NUTRITION THERAPY I

LJ Shaine T. Villan, RND | Tuesday

GRADED RECITATION  prevent physiologic deterioration
QUESTIONS
Traditionally, nutrition support in critically ill patients was
• Enteral nutrition along with adequate fluid resuscitation regarded as adjunctive care designed to provide energy to
should be initiated 24 to 48 hours after injury or admission support the patient during the stress response.
to the intensive care unit.
• ARGININE – function and wound healing and is commonly Goals have become more focused on nutrition therapy,
found in immune-enhancing specifically attempting to attenuate the metabolic response to
• Specialized nutrition support therapy is the provision of stress, prevent oxidative cellular injury, and favorably modulate
nutrients orally, enterally, or parenterally with the immune response.
THERAPEUTIC intent
• 1 ml / 1 kcal – recommended intake of fluid for adults INDICATIONS
• CONTINUOUS FEEDING/DELIVERY – require that the
enteral formula be administered at a controlled rate with a  Evidence-based guidelines for managing critically ill
pump over a 24-hour period. patients support early nutrition intervention.
• the use of parenteral nutrition should be reserved and  Enteral nutrition is recommended over parenteral
initiated only after the first 7 days of hospitalization. nutrition in critically ill patients who are
• Two basic types of polymeric formula: hemodynamically stable and have a functioning
• SYNTHETIC FORMULA gastrointestinal tract.
• BLENDERIZED FORMULA  Enteral nutrition along with adequate fluid resuscitation
• ELEMENTAL OR SEMI-ELEMENTAL FORMULAS – should be initiated 24 to 48 hours after injury or admission
consist of hydrolyzed macronutrients to the intensive care unit.
• Parenteral nutrition should be initiated only if the duration  In the critically ill patient, early enteral nutrition is
of therapy is anticipated to be at least 7 days. associated with a reduction in infectious complications and
• ESOPHAGOSTOMY – the feeding tube is inserted through may reduce the length of hospitalization.
a surgical opening in the neck and passed through the  Patients who receive enteral nutrition experience lower
esophagus, with the tip resting into the stomach rates of septic morbidity and fewer infectious
• STANDARD OR POLYMERIC FORMULAS – must be complications than patients who receive parenteral
digested into dipeptides and tripeptides, free amino acids, nutrition.
and simple sugars. Polymeric formulas require adequate  In a large sample of patients with traumatic brain injury,
digestive and absorptive capability and are indicated in early nutrition intervention was associated with improved
patients with normal or near-normal gastrointestinal medical outcomes and reduced mortality. 24 to 48 hours
function after injury to support their increased energy needs.
• GASTRONOMY – feeding tube is inserted through the  In surgical patients and critically ill patients, enteral
abdominal wall into the stomach via percutaneous feedings should be provided without waiting for the
endoscopic guidance (surgical “open” gastronomy) resumption of flatus or bowel movements.
• NASOJEJUNAL – feeding tube is inserted through the
nose, with the tip resting in the jejunum Guidelines from ASPEN & SCCM:
• JEJUNOSTOMY – feeding tube is inserted through the
abdominal wall into the jejunum  If enteral nutrition support is not feasible or available for the
• 60 % - average intake delivered within the first week first 7 days following the intensive care unit admission of
• NASOGASTRIC – feeding tube is inserted through the critically ill patient who was previously healthy with no
nose, with the tip resting in the stomach evidence of protein-calorie malnutrition, no nutrition support
• PARALYTIC ILEUS – temporary loss of contactile therapy should be provided.
movements of the intestinal wall that results in an absence  The use of parental nutrition should be reserved and
of bowel sounds or flatus. initiated only after the first 7 days of hospitalization.
• PARENTERAL NUTRITION SUPPORT – provision of
 However, if there is evidence of protein-calorie malnutrition
nutrients intravenously
on admission and enteral nutrition is not feasible, it is
appropriate to initiate parental nutrition as soon as possible
SPECIALIZED NUTRITION SUPPORT THERAPY
following adequate resuscitation.
 If a patient is expected to undergo major upper
Specialized nutrition support therapy is the provision of
nutrients orally, enterally, or parenterally with therapeutic gastrointestinal surgery and enteral nutrition is not feasible,
intent. parenteral nutrition should be provided under the specific
conditions described below:
The preferred route for patients who cannot meet their nutritional • If the patient is malnourished, parenteral nutrition
needs through voluntary oral intake is enteral nutrition, the should be initiated 5 to 7 days preoperatively and be
nonvolitional delivery of nutrients by tube into the continued into the postoperative period.
gastrointestinal tract through a feeding tube, catheter, or stoma. • Should enteral nutrition not be feasible after surgery,
the initiation of parenteral nutrition should be delayed
Parenteral nutrition is the administration of nutrients for 5 to 7 days.
intravenously. • Parenteral nutrition should be initiated only if the
duration of therapy is anticipated to be at least 7 days.
GOALS OF NUTRITION SUPPORT THERAPY IN BOTH • Parenteral nutrition therapy provided for a duration
WELLNOURISHED AND MALNOURISHED CRITICALLY ILL less than 5 to 7 days would be expected to have no
PATIENTS: beneficial effect and may result in an increased risk
to the patient.
 prevent the depletion of lean body mass
 promote acute phase and whole body protein synthesis

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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
CONTRAINDICATIONS • conditions warranting total bowel rest, such as severe
acute necrotizing pancreatitis (unless jejunal enteral
Specialized nutrition therapy is usually not indicated for: feeding can be provided beyond the ligament of Treitz)
• severe inflammatory bowel disease
 malnourished patients who are eating adequate amounts • upper gastrointestinal hemorrhage (caused by esophageal
to meet their estimated nutrient requirements varices, portal hypertension, or cirrhosis)
 well-nourished patients who are anticipated to resume • short-bowel syndrome (less than 100 cm of small bowel
adequate oral intake within 7 days; and remaining)
 patients whose prognosis does not warrant aggressive • intestinal obstruction (depending on location)
nutritional care • a prognosis that does not warrant aggressive nutrition
support
The decision to provide nutrition therapy should be based on
effective communication with the patient and family, realistic NUTRITION INTERVENTION
goals, and respect for patient autonomy.
 Enteral feedings can be nutritionally adequate if an
ENTERAL NUTRITION SUPPORT THERAPY FOR ADULTS appropriate formula is selected with consideration of each
patient’s individual estimated requirements.
 Enteral nutrition support therapy – provision of nutrients  Tube feedings may be used as the sole source of nutrients
to the gastrointestinal tract via a feeding tube, catheter, or or as a supplement to inadequate oral nutrition.
stoma to maintain or replete the patient’s nutritional  permissive underfeeding rather than overfeeding obese
reserves. critically ill patients may produce better medical outcomes
 Enteral nutrition is the preferred route for the provision  For patients with a body mass index (BMI) greater than 30
of nutrition for patients who cannot meet their needs kg/m2, the goal of the enteral nutrition regimen should not
through voluntary oral intake. This section pertains to exceed 60% to 70% of target energy requirements or 11
nutrition support via enteral tube feeding. TIONS to 14 kcal/kg actual body weight per day (or 22 to 25
kcal/kg ideal body weight per day)
NUTRITION ASSESSMENT  Antioxidant vitamins (including vitamin E and ascorbic
acid) and trace minerals (including selenium, zinc, and
INDICATIONS copper) may improve patient outcome, especially in burns,
trauma, and critical illness requiring mechanical ventilation.
A combination of antioxidant vitamins and trace minerals
 Enteral nutrition support via tube feeding should be
(specifically selenium) should be provided to all critically ill
considered as a proactive therapeutic strategy for patients
patients receiving specialized nutrition therapy.
who are unable to ingest adequate amounts of nutrients
orally and have an adequately functioning gastrointestinal
How to Order the Diet
tract.

ADVANTAGES OF ENTERAL NUTRITION OVER  The physician in collaboration with the dietitian determines
PARENTERAL NUTRITION: the appropriate prescription for the enteral nutrition
regimen, including the route and type of formula.
• a much lower cost and shorter length of hospital stay  A dietitian should facilitate the selection of the formula type
• the avoidance of complications associated with parenteral and goal rate for tube feeding.
feedings (eg, infectious complications pneumothorax,
catheter embolism, and cholecystitis) (the support of the The order specifies:
metabolic response to stress and a favorable modulation of • product, either by name or as “Standard Tube Feeding,”
the immune response in critically ill patients according to hospital protocol
• the maintenance of gastrointestinal mucosal integrity and • volume, rate, and timing, including the initial volume and
prevention of bacterial translocation. rate, as well as the progression and goal volume and
rate (at a standard dilution of 1.0 kcal/mL, the volume
Guidelines from the ASPEN and the SCCM states: will be roughly equal to the number of kilocalories
specified.)
 traditional nutrition assessment tools (albumin, prealbumin,
• administration and monitoring, following either the
and anthropometry) are not validated in critical care
facility’s standard procedures or individualized orders,
patients.
including the administration of extra water to flush the
 Before the initiation of feedings, assessments should
tube or meet fluid requirements.
include the evaluation of weight loss and previous nutrient
intake prior to admission, level of disease severity,
comorbid conditions, and function of the gastrointestinal Routes of Access for Enteral Tube Feeding
tract.
 The type and route of feeding tube should depend on
CONTRAINDICATIONS the patient’s needs and the route that optimizes nutrient
delivery (stomach or small bowel) for disease management
 The smallest tube possible should be used for patient
Enteral nutrition support should be avoided in patients who do
comfort, and correct placement of the feeding tube should
not have an adequately functioning gastrointestinal tract or who
are hemodynamically unstable. Specific contraindications be confirmed by X-ray prior to use.
include:  When the anticipated need for enteral nutrition exceeds 4
to 6 weeks, a more permanent enteral access device is
• intractable vomiting indicated.
• severe diarrhea
• high-output enterocutaneous fistula (greater than 500
mL/day) and distal to site of feeding tube tip placement
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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
SEVERAL TYPES OF FEEDING TUBE PLACEMENTS:  Soy polysaccharide an insoluble fiber, and guar gum a
soluble fiber are common types of fiber used in formulas.
• Orogastric: The feeding tube is inserted through the
mouth, with the tip resting in the stomach. Formulas containing omega-3 fatty acids:
• Nasogastric: The feeding tube is inserted through the
nose, with the tip resting in the stomach.  The type and amount of fat in enteral formulas may affect
• Nasoduodenal: The feeding tube is inserted through the immune function
nose, with the tip resting in the duodenum.  Fish oils, a rich source of omega-3 fatty acids, provide
• Nasojejunal: The feeding tube is inserted through the eicosapentaenoic acid.
nose, with the tip resting in the jejunum.  Unlike omega-6 fatty acids, which are found in more
• Esophagostomy: The feeding tube is inserted through a common fat sources (eg, corn oil and soybean oil) and have
surgical opening in the neck and passed through the a greater immunosuppressive effect, eicosapentaenoic
esophagus, with the tip resting in the stomach. acid metabolizes into less immunosuppressive
• Gastrostomy: The feeding tube is inserted through the prostaglandins and leukotrienes.
abdominal wall into the stomach via percutaneous
endoscopic guidance or surgical placement (surgical Formulas containing arginine:
“open” gastrostomy).
• Jejunostomy: The feeding tube is inserted through the  Arginine is a conditionally essential amino acid during
abdominal wall into the jejunum via percutaneous stress due to the greater utilization of the urea cycle.
endoscopic guidance or surgical placement (surgical  Arginine is important in immune function and wound
“open” jejunostomy). healing and is commonly found in immune-enhancing and
wound-healing enteral formulas.
Enteral Formula: Categories and Selection  Arginine may be useful in treating inflammatory diseases
and acquired immunodeficiency syndrome, and it
 Formulas should be selected based on enhances collagen formation in wound healing
digestibility/availability of nutrients, nutritional adequacy,
viscosity, osmolality, ease of use, and cost. Formulas containing glutamine:
 Enteral formulations are considered medical foods by the
Food and Drug Administration (FDA)  Classified as a nonessential amino acid, glutamine is the
primary oxidative fuel for rapidly dividing cells, such as
 Standard formulas include synthetic formulas and enterocytes and leukocytes.
blenderized formulas.  Glutamine is not present in standard parenteral formulas,
 Enteral formulas contain a large amount of water; their and it is present in only small amounts in enteral formulas.
water content generally ranges from 70% to 85%  Glutamine supplementation is contraindicated in patients
 Standard or polymeric formulas: Standard or polymeric with hyperammonemia, hepatic failure, or renal failure
formulas must be digested into dipeptides and tripeptides, due to excess ammonia production.
free amino acids, and simple sugars in the small bowel.
 Lactalbumin, whey, and egg albumin are also sources of Formulas containing branched-chain amino acids (BCAA):
intact proteins
 Carbohydrates provide 40% to 90% of total energy. The  Formulas supplemented with BCAA have primarily been
fat content ranges from less than 10% to more than 50% of used for patients with hepatic failure in an attempt to
total energy. improve the ratio of BCAA to aromatic amino acids and
 Elemental or semi-elemental formulas: These formulas prevent or improve hepatic encephalopathy.
consist of hydrolyzed macronutrients. Protein is present
either as free amino acids (monomeric) or as bound amino Formulas for renal disease:
acids in dipeptides or tripeptides (oligomeric).
 Modular components: These products are individually
 Renal formulas are energy-dense formulas that contain
packaged components that may be combined in varying
whole proteins and have a modified electrolyte content (eg,
amounts to meet the patient’s individual nutritional needs.
sodium, potassium, phosphorus, and magnesium).
 These formulas may be indicated in renal patients whose
NUTRIENT-MODIFIED AND DISEASE-SPECIFIC
serum electrolyte levels are difficult to manage or for whom
FORMULAS
renal dialysis is delayed
 Most specialty renal formulas are energy dense, so that
 Nutrient-modified and disease-specific formulas have
volume can be restricted if needed. The protein content
been altered in one or more nutrients in an attempt to
ranges from less than 40 g to more than 70 g in 2,000 kcal.
optimize nutrition support without exacerbating the
 If dialysis is delayed, an energy-dense, reduced-protein
metabolic disturbances associated with various diseases.
formula is appropriate.
NUTRIENT-MODIFIED FORMULAS INCLUDE:
Formulas for hepatic disease:
Formulas containing fiber:
 Standard formulations should be used in ICU patients with
acute and chronic liver disease.
 Fiber is added to enteral formulas for a variety of potential
 Nutrition regimens should avoid restricting protein in
health benefits. patients with liver failure.
 Short-chain fatty acids, the preferred fuel for colonocytes, Special enteral formulas have been designed for patients
help to increase mucosal growth and promote sodium and with hepatic failure.
water absorption. It is important to consider the type of fiber
supplemented in the enteral formula.

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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
Formulas for pulmonary disease and ARDS: Approximate Free Water Content of Nutritional Formulas

 Pulmonary disease formulas are low in carbohydrate and Formula mL H2O/mL Formula mL
high in fat to decrease carbon dioxide (CO2) production in H20/kcal
patients with compromised pulmonary function. 1.0 kcal/mL 0.84 0.84
 Formulas that contain omega-3 fatty acids may be 1.0 kcal/mL with 0.83 0.83
beneficial in patients with early ARDS. fiber
1.5 kcal/mL 0.78 0.52
Formulas for diabetes mellitus:
2.0 kcal/mL 0.71 0.36
 Patients with diabetes mellitus who follow a diet with
CRITERIA FOR FORMULA SELECTION
increased intake of monounsaturated fatty acids along with
lower carbohydrate intake may have improved blood
 Energy density: An energy density of 1 kcal/mL is
glucose control. Therefore, enteral formulas with modified
considered standard.
amounts and types of carbohydrate and fat have been
 Osmolality: Products are available at isotonic
developed
osmolalities (300 mOsm/kg), moderate osmolalities
(400 mOsm/kg), and high osmolalities (700 mOsm/kg).
Formulas containing immune modulating nutrients:
The main contributors to osmolality are sugars, free amino
acids, and electrolytes. Lipids are isotonic and therefore
 Formulas have been designed with increased amounts of do not contribute to osmolality. Highcarbohydrate, amino
immune-enhancing nutrients (eg, arginine, glutamine, acid–based, or peptide-based formulas have moderate to
nucleotides, omega-3 fatty acids or fish oil) and high osmolality.
antioxidant vitamins and minerals.  Protein: Protein sources are intact proteins, peptides, or
amino acids. Generally, protein contributes 9% to 24% of
WATER/FLUID REQUIREMENTS total energy. High-nitrogen formulas may not be well
tolerated in patients with certain renal or hepatic disorders.
 The National Research Council recommends 1 mL of fluid High-nitrogen concentrations can result in a higher renal
per 1 kcal of energy expenditure for adults with average solute load and can predispose elderly patients to
energy expenditure who live under average environmental dehydration. One gram of nitrogen requires 40 to 60 mL of
conditions. water for excretion.
 Fat: Fat sources are long-chain triglycerides (LCT) and
Medical conditions that may reduce fluid requirements: MCT. The fat content usually ranges from 3% to 35% of
• heart failure energy for amino acid–based or peptide-based formulas
• acute respiratory failure and from 25% to 55% of energy for standard formulas. Fats
• renal failure do not contribute to osmolality.
• ascites, syndrome of inappropriate antidiuretic hormone  Carbohydrate: Carbohydrate is the most easily digested
• malignant hypertension and absorbed nutrient. Enzyme digestion is very efficient,
as surface digestion is not rate limiting (except with
Fluid requirements may be increased for: lactose). The carbohydrate content of formulas ranges from
• pregnant patients 35% to 90% of energy.
• patients with fever, burns, diarrhea, vomiting, or high  Lactose: Lactose is present in milk-based formulas and
output fistulas or ostomies some blenderized formulas. Most commercial formulas
• patients receiving ventilatory support. are lactose free. Due to the presumed high incidence of
secondary lactase deficiency in illness, lactose is not
 Patients with pressure ulcers and patients medically present in most enteral formulas.
managed on air-fluidized beds also have additional fluid  Residue: Milk-based formulas and other formulas with
needs. intact nutrients are generally low residue. Blenderized and
fiber-supplemented formulas leave a moderate to high
Methods to determine fluid requirements: residue.
 Fiber: See the previous discussion of formulas containing
Method 1: Holliday-Segar Method fiber in the nutrient-modified formulas list.
 Sodium and potassium: Select formula according to the
Body Weight (actual) Water Requirement patient’s nutrition prescription and laboratory profile.
 Renal solute load: The main contributors to renal solute
≤ 10 kg 100 mL/kg
load are protein, sodium, potassium, and chloride. A
1,000 mL + 50 mL/kg for
between 10 kg and 20 kg high–renal solute load in sensitive patients can result in
each kg > 10 kg clinical dehydration.
> 20 kg 1,500 mL + 20 mL/kg for Safety: A ready-to-use closed bag or system is
each kg > 20 kg recommended, as it is more sterile and provides less risk
for contamination than canned or powdered products.
Method 2: Recommended Daily Allowances Method Formulas that are made in a blender in the facility are
discouraged because they carry a greater risk of infection,
 1 mL per kilocalorie of energy expenditure require careful handling, tend to clog tubes, and need a
high volume to meet nutrient needs.
Method 3: Fluid Balance Method  Viscosity: Blenderized, high-fiber, and high-density
formulas should not be administered through tubes with a
 Urine output + 500 mL/day diameter smaller than 10 French unless a pump is used.
Formulas may flow through an 8-French diameter tube
when a pump is used (15).
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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
 Vitamin K: Patients who are receiving enteral nutrition  Bring formula to room temperature before feeding, but do
support while on anticoagulant therapy should be not allow the formula to remain unrefrigerated for more
monitored closely. Significant vitamin K intake from enteral than 12 hours.
formulas can antagonize the effect of the anticoagulant  The hang time for formula in an open system should be
drug warfarin and result in treatment failure. Most enteral less than 8 hours or as specified by the manufacturer.
formulations contain modest amounts of vitamin K and Formula from a closed system is provided in ready-
provide daily vitamin K intake similar to the average dietary tohang, prefilled containers and may hang for 24 to 48
intake from foods. Consistent intake of an enteral hours per manufacturer’s guidelines. Discard any
formulation containing less than 100 mcg of vitamin K per formula remaining in the container after the hang time has
1,000 kcal is not expected to cause warfarin resistance expired.
 Cost: Amino acid–based formulas and peptide-based  Opened, unused formula should be kept refrigerated for
formulas are usually more expensive than synthetic no longer than the manufacturer’s specifications (usually
formulas containing intact nutrients. 24-48 hours)

ENTERAL FEEDING ADMINISTRATION Formula delivery guidelines:

Continuous feeding/delivery:  Irrigate the tube every 4 hours with 20 to 30 mL of warm

sterile water or saline to ensure patency for continuous
 Continuous feedings require that the enteral formula be feeding. Also, irrigate the tube before and after each
administered at a controlled rate with a pump over a intermittent feeding or medication administration.
24hour period.  To reduce bacterial contamination, flush water through the
 The pump should deliver the controlled rate within 10% bag and tube every 8 hours before adding new formula
accuracy and be calibrated periodically to ensure accuracy. when an open system is in place.
 Avoid putting food and beverages into the tube (e.g., juice,
Continuous feedings are indicated for: milk, and soda).
• unstable critically ill patients  Flush tube with purified sterile water or saline before and
• patients unable to tolerate high-volume feedings immediately after the administration of medicines to avoid
• patients with malabsorption clogging the tube
• patients at increased risk for aspiration.  To reduce the risk of contamination and infection, the
feeding bag should be properly labeled, and tubing should
 Feedings may be initiated at full strength in the stomach or be changed every 24 hours or as specified by the
at an isotonic strength in the small bowel at a rate of 10 to manufacturer
30 mL/hour. Then, the rate may be gradually increased as  Refer to organization-specific interdisciplinary enteral
tolerated in increments of 10 to 25 mL/hour every 4 to 8 nutrition monitoring protocol and policy as needed.
hours to the goal rate. Strength and volume should not be
increased simultaneously. PATIENT MONITORING GUIDELINES

Intermittent or cyclic feeding/delivery: Patients with nasoenteric tubes:

 Intermittent or cyclic feedings are administered over an 8-  Provide mouth and nose care every 8 hours to prevent
to 20-hour period by using a pump to control the rate of parotitis and skin breakdown around the nose.
delivery.  Verify the placement of a nasoenteric tube prior to feeding
 This method of tube feeding is most beneficial for patients initiation and every 4 to 8 hours thereafter, or as specified
who are progressing from complete tube feeding by the organization’s protocol.
support to oral feedings as discontinuation of feedings
during the day may help to stimulate the appetite. Avoidance of intestinal hypoxia and bowel necrosis:
 Intermittent or cyclic feeding is also beneficial for
ambulatory home-care patients who are unable to  Assess bowel sounds every 8 hours.
tolerate bolus feedings because it allows freedom from the  Feed into the small bowel (postpyloric position).
pump and equipment. Administer feeding in patients who are adequately fluid
resuscitated and have a sustained mean arterial pressure
Bolus formula delivery not requiring a pump: of at least 70 mm Hg, and are at steady or decreasing dos
of vasoactive agents.
 The syringe bolus-feeding method involves the delivery of  Use iso-osmolar, low residue formulations, initiated at 10 –
240 to 480 mL of formula via a feeding tube over a 20- to 20 ml/hr and advance the feedings when tolerance is
30-minute period, three to six times a day, to meet demonstrated.
estimated nutritional requirements.  Assess the need to hold feedings if the patient experiences
 This method is usually restricted to gastric feedings and a sudden period of hypotension (mean arterial pressure <
may be contraindicated in patients who have a high risk of 60 - 70 mm Hg), if the dosages of pressor agents (e.g.,
aspiration, disorders of glucose metabolism, or fluid dobutamine, norepinephrine, and epinephrine) are
management issues. increased, or if the need for ventilatory support is increased
(3, 56).
ENTERAL FEEDING FORMULA AND EQUIPMENT  Assess the need to hold feedings if the patient develops
MAINTENANCE GUIDELINES increased nasogastric output, abdominal distention, or
abdominal pain.
Formula:
Avoidance of gastrointestinal intolerance and aspiration:

 Recommendations from the North American Summit on

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LJ Shaine T. Villan, RND | Tuesday
Aspiration in the Critically Ill state that feeding ideally determine the morbidity, mortality, or severity of disease or
should be into the small bowel with the tube tip at or below inflammatory status (not reliable in critically ill patients)
the ligament of Treitz when two or more risk factors for  baseline measurements of liver function tests
aspiration are present. These risk factors include: prior  daily measurements of calcium, magnesium, and
aspiration, decreased level of consciousness, phosphorus until stable, then weekly measurement
neuromuscular disease, structural abnormalities of the  baseline complete blood cell count, then measured as
aerodigestive tract, endotracheal intubation, vomiting, needed
persistently high gastric residual volumes (GRVs), and the  a 24-hour urine analysis for urine urea nitrogen (or total
need for a supine position. urea nitrogen) once the goal rate of tube feeding is
 Use a 50-mL or 60-mL syringe to check GRVs in attained, then weekly measurements until stable
nasogastric-fed or gastrostomy-fed patients before each
intermittent or bolus feeding. Feeding tubes with a diameter Other patient monitoring guidelines:
smaller than 10 French may be unreliable in determining
residuals. The GRV should be checked before bolus  Weigh the patient at least once per week.
feedings.  Maintain daily records of intake, output, and bowel
 Blue dye should not be added to enteral formulas to detect movements.
aspiration. The risk of using blue dye outweighs any  Monitor vital signs to determine whether a systemic
perceived benefit. The presence of blue dye in tracheal inflammatory response is present
secretions is not a sensitive indicator for aspirations.
 If not contraindicated, maintain the head of the patient’s Signs of systemic inflammatory response syndrome:
bed at a 30-45 angle during feedings to reduce the risk of
aspiration pneumonia and the reflux of gastric contents into  body temperature of >38.0°C or <36.0°C
the esophagus and pharynx. If bolus feeding, keep the  heart rate of >90 beats/minute
head of the bed in this position for 30 to 60 minutes after  breathing rate of >20 breaths/minute (often obscured by
feeding. mechanical ventilation)
 If the patient has a history of gastroparesis or repeated high  leukocyte count of >12,000 mm3 or <4,000 mm3, or a left
GRVs ranging from 200 to 500 mL, then consider the shift (>10% bands)
use of a promotility agent, if there are no contraindications
Medications via enteral feeding tubes:
Diarrhea and Probiotics:
 Feeding tubes should be irrigated with at least 15 mL of
 Diarrhea in the ICU patient receiving enteral nutrition warm purified or sterile water (or saline) before and
should prompt an investigation to distinguish between immediately after the administration of medications.
infectious diarrhea, osmotic diarrhea, or malabsorption.  Multiple types of medication should be administered
separately.
Metabolic/laboratory data monitoring guidelines:  Temporary cessation of enteral feeding may be indicated
for 1 hour before and 1 hour after the administration of
 Serum protein levels are no longer considered to be phenytoin sodium (Dilantin), a commonly used
reliable or valid as an indicator of a critical care patient’s anticonvulsant medication, because components of the
nutritional status or response to nutrition therapies enteral formula, such as calcium, decrease the
bioavailability of this drug.
Evidence has shown that serum protein levels are markers of
the stress response and disease severity, rather than Transitional feedings, enteral to oral or supplemental
indicators of nutritional status or protein requirements. For parenteral nutrition:
monitoring the adequacy of protein intake, the most useful
(although still limited) laboratory indicator may be nitrogen
 Depending on the swallowing function of the patient, oral
balance, which reflects the adequacy of protein intake in
intake should begin with liquids and advance to appropriate
matching catabolic demand.
foods as tolerated.
 Switching the patient from a continuous tube feeding to
Requirements or Section III: Burns
night tube feeding only or discontinuing tube feeding 1 to 2
hours before meals will often stimulate the appetite and
 In critically ill adult patients the promotion of glucose levels speed transition to adequate oral intake.
between 140 and 180 mg/dL is currently recommended  When oral intake consistently meets or exceeds 60% of the
 Tight blood glucose control (80 to 110 mg per dL) is not patient’s energy requirements and 100% of the fluid
associated with reduced hospital length of stay (LOS), requirements, discontinuation of tube feedings should be
infectious complications, cost of medical care, days on considered. If a critically ill patient is unable to meet energy
mechanical ventilation or mortality and increases risk of requirements (100% of the target energy goal) after 7 to 10
hypoglycemia as previously suggested days by the enteral route alone, supplemental parenteral
 In surgical (primarily cardiac) patients, tight control of blood nutrition should be considered. The provision of
glucose reduces the risk of some types of infectious supplemental parenteral nutrition prior to this 7- to 10-day
complications. period does not improve the patient’s nutritional status and
may be detrimental.
Suggested laboratory monitoring guidelines include:

 daily measurements of sodium, potassium, chloride, CO2,

blood urea nitrogen, creatinine, and glucose levels until
stable, then biweekly to weekly measurements
 baseline measurements of prealbumin or albumin for
patients, such as chronic kidney disease patients, to

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LJ Shaine T. Villan, RND | Tuesday

PARENTERAL NUTRITION SUPPORT FOR ADULTS  perioperative support of moderately to severely

malnourished patients with gastrointestinal cancer
 Parenteral nutrition is the provision of nutrients  after 7 days of hospitalization when enteral nutrition has
intravenously. not been feasible or has been insufficient to consistently
meet the target energy goal
The two primary types of parenteral nutrition:  severe malabsorption caused by massive bowel resection
1) central parenteral nutrition (CPN) (≥ 70% resected) or severe diarrhea
2) peripheral parenteral nutrition (PPN)  intractable vomiting
 severe acute, necrotizing pancreatitis in patients who
 In CPN (or total parenteral nutrition), nutrients are have a history of poor tolerance to enteral nutrition or for
provided through a large-diameter vein, usually the whom enteral feeding is not possible at or beyond the
superior vena cava, by access of the subclavian or internal ligament of Treitz (Parenteral nutrition should not be
jugular vein. initiated until after the first 5 days of hospitalization.)
 The CPN formulas are hyperosmolar (1,300 to 1,800  paralytic ileus requiring prolonged bowel rest
mOsm/L) and consist of dextrose (15% to 25%), amino  complete intestinal obstruction
acids, and electrolytes to fully meet the patient’s  enterocutaneous fistula with an output greater than 500
nutritional needs. mL/day (A trial of enteral nutrition can be considered when
the output is less than 200 mL/day or when enteral access
 In PPN, a peripheral vein provides venous access. This may be placed distal to the fistula.
form of parenteral nutrition is similar to CPN except that  acute exacerbations of inflammatory bowel disease (eg,
lower formula concentrations must be used because the Crohn disease) complicated by fistulas
peripheral vein can only tolerate solutions that are less  radiation therapy or allogeneic bone
than 900 mOsm/L. marrow transplantation
 hemodynamic instability with mean arterial pressure < 70
 Compared with CPN formulas, PPN formulas have lower mm Hg
concentrations of dextrose (5% to 10%) and amino acids  increased doses of vasopressors
(3%).  increased need for mechanical ventilation
 The maximum volume of PPN that is usually tolerated is 3  worsening signs of GI intolerance
L/day (125 mL/hour).
 The use of PPN is indicated only for mildly to moderately CONTRAINDICATIONS
malnourished patients who are unable to ingest adequate
energy orally or enterally, or for patients in whom CPN is Parenteral nutrition is not indicated for patients:
not feasible.
 Typically, PPN is used for short periods (5 days to 2  who have a fully functional and accessible gastrointestinal
weeks) because of limited tolerance and the vulnerability tract
of peripheral veins (e.g., risk of peripheral venous  for whom venous access cannot be obtained
thrombophlebitis) (1). whose prognosis does not warrant aggressive nutrition
support
NUTRITION ASSESSMENT  whose need for parenteral nutrition is expected to be less
than 7 days
 A meta-analysis of parenteral nutrition suggests that this  for whom the risks of parenteral nutrition exceed the
route of nutrition support increases infection rates without potential benefits, such as in cases of severe
measurable beneficial outcomes when compared to hyperglycemia (>300 mg/dL), azotemia, encephalopathy,
controls. hyperosmolality (>350 mOsm/kg), and severe fluid and
 Parenteral nutrition is costly and may result in serious electrolyte disturbances (3)
complications and risks if the patient is not monitored
closely. NUTRITION INTERVENTION
 Steps must be taken to maximize the benefit and efficacy
of parenteral nutrition while reducing the inherent risks of Parenteral Feeding Formulations
hyperglycemia, immune suppression, increased oxidative
stress, and potential infectious morbidity.
 The osmolarity of a parenteral formula depends on the
 Patients who are candidates for parenteral nutrition must
energy substrate mixture, primarily the dextrose (5
be carefully evaluated, and steps must be taken to provide
mOsm/g), amino acid (10 mOsm/g), and electrolyte (1
the most effective dose, content, monitoring process, and
mOsm/mEq) content.
supplemental additives.
 Formulas for peripheral vein administration usually require
more fluid and a higher content of fat as an energy source
INDICATIONS
than formulas for central access, as lipids are isotonic.
 Midline catheters can be used to improve peripheral vein
 Parenteral nutrition is indicated for patients who are tolerance to the nutrition infusion because these catheters
unable to receive adequate nutrients via the enteral route can access larger veins where the blood flow may dilute
(e.g., patients who have a nonfunctional or severely the parenteral feeding formulations to a more tolerable
compromised gastrointestinal tract). concentration.
 Fluid-restricted, energy-dense formulations should be
The indications for parenteral nutrition include: considered for patients with acute respiratory failure.

 malnutrition when enteral nutrition is not feasible

 major surgical procedures

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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday

Nutrient Sources and Indications • Protein requirements for the critically ill patient are at
least 1.5 g/kg per day
Energy requirements: Mildly permissive underfeeding should • The protein requirements of critically ill patients who are
be considered, at least initially, for all adult critically ill intensive not obese (BMI <30 kg/m2) are 1.2 to 2.0 g/kg actual
care unit (ICU) patients receiving parenteral nutrition. body weight per day
• Protein sparing does not typically improve with
Carbohydrate sources: The most commonly used source protein intakes greater than 1.5 g/kg per day, except in
of carbohydrate is dextrose. Dextrose in its monohydrate severely burned patients.
form provides 3.4 kcal/g. Commercial dextrose solutions are • The ASPEN guidelines for critical care ICU adult
available in concentrations ranging from 2.5% to 70%. These patients recommend a daily protein intake of more than
solutions are acidic, with a pH ranging from 3.5 to 6.5. 2.0 g/kg ideal body weight for class I and II obese
Carbohydrate requirements: The minimum requirements for patients (BMI, 30 to 40 kg/m2) and more than 2.5 g/kg
dextrose are 1 mg/kg per minute (approximately 100 g/day for ideal body weight for class III obese patients (BMI >40
a 70-kg person). The maximum amount of carbohydrate kg/m2) (6).
tolerated is approximately 5 to 7 mg/kg per minute. • For all patients, a 24-hour urine collection for urinary
urea nitrogen may be collected and used to
Hyperglycemia, which is caused by various factors including subsequently adjust the prescription for protein delivery.
stress, is the most common complication of parenteral nutrition.
For patients with hyperglycemia, the parenteral nutrition Lipid sources: Isotonic lipid emulsions provide energy and
dextrose should be started conservatively and gradually essential fatty acids. Lipid sources are derived from soybean
increased to the patient’s individualized goal rate. oil or a 50:50 mixture of soybean and safflower oils.

Protein sources: Crystalline amino acids, which provide 4 Lipid requirements: When a patient is medically stable, lipids
kcal/g, are the most common source of protein in parenteral provide an important source of essential fatty acids.
formulas. Standard or balanced amino acid products are • 2% to 4% of daily energy needs should be supplied as
mixtures of essential and nonessential amino acids ranging in linoleic acid (1% to 2% of linoleic acid and 0.25% to
concentrations from 3% to 20%, although 8.5% and 10% are 0.5% of alpha-linolenic acid) or 25 to 100 mg/kg of
most frequently used for parenteral nutrition compounding. essential fatty acids.
Most commercially available amino acid formulations also • A minimum of 500 mL of 10% lipid stock solution or 250
contain electrolytes, buffers, or both. Modified or special amino mL of 20% stock solution administered over 8 to 10
acid products have been formulated for certain disease states hours, two to three times per week, is sufficient to
and conditions in which conventional amino acid solutions may prevent a deficiency of essential fatty acids.
not be well tolerated (eg, renal failure and hepatic failure) • 500 mL of a 20% fat emulsion can be given once a
week.
ASPEN guidelines for nutrition support are the basis for • Four hours after lipid infusion, acceptable serum
the following discussion of specialized amino acid triglycerides levels are less than 250 mg/dL for
formulas: piggybacked lipids and less than 400 mg/dL for
continuous lipid infusion
 Formulations for liver disease: Standard formulations • Infusion rates of greater than 110 mg/kg per hour may
should be used in ICU patients with acute and chronic liver result in reduced lipid clearance and impaired
disease. Protein restriction should be avoided in reticuloendothelial function and pulmonary exchange.
patients with liver failure • It is recommended that fat intake be restricted to less
 Formulations for renal disease: Essential amino acids than 25% to 30% of total energy, or 1 g/kg per day, and
are the primary protein source in formulations designed for provided slowly over 8 to 10 hours if administered as an
patients with renal disease. This formula design is based intravenous supplement.
on the theory that nonessential amino acids can be • No more than 2.5 g/kg per 24 hours should be provided
physiologically recycled from urea, while the essential to adult patients
amino acids must be provided by the diet
 Concentrated amino acid formulations: Highly Parenteral Intravenous Vitamins and Requirements
concentrated (15% to 20%) amino acid formulations are
available for use when fluid restriction is required. These  The required amounts of ascorbic acid, thiamin,
formulations are similar in composition to standard amino pyridoxine, and folic acid were increased, and a
acid formulas, except that they may contain larger requirement for vitamin K was added
amounts of acetate  With the addition of vitamin K to these formulations, the
 Pediatric formulations: Pediatric formulas have been prothrombin time and international normalized ratio of
designed to meet the unique amino acid requirements of patients who receive anticoagulant therapy should be
neonates, infants, and children in order to promote weight closely monitored, and anticoagulant medication should
gain, nitrogen balance, and growth and to avoid an excess be adjusted as needed
of certain amino acids (eg, phenylalanine and methionine)  One formula without vitamin K is available for patients
 Glutamine: Glutamine is a conditionally essential amino whose prothrombin time or international normalized ratio
acid during times of metabolic stress. levels are difficult to manage
 Weekly intravenous supply of 250 to 500 mcg
Protein requirements: Protein requirements should be based phylloquinone is adequate to preserve coagulation in PN
on the patient’s individual needs and disease process. patients.

FDA Requirements for Parenteral Multivitamin Products

• During a critical illness, protein requirements can double
increasing to approximately 15% to 20% of total energy.

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NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
Vitamin Amount
Thiamin (B1) 6 mg  The serum phosphate levels of critically ill patients should
Riboflavin (B2) 3.6 mg be monitored closely, and phosphate should be provided
Pyridoxine (B3) 6 mg when needed due to its essential role in optimal
pulmonary function
Cyanocobalamin (B12) 5 mcg
 Electrolytes are available in salt forms, including sodium
Niacin 40 mg
and potassium as chloride acetate or phosphate; calcium
Folic acid 600 mcg as chloride, gluconate, or gluceptate; and magnesium as
Pantothenic acid 15 mg sulfate or chloride. Calcium gluconate and magnesium
Biotin 60 mcg sulfate are the preferred forms of these cations because
Ascorbic acid 200 mg they produce fewer physiochemical incompatibilities
Vitamin A (retinol) 1 mg Acetate and chloride do not have specific ranges for
Vitamin D 5 mcg intake; rather, they are adjusted as needed to maintain the
Vitamin E 10 mg acid-base balance
Vitamin K 150 mcg
Daily Electrolyte Requirements
Parenteral Intravenous Trace Minerals and Requirements
Electrolyte Requirement
 The ASPEN recommendations for daily parenteral intake Sodium and potassium 1-2 mEq/kg + replacement
of the trace elements zinc, copper, chromium, and losses
manganese were updated in 2004 (Table B-5) and Calcium 10-15 mEq
remains the most current. Magnesium 8-20 mEq
 addition of selenium supplementation (20 to 60 mcg/day). Phosphate 20-40 mmol
 Trace minerals are available as single-entity and
combination products in various concentrations for adults,
Total Nutrient Admixture Parenteral Solutions
children, and neonates; products with a combination of
trace minerals and electrolytes are also available.
 Total nutrient admixture parenteral solutions, also known
 Other elements that may be supplemented on an
as three-in-one or all-in-one solutions, are composed of
individualized basis include molybdenum, iodine, and iron.
amino acids, dextrose, lipids, vitamins, trace
 Iron supplementation is generally not required for short-
elements, and electrolytes in one container.
term parenteral nutrition, unless the patient is anemic.
Oral iron supplementation is the preferred route.
Stability and Compatibility
Daily Parenteral Trace Element Supplementation for
Adults (Dose per Day)  The concentrations of calcium and phosphate ions are
directly related to the risk of precipitation, which can result
in serious injury and death.
Trace Element 2004 ASPEN Gastrointestinal
 As the concentration of either micronutrient rises, the
Recommendation Losses
likelihood of precipitation increases.
Zinca 2.5-5.0 mga Addb  The salt form of calcium added to the PN formulation can
Copper 0.3-0.5 mg 500 mcg/d have a dramatic impact on the risk of precipitation
Chromium 10-15 mcg 20 mcgc
Manganese 60-100 mcg —  Calcium gluconate and calcium gluceptate are generally
Selenium 20-60 mcg — less dissociated salt forms of calcium than the chloride
• a Add 2 mg/day for hypermetabolic patients for a total of 6 salts
to 12 mg/day.  The amount of free calcium available to form insoluble
• b Add 12 mg/L of small bowel losses, and add 17 mcg/kg complexes with phosphate is reduced
of stool or ileostomy losses.

Parenteral Electrolytes and Requirements

 Therapeutic amounts of electrolytes are added to

parenteral formulations depending on the patient’s
requirements
Monitoring Hospitalized Patients Receiving CPN

Metabolic or Clinical Parameter Monitoring Frequency

Blood glucose Every 6 hours until stable; 100 to 150 mg/dL in critically ill
patients (6,16,20,44) and 140 to 180 mg/dL in critically ill
diabetic patients (19)
Electrolytes (Na, K, Cl), CO2, blood urea nitrogen, creatinine,
Baseline, daily until stable, then two or three times per week
Mg, Caa, phosphorus
Total bilirubin, liver function tests (alanine aminotransferase,
Baseline, daily until stable, then weekly
aspartate aminotransferase, and alkaline phosphatase)
Complete blood cell count with differential Baseline, then weekly
Prothrombin time/partial thromboplastin time Baseline, then weekly
Albuminb Baseline, then as needed (>21 days)
Prealbuminb Baseline, then weekly

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 NUTRITION THERAPY I
LJ Shaine T. Villan, RND | Tuesday
Transferrinb Baseline, then weekly
Nitrogen balance As needed
Weight Daily until stable, then two or three times per week
Vital signs (temperature, pulse, blood pressure, respiratory
Every 8 hours as needed
rate)

• a Half of total calcium (Ca) is protein bound; therefore, during hypoalbuminemia, the true calcium status may not be represented
by measuring serum calcium levels. There is a 0.8 mg/dL decrease in the total concentration of serum calcium for each 1.0 mg/dL
decrease in the albumin concentration below 4.0 g/dL. Correct serum calcium can be estimated by the following formula: Ca++
(mg/dL) = Measured Ca++ (mg/dL) + 0.8 [4.0 – Albumin (g/dL)]. However, this formula provides only an estimate and a review of
the evidence suggests this formula may actually overestimate the corrected calcium concentration in critically ill patients (45).
When an accurate evaluation is needed, the ionized calcium level should be obtained.
• b The levels of acute phase hepatic proteins (albumin, prealbumin, and transferrin) can decrease by as much as 25% as a result

of acute or chronic inflammatory conditions and are no longer reliable indicators in critically ill patients. This decrease impacts
their usability in determining nutrition repletion. If inflammatory markers (eg, C-reactive protein) indicate an inflammatory
metabolism, these proteins may not be reliable indicators of nutritional status. Acute phase hepatic proteins may only be reliable
when malnutrition is not complicated by inflammatory metabolism caused by acute or chronic disease.

See Section III: Clinical Nutrition Management, Parenteral Nutrition: Metabolic Complications of Central Parenteral Nutrition
and Calculating Total Parenteral Nutrition.

TRANSITIONAL FEEDING  When the patient is transitioned from parenteral support to

enteral support, the tube feeding can be initiated at full
CYCLIC CPN: strength (10 to 30 mL/hour).
 As the rate of tube feeding is increased, the rate of parenteral
 The infusion of CPN over a limited amount of time (usually 12 nutrition is proportionately decreased.
to 18 hours) is called cyclic CPN.  Tapering of parenteral formula can begin when enteral tube
 Cyclic CPN is indicated for patients who are metabolically feedings are providing 33% to 50% of nutrient requirements.
stable and for patients who require long-term CPN, such as Once enteral tube feedings are well tolerated and provide
patients who receive CPN at home. more than 60% of energy requirements and 100% of fluid
requirements, parenteral nutrition can be discontinued
ADVANTAGE OF CYCLIC CPN
PARENTERAL TO ORAL:
 feedings more closely resemble physiologic (discontinuous)
feedings, which may reduce the hepatic toxicity associated  When patients are transitioned from parenteral support to an
with continuous feedings. oral diet, oral intake is started as clear liquids and then
 improved quality of life, because the patient is free from CPN progressed in a stepwise fashion to an appropriate diet as
equipment during the day. tolerated.
 Nutrient intake studies should document the adequacy of oral
 Transition to cyclic is best done over 2 to 4 days by reducing intake.
the infusion time in increments of 4 to 6 hours.  The total parental nutrition should be tapered to half of the
 Cyclic TPN should be tapered up 1 to 2 hours (for patients original rate when the patient is eating 50% of the total
with DM or hyperglycemia) to decrease hyperglycemia and estimated energy needs.
hypoglycemia.  The CPN should be discontinued when oral intake
consistently meets 60% of estimated nutrient needs and 100%
PARENTERAL TO ENTERAL: of fluid needs.
 If oral intake does not progress to adequate amounts, enteral
nutrition should be considered in lieu of PPN or CPN.

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