10 - Special Populations, Nutrition Flashcards
(35 cards)
Parenteral Nutrition
for Special Populations - DIABETES
- *< 150 gm Glucose_ = _1.5 mg/kg/min**
- HALF of normal 3*
- *Insulin in TPN** or seperate infusion
- *10-50% of insulin ADHERES TO BAG** –> need to adjust
- *START with 2/3 of previous needs**
LA SQ Insulin Glargine
Monitor BG >q6hr
provide correction bolus w/ SA insulin PRN
ENTERAL Nutrition
for Special Populations - DIABETES
Select formula that limits carbs to:
<50% of total Calories
HIGH FIBER formulations –> less BG elevation
CONTINUOUS DELIVERY
of enteral feedings vs bolus feedings
Start w/ 25% of estimated needs
& monitor BG q6 hours
Advaance q1-2 days as tolerated
Goal of Nutritional Support
for Special Populations - RENAL DISEASE
Provide adequate PROTEIN
without causing azotemia / uremia
Insulin lasts LONGER in renal pts –> GLUCOSE monitoring
Correct & Maintain:
Normal Fluid / Electrolyte / A-B balance
Macro & Micro - nutrient requirements vary with:
TYPE of renal disease (AKI / CKD)
TYPE of renal replacement therapy:
Hemodialysis / peritoneal dialysis / CVVHD
Glucose Considerations
HYPERGlycemia
for Special Populations - RENAL DISEASE
HYPERGlycemia
Peripheral Insulin RESISTANCE
in AKI –> INCREASED levels of glucagon / GH / catecholamines
Initiate glucose at LOWER AMOUNT
titrate up slowly
Treatment similar to DIABETES patients
Glucose Considerations
HypoGlycemia
for Special Populations - RENAL DISEASE
HypoGlycemia
decreased Glucagon Reserve
decrease in insulin renal elimination
- *CAPD** = continuous dextrose dialysis
- may result in* loss of carbs due to absorption in dialysis fluid
Protein Considerations
for Special Populations - RENAL DISEASE
AZOTEMIA occurs without renal replacement
IF - standard protein amounts are provided
Goal is to MAINTAIN a POSITIVE nitrogen Balance
GI Bleeding / overfeeding of protein –> BUN elevations
AKI is associated w/ marked protein catabolism / urea accumulation
HEMODIALYSIS
loss of 6-8 g protein per treatment
CVVHD
loss of 10-12g per 24 hours
Protein Requirements
for NON-DIALYZED
for Special Populations - RENAL DISEASE
0.6 - 1.0 g/kg/d
Use
Actual Body Weight
unless OBESE –> use IBW
Protein Requirements
for Intermittent Hemodialysis / CAPD
for Special Populations - RENAL DISEASE
1.2 - 1.4 g/kg/d
Use
Actual Body Weight
unless OBESE –> use IBW
Protein Requirements
for Continuous Renal Replacement Therapy = CRRT
for Special Populations - RENAL DISEASE
1.8 - 2.5 g/kg/d
Use
Actual Body Weight
unless OBESE –> use IBW
Protein Source
for Special Populations - RENAL DISEASE
A mixture of:
Essential AAs + Non-Essential AAs
recommended for pts w/ renal failure
TRAVISOL = standard
Renal specialty formulas are available
but NO BENEFIT over standard
Aminosyn RF // NephrAmine
Fat Considerations
for Special Populations - RENAL DISEASE
PRO = Volume Sparing
OUTWEIGHS ANY CONS
Fat is 9cal/gram –> less volume for more energy
Cons
Need to closely monitor:
TG’s**&**PHOS levels
500 mL IVLE –> 7.4 mM phos
1/2 of AKI pts have decreased hepatic lipoprotein lipase –> Elevated TG’s
Water Considerations
for Special Populations - RENAL DISEASE
AKI - Oliguric Renal Failure
Restrict to 1500mL/day of water
AKI - non-aliguric renal failure
depends on urine output
CKD - dilutional HypoNatremia
Restrict to 1500 mL/day of water
Sodium Considerations
for Special Populations - RENAL DISEASE
AKI - Oliguric Renal Failure
- LESS* sodium, start @
- *0.5 mEq/kg/d**
- AKI - non-aliguric renal failure*
- may have increased sodium loss*
CKD - dilutional HypoNatremia
start at lower end of standard amount
1 mEq/kg/d
OTHER Electrolyte Considerations
for Special Populations - RENAL DISEASE
- *Potassium & Magnesium**
- DO NOT SUPPLEMENT UNTIL STABLE*
- decreased excretion in BOTH AKI / CKD*
- *Phosphate**
- *usually NOT required**, not excreted in AKI or CKD
Acid - Base
MAXIMIZE ACETATE in TPN solutions
CKD frequently have metabolic ACIDOSIS
Vitamin Considerations
for Special Populations - RENAL DISEASE
NORMAL DOSE
in AKI & CKD +/- renal replacement
Might need some Additional Supplementation if needed:
CKD has some DECREASED Vitamin D activation
Folic Acid / Pyridoxine / Vit C
most commonly REMOVED during dialysis
Trace Element Considerations
for Special Populations - RENAL DISEASE
SELENIUM
eliminated in urine
- DECREASE* Dose to 1/2 for MOST renal Patients
- *30mcg**
- EXCEPT FOR*
- *CRRT** - use standard dose = 60mcg
Goals of Nutritional Support
for Special Populations - HEPATIC DISEASE
Provide Adequate PROTEIN w/o causing or worsening:
Complications of Cirrhosis
HE(hepatic encephalopathy) =High protein
Ascites = High Protein + Fluids
Over come impaired abs & digestion of nutrients
Improve immune response –> minimize infectious disease related complications of cirrhosis
Support pt until xplant
Glucose Considerations
for Special Populations - HEPATIC DISEASE
Glucose infusions typically cause HYPERglycemia
in pts w/ hepatic disease
–> initiate glucose as described in DIABETIC PATIENTS
- *Glucagon + Insulin** metabolized by liver
- *elevation in both** seen in cirrhosis
Cirrhotic patients –> MAY develop peripheral Insulin resistance
Protein Considerations
for Special Populations - HEPATIC DISEASE
- *Protein INTOLERANCE common**
- *AAA –> encephalopathy**
- *BCAA** –> catabolized for energy in peripheral muscle
- *BCAA specialy formula** = 35% vs 16%
- *MAY HAVE BENEFIT** in patients with HE
Protein Requirements for
Compensated Cirrhosis w/ no symptoms of encephalopathy
for Special Populations - HEPATIC DISEASE
1 - 1.2 g/kg/day
Use
Actual Body Weight
unless OBESE –> use IBW
Protein Requirements for
Mild = Grade 1-2 Encephalopathy
for Special Populations - HEPATIC DISEASE
0.5 g/kg/day
start there, slowly advance to target
Use
Actual Body Weight
unless OBESE –> use IBW
Protein Requirements for
SEVERE = Grade 3-4 Encephalopathy // Significant Ascites
for Special Populations - HEPATIC DISEASE
<0.5 g/kg/day
(20 grams)
Start there –> slowly advance to target
Use
Actual Body Weight
unless OBESE –> use IBW
Fat Considerations
for Special Populations - HEPATIC DISEASE
- *ESLD** associated w/
- *Lipid Intolerance & HYPER-TG’s**
Monitor TG’s frequently
- Oral fat intake** should be *_decreased_ in patients with
- *streatorrhea** = fatty stools / diarrhea
Water & Sodium Considerations
for Special Populations - HEPATIC DISEASE
Restrictions required due to
EDEMA & ASCITES
Water
HYPERvolemic HypoTonic HypoNateremia
restrict to 1500 mL/day
Sodium Restriction
Ideally no more than <90 mEq/day
start @ 0.5 - 1.0 mEq/kg/day
