Flashcards in Nutritional Issues in the Hospital Deck (14):
When does nutritional depletion occur?
- This is when you ought to be moving towards feeding
- Normal, not sick = 10-14 days
- Normal and pretty sick or nutritionally depleted and not sick = 5-7 days (oxidizing more)
- Nutritionally depleted and sick = 3-5 days
- Need to assess pre-morbid nutritional state
- Hx of alcoholism, homelessness, unusual diet, elderly, disabled
- Chronic medical problems: GI, pulm, renal, cancer
- Prior weight loss before or in hospital
- Weight for height BMI
How much to feed?
- Energy intake = expenditure
- Harris benedict equation
- Indirect calorimetry
- Swan Ganz AV O2 balance using the fick principle
- Sick-o-meter: 25-35 kcal/kg/day, the sicker the person, the greater the energy requirement. The bigger the person the greater the energy requirement
What route to feed?
- Enteral: feed the GI tract and body; may improve gut barrier function
- Parenteral: requires central IV catheter (risk of placement, bleeding, infection) give AA, glucose and lipid emulsion IV.
What to feed?
- Ask nurse or dietician for a copy of the hospital's enteral feeding formulary.
- 1 kcalml
- 44g protein /l
- 152 g/l carb
- 37 g/l fat
- vitamins, micronutrients
- 1.321 l to get "RDA" for a 70 kg person
Initiating tube feedings
- place N/G tube
- start tube feeding slowly (10-20 ml/hr) and check residuals after 5-10 hrs
- Gradually increase flow rate and continue to check residuals. If the residual >100 ml reduce the flow rate
- If residauls persist, have patient repositioned, elevate head of bed, right lateral decubitus position
How do we determine the adequacy of what we are feeding?
- check and record total calories per day
- overfeeding causes hyperglycemia; may take 1-2 days to show up because glycogen pool buffers; may take 1-2 days to resolve because glycogen pool needs to deplete
- nitrogen balance = 1 wk after you get your target infusion
UUN (urine urea nitrogen)
If BUN is stable, then most of the UUN represents the oxidation of the protein
- usual protein requirement is 0.5-0.8 g/day
- higher requirements in burns and post-op patients
g protein out = (2g skin + 2g stool + 24 hr UUN) x 6.25 (corrects grams of nitrogen to grams of protein)
Water soluble vitamins vs. Fat soluble vitamins
Water soluble pool
-Zn deficiency - diarrhea
-Fe deficiency - anemia, immune dysfunction
-Chromium deficiency - insulin resistance
-Selenium deficiency - CHF (Keshan's Disease)
- not very stable in enteral formulations "conditionally essential"
- precursor for NO
- direct immunomodulatory measured by response to mitogens
- Supplementation improves nitrogen balance
- Stimulates GH and insulin secretion
- Preferred nutrient for gut epithelium
- "conditionally essential" as requirements increase with serious illness
- Supplementation increases immune function, gut histology, and barrier function
- Important gluconeogenic precursor so supplementation improves nitrogen balance
- very little omega 3 FA in standard "house formulas"
- LC polyunsaturated fats are precursors for leukotrienes and PGs