears malnourished/high nutrition risk (i.e. cachexia, presence of wounds/pressure ulcers, poor kcal intake, weight loss, obesity etc.)

For a new nutrition related problem (i.e. pancreatitis, diabetes, celiac sprue, short gut syndrome, cancer, CHF, crohn’s, renal failure)

3

CLINICAL NUTRITION CARE PROCESS Nutrition Screening – the process of identifying characteristics known to be associated with nutrition inadequacies. Its purpose is to identify persons who are at increased nutritional risk and provide intervention. Nursing completes the screen within 24 hours of admission including triggers that may identify at nutrition risk. The clinical nutrition staff utilizes the screening data along with other criteria to determine the patients’ potential risk and need for a comprehensive nutrition assessment and intervention. Nutrition Assessment – is completed by clinical nutrition when a patient has been identified at potential nutrition risk via the screening process. A comprehensive nutrition assessment is completed and a plan of care is devised to improve nutritional status. Nutrient Intake Analysis (calorie count) – calorie and protein intake will be calculated. It is ordered for two days. An intake analysis is appropriate for patients when adequacy of intake is questionable or a change in therapy is being considered. Examples might be transitioning from enteral (EN) or parenteral (PN) feedings to oral intake, or if initiation of EN or PN feedings are being considered.

4

IDENTIFING PATIENTS AT NUTRITION RISK Diets: Clear/NPO x 4 days, TPN, New Enteral or parenteral feedings Eating : Aspiration precautions, Poor PO, new tube feed/parenteral nutrition Problems: New choking/swallowing/chewing difficulty Weight: BMI (Body Mass Index) < 18.5, >40 Labs: HbA1c > 8 Skin Stage III, IV, and unstageable wounds or

pressure sores, Fistula Dx: Eating disorders: anorexia, bulimia

Malnutrition Failure to Thrive New HIV/AIDS New Hepatic Diseases DKA Gestational Diabetes Pediatric Diabetes Cancer of the head/neck, GI tract Short gut syndrome Chronic Pancreatitis New gasterectomy New Renal with HD/PD New Gastric bypass/Weight loss surgery Pregnancy with hyperemesis

Active Crohns / IBS New CVA Trauma

5

How to Access Nutrition Assessment In Physician Web Portal

1. Log in, choose a patient and then click

Flow sheet tab. 2. On the Report drop down list select

Nutrition Assessment and then click refresh.

How to make the Nutrition Assessment a

Hotlink:

1. In either the Doc view or Flow sheet modules, click the Edit tab on the module header to open the Personalize Module page.

2. Select “Nutrition Assessment 2 ” from the drop down list next to one of three hotlinks.

3. Click Save at the bottom of the page.

How to Access Nutrition Assessment in Horizon Clinical:

1. Log in and select patient 2. Go to the menu bar 3. Select Review and select “Nutrition

Assessment 2 ”

6

St. Luke's University Health Network APPROVED DIETS

(Approved through the Nutrition care Committee)

Nutrition prescriptions: When ordering a diet the entire diet order must be reordered each time you revise a single component of the diet prescription. Patients are able to select their food choices on most diets. A hostess will visit the patients or the patient may call the call center to place their meal order. Diets that are not selective are denoted with an asterisk*. Regular (House) Diet Provides approximately 90g

protein and 2000 calories with no restrictions.

Finger Food Diet Regular diet allowing patient to eat without utensils.

Pediatric Diet (Only @ SLB) Age appropriate diet for ages ~2-17.

Toddler Diet (Only @ SLB) Age appropriate diet for ~1-4 year olds.

NPO Nothing by mouth

TRANSITIONAL/LIQUID DIETS

Clear Liquid Includes fluids with minimal residue; no milk products. Limit 24-48 hrs, provides approximately 800 calories and 200 gm. carbohydrate. Is appropriate for patients with diabetes.

Full Liquid Includes wide variety of liquids; liberal use of milk

7

products. Not for extended time use.

Surgical Soft (GI) Foods may be easier to

digest. Inadequate in calories and protein - recommended for use only 1-2 days. Limits most raw, highly seasoned, fried or fatty foods. If “soft to chew” diet desired, see dysphagia diets.

T & A* Used post-operatively for

tonsillectomy and adenoidectomy on the pediatrics unit.

TEXTURE MODIFIED (Need to order liquid

consistency separately) Level 1 Dysphagia Regular diet pureed (Pureed) (pudding-like) consistency.

Mechanically non-irritating. Should be used for those who have difficulty swallowing or chewing

Level 2 Dysphagia Transition diet between the (Mechanically Altered) pureed and dental soft.

Meats are minced and most other foods are chopped.

There are no particulates such as rice or corn. Bread and crackers are not served with this diet.

8

Level 3 Dysphagia Regular diet modified to (Dental Soft) include only foods that are

easy to chew. Tougher meats are diced or thinly sliced.

Liquid Consistency Thin, nectar thick, honey

thick and pudding thick consistencies are available. Consult speech therapist to determine appropriate liquid consistency.

CARBOHYDRATE / CALORIE CONTROLLED / WEIGHT MANAGEMENT

These diets are used for those who those patients that have blood glucoses. Patients who are receiving medication that may elevate blood glucose such as steroids, or s/p cardiac surgery and may benefit by a carb controlled diet.

1 Carbohydrate (CHO) Serving = 15 grams of Carbohydrate (CHO) Consistent Carbohydrate Carbohydrates are Level 1 consistent at each meal. (1500 – 1800 Kcals) Level 1 provides 4 CHO

servings (60 gms) each meal. Protein and fat is

added to fill the calorie needs. An evening snack is not routinely provided but will be provided if ordered.

9

Consistent Carbohydrate Level 2 provides 5 CHO Level 2 servings (75 gms) at each (1900 – 2100 Kcals) meal. An evening snack is

not routinely provided but will be provided if ordered

Consistent Carbohydrate Level 3 there are 6 CHO Level 3 servings (90 gms) at each (2200 – 2400 Kcals) per meal. An evening snack

is not routinely provided but will be provided if ordered

DIABETES AND PREGNANCY

Diabetes can occur during pregnancy due to increased insulin resistance. The goal is to attain glycemic control and prevent the body from spilling ketones in the urine. Gestational Diabetes Provides 3 CHO servings at 1800 Kcals each meal and 1 CHO

serving at AM and PM snacks, and 2 CHO servings at HS snack. 5 oz. protein is divided between 3 meals, and 1 oz. protein at each snack.

Gestational Diabetes Provides 3 CHO servings at 2000 Kcals breakfast and 4 CHO servings at lunch and

dinner. Between meal snacks contain 1-2 CHO servings and 1 oz. protein. 6 oz. of protein servings at meals are divided as 1 oz. at breakfast, 2 oz. at lunch and

10

3 oz. at dinner. 1 serving of fat per meal is permitted.

Gestational Diabetes Provides 3 CHO servings 2200 Kcals at breakfast and 4 CHO at lunch and dinner. 2 CHO

servings and 1 protein serving is provided as 3 snacks. 7 oz. of protein is divided between the meals: 1 oz. at breakfast, 3 oz. at lunch, and 3 oz. at dinner. 1 fat serving per meal is also permitted.

Gestational Diabetes Provides 3 CHO servings 2400 Kcals at breakfast and 4 CHO

servings at lunch and dinner. 2-3 CHO servings and 1 protein serving is provided in 3 snacks. Protein servings at meals are divided as 2 oz. at breakfast, 3 oz. at lunch, and 3 oz. at dinner. 1-2 fat servings per meal are permitted.

CARDIAC

Low Cholesterol Limits cholesterol in the

diet to < 300 mg/day. . Limits saturated fat. High fiber foods promoted.

Low Fat Limits all types of fat to 40

to 50 gm/day.

11

2 gm. Sodium Most restricted sodium level offered.

4 gm. Sodium (NAS) Least restrictive of the

sodium diets. Salt packet and high Na foods are not permitted.

Step 1 Cardiac Less than 30% of total

calories from fat with less than 10% from saturated fat. Contains about 3 gms. Na, 300 mg cholesterol, 25 to 30 gms of fiber and is approximately 1800 calories.

TLC 2.3gm Na < 25% total calories from

fat w/ < 7% from sat fat. < 200 mg cholesterol, 2gm plant sterols, 10-25gm soluble fiber. Meat portion 2 to 3 oz. @ meals. A stand-alone lifestyle diet. Should not be used in combination with other diets.

Open Heart For use up to 48 hrs. s/p

surgery to aid with BG control.

Cardiac Cath Cardiac step 1 finger food

diet used for 1-2 meals after procedure.

12

RENAL Low Phosphorus Provides 1000 mg

phosphorus. 2 gm. Potassium 2 or 3 gm. restriction per

renal function. Often restricted when urine output

is less than 1 liter/day and if the patient is on dialysis.

Renal (Dialysis) Diet provides ~ 2000 kcal,

80 gm. protein, 2.5 gm. K+ and Na, 1000 mg phos. Fluid restriction per physician order.

GASTROINTESTINAL

Gluten Free Eliminates all wheat,

barley, rye and oat products (ie, breads, pastas). Gluten free substitutes are available.

High Fiber Soluble and insoluble fiber

is gradually added to the diet as needed.

Lactose Restricted Lactose is limited to tolerance level. Lactaid or soy milk is provided.

Low Fiber/Residue Diet limits dietary fiber to < 10g.

13

Non-Ulcerogenic Avoids alcohol, caffeine, and pepper and pepper seasoned foods.

Post-Gasterectomy Provides 5-6 small meals.

High fat foods, sweets, sugars, and carbonated beverages are avoided. Milk is provided as tolerated.

WEIGHT MANAGEMENT

These diets restrict calories and assist weight management therapies. (not available at SLB) Weight Management level 1 1500-1800 calories Weight Management level 2 1900-2100 calories Weight Management level 3 2200-2400 calories

BARIATRIC DIETS Bariatric Sugar-free beverages, no Clear Liquid* carbonation, small portions

(1 oz.) every 15 min. No Straw

Bariatric Low-fat, sugar free liquids, Full Liquid includes milk products.

Lactaid and soy products

14

are available. small portions (1 oz.) No straw

Bariatric Pureed Transition diet s/p tolerating

bariatric clear/full liquid. Recommended 3-5 days post-op bariatric surgery. ½ portions of food. Non-fat milk. No high sugar.

Bariatric Soft Transition diet s/p tolerating

bariatric pureed diet. Recommended for patients who are 6 days post op. ½ portions of moist foods. Soft fruits and vegetables allowed. No high sugar foods or carbonated beverages. No straw.

Bariatric Maintenance Limits calories and

concentrated sugar foods. Non-carbonated, low sugar beverages permitted. Appropriate for gastric bypass patients who are at least 6 months post-op.

15

MISCELLANEOUS Fluid Restriction Ordered as a modifier.

Specify restriction ml. See food service allotment below.

Physician Ordered 24 Hour Fluid Allowance

Fluid Allotment Provided by Food and Nutrition Services for Each Meal

<800 ml

800-999 ml 1000-1199 ml 1200-1499 ml 1500-1799 ml 1800-1999 ml 2000-2200 ml

No fluid provided by Food and Nutrition 120 ml per meal 180 ml per meal 180 ml per meal 240 ml per meal 240 ml per meal 360 ml per meal

Kosher Diet per patient needs to follow their kosher dietary laws. Frozen meals provided for patients following strict kosher law. Low Purine Foods restricted of animal

origin, fatty foods and alcohol. Patients are encouraged to drink plenty of fluids.

Low Tyramine Indicated when MAOI

drugs are administered. Diet avoids aged or fermented products.

16

Low Iodine Diet includes approx 50 mcg of iodine. Used with thyroid disorders. Should be started 2 weeks prior to treatment.

Pre-renal Diet is 200 mg K+, 1500 mg Phos,70 gms Protein, 3000 mg Na

Vegetarian This diet is a lacto-ovo vegetarian diet. Individualized per patient’s needs / requests.

Wired Jaw Diet Consists of a fortified full liquid diet w/ liquid supplements & pureed items which pass easily through a large straw. It is approx 2000 calories per day.

Diets will be modified to accommodate food allergies. The food allergy should be entered in HEO in the allergy screen. The allergy should be entered in the instruction field also when diet is ordered.

TUBE FEEDING DIET ORDERS

Tube feeding diet can be ordered two ways: “Tube Feeding” or “Tube Feeding with Oral Diet.” If a patient is able to eat and have a tube feeding, “Tube Feeding with Oral Diet” must be selected. If only “Tube Feeding” is selected, the subsequent diet order will not be accepted as diets are non-compliant with “Tube Feeding” only selection. (consult a dietitian or see enteral formulary for enteral product selections)

17

RD to Adjust Diet Order Nutrition

Protocol This protocol can be approved when a diet is ordered in HEO. To approve the protocol, the physician responds “yes” when asked if they desire to “Notify Nutrition, RD to adjust Diet Order” per protocol. The purpose of the protocol is to permit the RD to adjust the diet per the patients’ needs. Protocol will be employed when the nutrition assessment indicates the patients’ energy, fluid, protein or nutrient intake is inadequate to meet estimated needs or when a patient condition requires an another therapeutic diet modification. Changes that may be made by the RD:

� Texture modification � Addition of supplements to assist in meeting patient’s

nutritional needs � Calorie level/Carbohydrate level adjustment in

coordination with patient’s estimated needs � Adjustments of diets for intolerances/allergies � Dysphagia diet changes made congruent with speech

recommendations for patients who are currently receiving PO intake

� Mineral adjustments � Correction of diet order if incorrectly ordered in

computer � Adjustment in diet per patient preferences or past diet

restriction � Increase / Decrease enteral kcal.

The dietitian will chart the assessment findings and rationale for any changes made in the Validate Protocol section of the nutrition note. The physician will be able to view the alteration via HEO. When critical alteration is being considered, the RD will discuss with the MD.

18

Nutrition Assessment of Adult Patients

ANTHROPOMETRICS

Estimating IBW

Women: Allow 45.4 kg for first 5 ft. of height plus 2.3 kg. for each additional inch above 5 ft. Men: Allow 48.1 kg for first 5 ft. of height plus

2.7 kg for each additional inch. ABW: Adjusted Body Wt.

Should be used if pt. is ≥ 125% of IBW ABW= [(Actual Wt. – IBW) x 0.25] + IBW

BMI Wt. (kg) or Wt. (lbs.) x 703

Ht (m)² Ht (in)² BMI result: Indication <18.5 Underweight

18.6-25 Normal Weight 25.1-29.9 Overweight 30-34.9 Obesity Grade I 35-39.9 Moderate Obesity (Grade II) ≥40 Morbid Obesity (Grade III)

19

IBW Weight adjustment for amputation* Type of amputation % Total Body Weight

Foot 1.5 BKA 5.9 AKA 15 Entire Lower Extremity 16 - 18 Hand 0.7 Forearm and Hand 2.3 Entire Arm 5 *Double if bilateral

Disability Adjustment Paraplegia: subtract 5-10% from IBW Quadriplegia: subtract 5-15% from IBW

ADULT NUTRITION REQUIREMENTS Calorie, protein and fluid needs are calculated during an in-depth nutritional assessment. An accurate height and weight are integral in determining the patient’s needs. Indirect calorimeter is the Gold standard to determine calorie and protein needs.

Kcal Requirements

Kcal needs based on calories/kg body wt:

Most commonly used method providing kcal/kg body weight depending on weight and severity of illness. For patients >125% of IBW, ABW should be used with a 25% correction factor. Grossly underweight or malnourished

20

individuals should have needs estimated using their actual weight.

Patient Status Kcal Needs (Kcal/kg)

Maintenance Wt. 25-30 No/Mild Stress Weight Loss 20-25 Weight Gain/Anabolism 30-35 Stressed Refeeding Risk 20 initially Morbid Obesity 15-25 BMI>30, Critically Ill 11-14kcal/kg Actual wt., or 22-25kcal/kg IBW

Other predictive equations validated to be useful in critical care are the Penn State 2003b and the Penn State 2010 equations in ventilated patients. Mifflin St, Jeor is validated outside of critical care. Indirect Calorimetry to determine REE

(Resting Energy Expenditure) ORDER AS: “Metabolic Cart Study” Indications • Clinical conditions and diagnoses that

significantly alter REE. • Failure of a patient to respond to

nutrition support per predictive equations.

• Individualization of nutrition support in a critical patient to avoid complications of over or under-feeding.

21

• Failure to wean from mechanical ventilation without known cause.

Recommended in patients with: • Extended ventilation > 1 week • Sepsis • ARDS • Multisystem organ failure • Large, or open, multiple wounds • Morbid obesity, critically ill

Consider for patients with:

• Extended use of paralytic agents • Obesity • Extended nutrition support • Multiple or neurological trauma • Amputations • Cachexia / underweight

Interpretation of Respiratory Quotient (RQ)

Energy Source/Measurement Condition RQ_ Fat Oxidation 0.7 Protein Oxidation 0.8 Carbohydrate Oxidation 0.95-1 Mixed Substrate Oxidation (goal)* 0.83 -0.85 Lipogenesis (overfeeding) >1.01 Hyperventilation >1.01 Ketosis <0.6

* ACCEPTABLE GOAL RANGE: 0.8 to 0.95 NOTE:

1. Pt. must be intubated for the test to be performed, FIO2 ≤ 60%, no air leak or chest

22

tube leak. 2. The validity of the test should be questioned

if the patient fails to achieve a steady state or if the overall RQ is <0.67 or >1.3.

3. The energy of critically ill ICU patients can range from 10% below to 23% above a “steady state REE”.

4. The test should be held until: --90 minutes after a change in vent setting --3 to 4 hours after hemodialysis treatment --12 hours after a TF / TPN change

Refeeding Syndrome Risk

REFEEDING SYNDROME Refeeding syndrome is defined as the metabolic and physiologic consequences of depletion, repletion, compartmental shifts, and interrelationships of phosphorus, potassium, magnesium, glucose metabolism, vitamin deficiency, and fluid resuscitation.

Individuals at risk for refeeding syndrome:

Those with anorexia, malnutrition, chronic alcoholism, morbid obesity, prolonged fasting, prolonged IV hydration, significant stress and depletion, those with large electrolyte imbalances, NPO ≥ 7 days.

Recommendations to reduce the risk of refeeding syndrome:

• Be informed about refeeding syndrome and the individuals at risk

23

• Correct electrolyte abnormalities before initiating nutrition support

• Administer nutrition volume and fluid

slowly (800-1000ml for first day)

• Estimate Kcal needs at 20 Kcal/kg for first 2-3 days. If TPN to be initiated use “Standard TPN”, recommended for Day #1.

• Monitor pulse rate and I/O’s closely

• Provide appropriate vitamin supplements

• Carefully monitor electrolytes over the

first week including: o Phosphorus o Potassium o Magnesium

Refeeding Syndrome Manifestations

• Hypophosphatemia • Increased intravascular volume • Hypokalemia • Hypomagnesemia • Less common, Wernicke’s

encephalitis Can occur up to 72 hours post start of feeding.

24

Protein Requirements – Protein is provided .8 to 2 gm./kg.

Patient Status Protein Needs (gm./kg)

No stress 0.8 to 1 Surgery 1.2-1.5 Mild Infection 1.2 Skeletal Trauma 1.5-2 Sepsis 1.5-2 Critically ill pts. with 1.2-2gm/kg BMI < 30 Actual wt² Critically ill pts. with BMI 30-40 ≥2g/kg IBW² Critically ill pts. with BMI ≥40 ≥2.0g/kg IBW² **Pts. on CRRT 1.5-2.5² ** (Grade C evidence)² Fluid Requirements – Fluid intake ranges from

25 to 40 ml/kg but varies greatly dependent of illness.

Factors affecting fluid requirements:

Increased fluid needs: Excessive diarrhea Large ostomy Fistula Polyuria Excessive vomiting Fever Incr Kcal and Pro intake Rapid or prolonged High gastric o/p hemorrhage Physical activity Large open wounds

25

Certain medications

Decreased fluid needs: CHF Respiratory failure Multi-system organ failure Renal failure Head trauma Hepatic failure

Estimating fluid requirements Note: Use Actual Body Weight unless otherwise

indicated. Age Fluid needs (ml/kg) 16-25 yrs. 40 25-55 yrs. 35 55-65 yrs. 30 >65 yrs. 25-30 or, 1ml/Kcal energy expenditure

BIOCHEMICAL DATA

Albumin (Half-life: 14-20 days) Not a reliable indicator of protein status in hospitalized patients due to long half-life and sensitivity to hydration status and inflammatory metabolism. Factors resulting in increased values: Dehydration, IV albumin, blood transfusions Factors resulting in decreased values:

Liver disease, ascites, infection, nephrotic syndrome, post-op edema, over-hydration,

26

malabsorption, poor intake, acute malnutrition, pregnancy

Prealbumin (Half-life: 2-3 days). Not a reliable indicator of protein status in acute care/critical care, hospitalized patients due to its sensitivity to inflammatory metabolism. Provision of additional protein in the face of critical illness will not improve PAB lab value. Factors resulting in increased value: Renal disease, corticosteroids Factors resulting in decreased value: Trauma, infection, stress, liver disease, ~5 day’s s/p surgery The appropriate use of hepatic proteins in the nutritional assessment process is as indicators of morbidity, mortality, or severity of illness. The sickest of patients are those who are the most likely to require nutritional intervention.

24 hr. UUN/Calculating Nitrogen Balance

(NB) NB = Protein intake (g/24hrs) - [Nitrogen o/p (gm./24hrs) + 4]

6.25 Values should be interpreted in context of the patient’s clinical status. Factors limiting validity include: adequacy of urine collection, nitrogen losses from large open wounds, severe burns, diarrhea, renal failure, liver failure.

27

CRITERIA FOR IDENTIFICATION OF NUTRITIONAL DEFICIENCIES

Identification of Malnutrition, morbid obesity and underweight status.

*The form: “Malnutrition/BMI Documentation Form” (Form no. 15889NP ) will be placed in the Progress Notes by the dietitian if a patient exhibits at least two characteristics of malnutrition per the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition. The form also can indicate a BMI that is ≤ 18.5 or ≥ 40. The form is used to alert the physician and other health care providers of an added risk, malnutrition or excessive/inadequate body weight. A dietitian will initiate the Malnutrition form, initiate an intervention, and place the form in the progress notes for physician review and signature. A signed form by a physician signifies agreement with the findings.

ENTERAL NUTRITION (EN) Enteral nutrition should begin if inadequate nutrition is expected > 7 days. If the patient has a pre-exsisting malnutrition and not consuming adequate nutrition, enteral nutrition should begin immediately. Indications for Enteral Nutrition Support in the face of inadequate oral intake unless contraindicated:

28

• Anorexia • Head and neck surgery • Neoplasms • Trauma • Dysphagia • Mandibular fractures • Coma • CVA • Demyelinating diseases

Markedly Increased Nutritional Requirements:

• Sepsis • Trauma • Closed head injury

Limited Nutrient Absorption:

• Malabsorption • GI Fistulas (enteral access placed distal

to fistula, or volume of o/p < 200ml) • Chronic Pancreatitis • Inflammatory bowel disease • Short bowel syndrome • Pancreatic insufficiency

Contraindications for Enteral Nutrition Support:

• High o/p GI fistula • Paralytic ileus • Mesenteric ischemia • Total Small bowel obstruction • Inability to gain access • Intractable vomiting or diarrhea • Lower GI Bleed

29

• Aggressive therapy not warranted “Specialized nutrition therapy is not obligatory in cases of futile care or end-of-life situations. The decision to provide nutrition therapy should be based on effective patient/family communication, realistic goals, and respect for patient autonomy.” (Grade E evidence).

Enteral Formula Selection Guidelines

See Enteral Formulary Card for product descriptions. Available from any dietitian or call #4166.

• “Immune-modulating enteral formulations should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation). (Grade A evidence for surgical ICU pts.; Grade B evidence for medical ICU pts.).² - Pivot 1.5

• “Patients with ARDS and severe acute lung injury (ALI) should be placed on an enteral formulation characterized by an anti-inflammatory lipid profile (i.e., ω-3 fish oils, borage oil) and antioxidants. (Grade A evidence).² - Oxepa

• “ICU patients with acute renal failure (ARF) or acute kidney injury (AKI) should be placed on standard enteral formulation, and standard ICU recommendations for protein and calorie provision should be followed. If significant electrolyte abnormalities exist

30

or develop, a specialty formulation designed for renal failure (with appropriate electrolyte profile) may be considered. (Grade E evidence).² - jevity

• “Standard enteral formulations should be used in ICU patients with acute and chronic liver disease. – jevity. Branched chain amino acid formulations (BCAA) should be reserved for the rare encephalopathic patient who is refractory to standard treatment with luminal acting antibiotics and lactulose.” (Grade C evidence).² - NutraHep

Initiation of Enteral Nutrition Support

• “In the ICU patient population, neither the presence nor absence of bowel sounds, nor evidence of passage of flatus and stool is required for the initiation of enteral feeding.” (Grade B evidence).²

• “In the ICU setting, evidence of bowel motility (resolution of clinical ileus) is not required in order to initiate EN” (Grade E evidence).²

• Start tube feeding full strength at 20-30 ml/hr. based on pt. status (lower if critical or on significant pressors; higher if was recently eating and status is stable).

• Advance by 10-20 ml every 4-8 hours as tolerated to goal rate. See aspiration precautions below.

• “Efforts to provide > 50-65% of goal calories should be made in order to achieve the clinical benefit of EN over

31

the first week of hospitalization.” (Grade C evidence). Studies suggest that this improve outcomes to promote faster return of cognitive function in head injury patients and to improve outcome from immune-modulating enteral formulations in critically ill patients.²

Monitoring of Enteral Nutrition Support

• Assessment of GI tolerance o Abdominal discomfort, pain o Nausea/Vomiting o Abdominal distention

• Aspiration Precautions o HOB should be elevated ≥ 30° “In all intubated ICU patients receiving EN, the HOB should be elevated 30° to 45°. (Grade C evidence).² o EN residuals ≥ 250 ml residual

x2 o “Holding EN for gastric residual

volumes <500 ml in the absence of other signs of intolerance should be avoided. (Grade B evidence).²

o “Agents to promote motility such as prokinetic drugs, metoclopramide or erythromycin should be initiated where clinically feasible. (Grade C evidence.²

o “Withholding of EN for repeated high gastric residual volumes alone may be sufficient reason to

32

switch to small bowel feeding.” (Grade E evidence).²

• Aspiration Detection o Clinical signs and symptoms

(dyspnea, tachypnea, wheezing, rales, tachycardia, cyanosis, decreased oxygenation, anxiety/agitation, fever/aspiration pneumonia)

• Hydration Status o Assess over hydration (edema,

high urine output, dilute urine specific gravity, hypertension, respiratory insufficiency, CHF, rapid weight gain)

o Assess dehydration (decreased urine output, concentrated urine, elevated urine specific gravity, dry lips and mucous membranes, poor skin turgor, sunken eyes, flat neck veins, lethargy, hypotension, tachycardia, elevated BUN, constipation, rapid weight loss)

o Fluid intake should approximate fluid output

o 1 kg of weight change is equivalent to 1 liter of fluid

• Assessment of Nutrient Intake o Assess actual nutrient intake to

determine the need for change in nutrition support. (Review RD FU note) Holding EN for

33

multiple or prolonged time periods should be avoided. Every effort should be made to infuse the missed EN.

• Body Weight o Same scale, minimal clothing o Frequency: daily if critically ill,

or unstable fluid status; weekly when stable

• Biochemical and Hematological Indices o Baseline: CMP, Mg, Phosphorus

(others per pt. morbidities) o Follow-up based on patient’s

clinical status. • Maintaining Feeding Tube Patency

o Irrigate tube before and after each intermittent feeding or medication administration.

o Medications should be given separately, with 5-10 ml of water given between each one.

o For continuous feedings, flush with at least 20-30ml of water every 4 hours.

“Tolerance to EN in patients with severe acute pancreatitis may be enhanced by the following measures:

• Minimizing the period of ileus after admission by early initiation of EN. (Grade D evidence)

• Displacing the level of infusion of EN more distally in the GI tract. (Grade C evidence).

34

NOTE: The underlying medical condition/s should be reassessed on an ongoing basis to evaluate transitional feeding and/or initiation of increasing oral intake. Review RD assessment. Consult dietitian for initial/reassessment.

PARENTERAL NUTRITION (PN) PN should be used only if the gut is not functional/available and PN use is anticipated > 7 days in a well-nourished person. When the gut is not useable and the patient is malnourished, PN should begin immediately

Indications for PN

• Failure of EN trial with proper tube placement.

• EN is contraindicated (see above) due to non-functioning intestinal tract.

• “If there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation.” (Grade C evidence).²

Contraindications for PN

• Functioning GI tract • Inability to obtain venous access • A prognosis that does not warrant

aggressive nutrition support • When the risks of PN are judged to

exceed the potential benefits What to do prior to PN initiation?

• Consult dietitian

35

• Obtain patient’s actual height and weight. Use adjusted weight if patient is >125% of IBW

• Obtain labs: Phos, K+, Mg and replete prior to TPN initiation. TG

Macronutrient Calculation in PN

1. Carbohydrate (CHO)

CHO is given as dextrose monohydrate which contains 3.4 kcal/gm.

CHO Load: mg CHO/kg/min = gm. CHO x 1000 = gm. CHO

Kg x 1440 Kg x 1.44

GOAL for Maximum Carbohydrate load: 3 – 5mg/kg/min < 4mg/kg/min for diabetics and critically ill

2. Protein

Amino Acids provide 4 Kcal/gm.

3. Fat

Lipids contain 10 Kcal/gm. Minimum required to prevent EFAD (essential fatty acid deficiency): 2-4% of the Kcal requirement should come from linoleic acid. (This is met with minimum of 500 ml of 20% lipids/week).

Maximum recommended: <30% of total Kcal, or < 1gm/kg/day to minimize effect of IV lipids on impaired immune response.

36

CALCULATING a PN FORMULATION:

Step 1: Determine dosing weight • Use actual body weight. • For patients who are overweight at > 125%

of their Ideal Body Weight (IBW) use Adjusted Body Weight (ABW) for Kcal and Pro requirements.

ABW: Adjusted Body Wt.

ABW= [(Actual Wt. – IBW) x 0.25] + IBW

IBW Women: Allow 45.4 kg for first 5 ft. of height plus 2.3 kg. for each additional inch.

IBW Men: Allow 48.1 kg for first 5 ft. of height plus 2.7 kg for each additional inch.

Step 2 (Day 1): Determine initial total Kcal requirements per day. Kcal: 20 Kcal/kg dosing weight Pro: 1gm/kg dosing weight See dietitian to determine Kcal/nutrient goals for succeeding days. Standard base solution is available for day #1. Step 3: Break down calorie requirement into

macronutrients ____ (Total Kcal/day) x 0.5 = _______Dextrose Kcal (maximum 3-7gm/kg/day)

37

____ (Total Kcal/day) x 0.3 = _______Lipid Kcal (limit to 1gm/kg/day) ____ (Total Kcal/day) x 0.2 = _______Protein Kcal (.8-2gm/kg/day) Breakdown of macronutrients may change based on patient condition and lab values.

Step 4: Convert calories to grams

______Dextrose Kcal ÷ 3.4 Kcal/gm. = _____gm.

Dextrose

______Lipid Kcal ÷ 10 Kcal/gm. = _____gm.

Lipid

______Protein Kcal ÷ 4 Kcal/gm. = _____gm. Protein

Step 5: Convert Grams to Milliliters

_____ gm. Dextrose/day x 100 ml ÷ _____ Dextrose %

= _____ ml Dextrose

_____ gm. Lipid/day x 100 ml ÷ 20 Lipid %

= _____ ml Lipid

_____ gm Protein/day x 100 ml ÷ _____ Amino Acid %

= _____ml Amino Acid

Step 6: Consult dietitian for further assessment and recommendations. If in doubt, order: Standard PN solution for first day and await recommendations from dietitian.

NOTES:

38

• Initial PN should NOT meet GOAL kcal level unless pt. has been well nourished within the previous 48 hours.

• Fluid needs are usually not met 100% by the PN. This allows for flexibility with fluid adjustments via IV’s at bedside.

• NOTE: Propofol provides 1.1 Kcal of fat per ml, and MUST be calculated into the total fat provisions and total kcals.

• When ordering PN, use form no. 14708, Adult Total Parenteral Nutrition (TPN) Order Sheet. On the back of the form is a calculation worksheet.

• “A combination of antioxidant vitamins and trace minerals (specifically including selenium) should be provided to all critically ill patients receiving specialized nutrition therapy.” (Grade B evidence).² Renal function needs to be considered.

Monitoring of Parenteral Nutrition Support

• Fluid o PN volume may be concentrated

for patients at risk for volume overload.

o Accurate I/O’s should be kept. • Biochemical and Hematological Indices

o Glucose Control See “Insulin Infusion

Protocol” sheet. o Electrolyte and Acid-Base

Imbalances Phos, Mg, K+ should be

monitored daily x at least 72

39

hrs. TG monitored initially and then weekly.

• Body Weight

o Frequency: Daily if critically ill or fluid status unstable; bi-weekly when stable.

NOTE: The underlying medical conditions should be reassessed on an ongoing basis to evaluate the possibility of complimentary or sole transition from PN to an enteral feeding or PO initiation. Consult a dietitian for reassessment when enteral feeding is a consideration. “In patients stabilized on PN, periodically repeated efforts should be made to initiate EN. As tolerance improves and the volume of EN calories delivered increases, the amount of PN calories supplied should be reduced. PN should not be terminated until ≥ 60% of target energy requirements are being delivered by the enteral route.”

40

References: 1. Gottschlich, MM, editor-in-chief. Nutrition Support Core Curriculum: A Case-Based Approach – The Adult Patient. American Society for Parenteral and Enteral Nutrition. Silver Spring, MD: 2012. 2. McClave, SA, Martindale, RG, Vanek, VW, MCCarthy, M, Roberts, P, Taylor, B, Ochoa, JB, Napolitano, L, and G Cresci. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral Nutrition. 2009; 33: 277-316. 3. McClave, SA, and HL Snyder. Use of Indirect Calorimetry in Clinical Nutrition. Nutrition in Clinical Practice. 1992; 7: 207-221. 4. Merritt, Russell editor-in-chief. The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition. American Society for Parenteral and Enteral Nutrition. Silver Spring, MD:2005. 5. Pronsky, ZM. Food Medication Interactions, 17th Ed. Food-Medication Interactions. Birchrunville, PA: 2012.

41

6. Robinson, Malcolm K, et al. Improving Nutritional Screening of Hospitalized Patients: The Role of Prealbumin. Journal of Parenteral and Enteral Nutrition. 2003; 27: 389-395. 7. Wooley, JA, and HC. Sax. Indirect Calorimetry: Applications to Practice. Nutrition in Clinical Practice. 2003; 18: 434-439. To contact a dietitian, call: Bethlehem 484-526-4166 Allentown 610-628-8798 Quakertown 215-538-4621 Miners 570-645-8107 Anderson 484-503-1029 Warren 908-859-2207

42

Updated 5/2014