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basic nutritional status assessments
- Height
- wt
- IBW/BMI
- Weight change
- primary diagnosis
- co-morbidities
other nutritional status assessments
- creatinine
- bilirubin
- pre albumin
- liver enzymes
- triglycerides
- Input and Output
- glucose
REE

rest energy expenditure
signs and sx
- 10% increase/decrease in wt within 6 mths
- 5% within 1 mth
20% over/under IBW

inadequate intake due to impaired ingestion or absorption
5 consequences of malnutrition
- delayed healing
- re-hospitalization
- increase stay
- increased cost
- increased mortality
3 ways to calculate energy expenditure
- predictive
- energy expenditure (calorimetry)
- weight based calculations
Harris-Benedict
- weight
- age
- stress
- height
ireton-jones
- weight
- age
- gender
- injury
- obesity
Fick predictive equation
- CO
- Hgb
- SaO2
- SvO2
how are O2 and CO2 used

to indirectly measure calories
ADV and dis ADV of indirect calorimetry
- requires expert skill
- time consuming (30-60 min)
- most accurate
- most expensive
indirect calorimetry is IND for
- pts who fail on predictive equations
- individualize nutrition
- nutrition requirements difficult to establish
where are calories derived from

macronutrients
what are caloric needs and fluid requirements based on
- expenditure estimates
- activity/stress
- malnutrition history
range of fluid a pt should receive in a day

20 - 35 kcal/kg/day
amt of total fluids a pt should receive a day
- 30 - 40 mL/kg/day
- 1 - 1.5 mL/kcal expended
disadvantages of parenteral
- cost
- complex
- morbidity/mortality increase
what are gastric residual volumes

accumulation of EN and gastric secretions
complications of EN
- diarrhea
- aspiration
- nausea
- pneumonia
- abdominal distention
- regurgitation/emesis
when do GRVs only occur

during delayed gastric emptying
how is pneumonia caused with EN

accumulation of EN leads to aspiration which eventually results in pneumonia
Taylor GRV trial

determine effects of early enhanced EN in head injured patients requiring mechanical ventilation
Pinilla GRV trial

compared GI tolerance of two EN protocols in critically ill pts
McClave GRV trial

determine whether GRV accurately predicts aspiration risk

there was no difference
Montejo GRV trial

compare effects of increasing the GRV limit in the adequacy of EN

no difference
daily salivary output

1500 ml
daily gastric secretions

3000 ml
volume of total fluid

188 ml/hr
EN infusion rate

25-125 ml/hr
GRV approximation

residual volumes should plateau between 232 and 464 ml/hr within 3-6 hrs of initial feeds
agents used to treat very high GRV
- cisapride
- erythromycin
- metoclopramide
- naloxone
elemental formulation contains
- individual AA
- glucose polymers
- low fat
- LCTs
semi elemental EN contains
- varying AA
- glucose polymers
- low fat
- MCTs
Standard EN formulation contains
- intact AA
- carbs
- mainly LCTs
complications with EN
clinical problems (diarrhea, aspiration, metabolic disturbances)
- clogged feeding tubes
- high gastric residuals
- delayed gastric emptying
- iatrogenic pneumothorax
how do you treat clogged EN feeding tubes

pancrealipase + bicarbonate
EN metabolic disturbances are less with

elemental than TPN
what is the #1 side effect in pts on EN

diarrhea
confounding factors that influence diarrhea in EN
- medications
- infections
- malabsorption
- co morbid conditions
treatment approaches for diarrhea
- remove offending medication
- give probiotic supplements
- antidiarrheal med (loperamide)
- change formulation
- assess fat content in stool
what is the most feared complication of EN

Aspiration
when will EN likely to cause primary disturbances
- re feeding
- hyperglycemia
IND for TPN

malnurouished prior to hospital or > 7 days in hospital

Inadequate or expected inadequate oral intake for 7 - 14 days

catabolic illness with normal energy/protein utilization
TPN goals
- preserve lean body mass
- support organ structure/function
- decrease morbidity and mortality
- support immune function
list the macronutrients
- AA
- dextrose
- lipids
list the micronutrients
- electrolytes
- vitamins
- minerals
other TPN components
- water
- medications
- -h2 blockers
- -thiamine
- -folic acid
- -vitamin k
- -insulin
only h2 antagonist used in TPN

famotidine
what is the primary TPN element

AA
AA metabolic demands for unstressed/maintenance range

0.8 - 1 g/kg/d
AA metabolic demands for catabolic

1.2 - 2 g/kg
AA contain how much protein

4 kcals/g of protein
AA contain how much acetate

75 - 150 mEq/L
AA which contain phosphate
- FreAmine III
- HepatAmine
- Hepatasol
AA containing phosphate should not be given with

Ca++
Which TPN element provides majority of non-protein calories

Dextrose (lipids provide other non-protein cal)
what does the dextrose load depend on

glucose tolerance
what are the limits to dextrose
- 7 g/kg/d
- 3.4 kcal/g
TPN dextrose does what to fat lvs in pts? what does it eventually lead to?
- activates insulin and reduces adipose lipolysis
- leads to linoleic acid deficiency
limit to TPN lipids
- 2.5 g/kg/d
- 10 kcals/g for 20-30% IV
- 11 kcals/g for 10% IV
what is added to TPN lipids to make it stable

glycerol which adds to the calories
what will dextrose do to electrolyte lvs
- decrease serum electrolytes
- IC shift caused by insulin release
how long until patients begin to show signs of fatty acid deficiency

20 - 21 days
when are trace elements used in TPN

if pt is not getting food
which MTE contains selenium

MTE-5
what trace elements are contained in MTE-4
- chromium
- zinc
- copper
- Mg++
what must you consider with micronutrient trace elements if total bilirubin is elevated

consider reduction (50%) or removal of trace elements (copper and Mg)
when do you add zinc IV to MTE
- high output fistula or ostomy
- open wounds
- intractable diarrhea
what element helps with wound healing

zinc
how much zinc is sufficient for positive balance

12 mg/d
which micronutrient is used for burns and trauma

glutamine
amt of AA indicated for pt with hepatic disease

1g/kg/d
what micronutrients should be avoided in pts with hepatic dysfunction

Cu and Mg (due to accumulation of bilirubin)
what are the special considerations in TPN
- AKI or CKD
- DM
- hepatic dysfunction
- obesity
- critical care
how many kcals are given to obese pts
- 22-25 IBW
- 11-14 Actual body weight
calories needed for critical care pts

25-35
lipid considerations with critical care pt
- limit is 1g/kg/d
- avoid giving during acute inflm
- lipid free TPN for first wk of hospitalization
monitoring for TPN rate advancement
- metabolic complications
- -hyperglycemia
- -refeeding syndrome
- -electrolytes
goal rate for TPN

2-3 days
pts at risk for refeeding syndrome
- prolonged inadequate intake
- alcoholic
- morbid obese and large wt reduction
metabolic complications of refeeding syndrome
- hypokalemia
- hypophosphatemia
- hypomagnesemia
- vitamin deficiencies (thiamine)

Author

alvo2234

217210

Card Set

TPN

Description

Final

Updated

2013-05-02T17:12:59Z

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