Professional Documents
Culture Documents
Nutrition Handbook
Contributors:
Ana Abad-Jorge, MS, RD, CNSD
Le Banh, MS, RD, CNSD
Cathleen Cumming, MS, RD, CNSD
Chitra Dadlani, RD
Pallavi Dharamsi, RD
Stacey Evans, RD
Lynda Fanning, MPH, RD
Theresa Fessler, MS, RD, CNSC
Tamara Karosanidze, MS, RD, CNSC
Joseph Krenitsky, MS, RD
Stacey McCray, RD
Carol Parrish, RD, MS
Kelly ODonnell, MS, RD, CNSC
Wendy Phillips, MS, RD, CNSD
Kate Robertson, RD, CNSD
Sherrie Walker, RD, CNSD
Kate Willcutts, MS, RD, CNSC
Andrea Yoder, RD, CNSD
II
III
IV
SECTION 2.
SECTION 3.
Develop and implement a nutrition care plan tailored to the individual patients needs.
Follow-up with revision of care plan as needed to improve nutritional status, as well as
nutrition counseling as needed.
Each patient unit has designated dietitians who can be contacted via EPIC, the Simon Paging
System, or by calling the Nutrition Services Office at 4-2286. The clinical dietitians are available
weekdays between 8:00 a.m. - 5:00 p.m. On weekends, a clinical dietitian is on site on Saturdays
for oral diet/education issues and a nutrition support dietitian is on site on Sundays.
Nutrition Support Teams: Medicine/Surgery: There are two nutrition support teams for adult
patients at UVA HS.
1.
Section 1.
INTRODUCTION
Nutritional assessment is evaluating nutritional status and determining the presence of, or
risk of developing malnutrition. Nutritional assessment does not stop with the first
evaluation, but is an ongoing process to monitor the adequacy and effectiveness of
nutritional support measures. The four basic components of nutritional assessment
include (1):
1.
2.
3.
4.
I.
Anthropometrics
Clinical Information
Nutrition Intake History
Biochemical Data
ANTHROPOMETRICS
The most common anthropometrics used in the hospital setting are weight (wt), height (ht)
and weight/height (wt/ht) and their comparisons to standard values (2).
A.
Estimating ideal body weight (IBW) or desirable wt/ht (Hamwi Method) (3):
Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%)
Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)
B.
Height/Weight:
Body weight is used in nutrition assessment as an overall indicator of body fat and somatic
protein stores. Body weight is compared with usual body weight (UBW) and with IBW as
determined by the Hamwi method. It is important to use clinical judgment and avoid using
a weight that is based on a fluid overloaded state when calculating nutritional needs. In
these cases, the patients euvolemic or estimated euvolemic weight should be used.
1.
Weight:
Weight is used to assess a patients degree of malnutrition including evaluation of
current weight as a percentage of IBW, current weight as percentage of usual
weight and recent weight change. The following formulas were devised by
Blackburn et al (4). Clinical judgment must also be used to consider frame size and
muscle mass and to adjust for any edema or excess fluid present.
A.
B.
The American Dietetic Association (ADA) and the American Society for Enteral and
Parenteral Nutrition (ASPEN) recommend basing caloric intake on actual body weight
rather than adjusted body weight and using a reduced calorie per kg level (38, 39).
However, clinicians at UVA have agreed to continue using AdjBW to determine energy
needs. The research for justification either way is limited, and the only research that
focused on patient outcomes used an adjusted body weight assuming 25% of the excess
weight was metabolically active (5). Therefore, for patients who are overweight at >130%
of their IBW, the nutritional requirements for calories should be based on an adjusted body
weight rather than their IBW or actual body weight. AdjBW can be calculated as follows
(5):
If patient is 130% or greater AdjBW = (Actual Wt IBW) 0.25 + IBW
3.
The Body Mass Index or the Quetlet Index accounts for differences in body composition by
defining the level of adiposity according to the relationship of weight to height and
eliminates dependence on frame size (6, 7). However, it does not account for muscle
mass.
BMI = wt (in kilograms)/ ht (in meters)2 or wt (in pounds)/ ht (in inches)2 705
Table 1.1 Risk of Associated Disease According to BMI and Waist Size
Waist less than
Waist greater
BMI*
Category
or equal to
than
40 in. (men) or
40 in. (men) or
35 in. (women)
35 in. (women)
< 18.5
Underweight
--N/A
18.5 24.9
Normal
--N/A
25.0 29.9
Overweight
Increased
High
30.0 34.9
Obesity Class I
High
Very High
35.0 39.9
Obesity Class II
Very High
Very High
40 or greater
Obesity Class III
Extremely High
Extremely High
*These values may underestimate the degree of malnutrition in some patients. An overweight or obese patient may be
malnourished if significant weight loss has occurred, but not fall into the category of malnutrition based on BMI alone.
Adapted from: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm. Accessed 3/3/11.
4.
If a patient has loss of a body part or parts, IBW should be adjusted to reflect
amputation. Percentages for adjustments in body weight (2):
% Total Body Weighta
1.8
6
15
18.5
1
3
5
6.5
Type of Amputation
Foot
Below Knee Amputation
Above Knee Amputation
Entire Lower Extremity
Hand
Below Elbow
Above Elbow
Entire Upper Extremity
a
Double if bilateral
5.
~
~
~
3 kg
7-8 kg
14-15 kg
II.
CLINICAL INFORMATION
Clinical variables can potentially influence all parameters of protein and calorie
status. Clinical information is derived from a variety of sources, some of which include:
Medical record
Physician and other health care professionals
Patient or patient family interviews
General observations of the patients physical appearance
Evaluation of psychosocial background
This combined data provides further information for the nutrition assessment.
Some physical signs of nutritional deficiency are summarized in Table 1.2
Vitamin A
Vitamin C or K
Vitamin A, Vitamin C, Essential Fatty Acid
Pellagrous dermatosis
Flaky Paint dermatosis
Niacin, Tryptophan
Protein
Hair
Eyes
Anemia
Vitamin A
Riboflavin and Niacin
Mouth
General
Appearance
Neurologic
Vitamin A
Magenta tongue,
Tastebuds atrophied
Riboflavin
Glossitis
Bleeding gums
Vitamin C
Cheilosis
Riboflavin, Pyridoxine
Angular stomatitis
Edema
Protein
Muscle wasting
Decreased subcutaneous fat
Protein-Calorie
Malnutrition
Disorientation
Thiamin, Niacin
III.
24 hour recall
3 day food record
Food habits
IV.
(3)
Problems with chewing, swallowing, motor skills or mobility alert the dietitian
to investigate potential nutrient inadequacies. Nutritional intake (calorie
count or 24 hr recall) data may help the dietitian assess the need for nutrition
support, education, etc.
(4)
BIOCHEMICAL DATA:
Table 1.3 summarizes selected lab values/tests that are most often used for
nutritional assessment of the adult patient at UVA. Although these lab values are helpful in
the assessment of nutritional status, they should be used in combination with other clinical
data, and no one value should be considered as a predictor of nutritional status.
TOTAL URINARY
NITROGEN ( TUN)*
Measures the net
changes in the bodys
total protein mass**
Interpretation of Values
Potential causes
for high values
Calculation of N2 balance**:
24 hr. protein intake TUN (gm) + 2 gm]
6.25
Growth
Pregnancy
Recovery from illness
Athletic training
+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to 1: Net catabolism
__________________________________________________________________________________________________________________
URINARY UREA
NITROGEN (UUN)*
Measures the net
changes in the bodys
total protein mass
Calculation of N2 balance**:
24 hr. protein intake UUN (gm) + 4 gm]
6.25
Growth
Pregnancy
Recovery from illness
Athletic training
+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to 1: Net catabolism
*Both TUN and UUN are used at UVA, however, TUN is preferred. When UUN is used to estimate nitrogen balance, it does not take into account 2 g for the dermal
and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine). TUN measures all the protein in the urine,
so a factor of 2 grams can be used instead of 4. The above equation may not be appropriate in certain circumstances. For example, the unmeasured nitrogen
losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.
**Note: Do not do a Nitrogen Balance Study if unable to collect the full amount of urine, if the patient is anuric due to renal failure, or if the
nutrition provision has changed in the past 2-3 days.
Hepatic Proteins
Albumin, Prealbumin and Transferrin are not listed in the previous section as research
has shown that these hepatic proteins are not reliable indicators of nutritional status and are
negative acute phase reactants. Synthesis is impaired due to alterations in protein metabolism
that occurs during metabolic stress. Albumin, prealbumin, and transferrin should not be used as
indicators of nutritional status in hospitalized patients due to the effects of stress and
inflammation on these parameters (12).
REFEEDING SYNDROME:
Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and
mortality in the malnourished patient (13). Complications resulting from refeeding syndrome
include electrolyte abnormalities (low serum values of potassium, phosphorus, magnesium),
glucose and fluid shifts, cardiac dysfunction, and impaired release of oxygen from oxyhemoglobin. The degree of symptoms exhibited depends upon the extent of malnutrition,
electrolyte supplementation prior to nutrition support initiation, and calorie and fluid load initiated
(14, 15).
Table 1.4 Patients at Risk for Refeeding Syndrome (16-19)
Anorexia nervosa
Chronic alcoholism
Oncology patients
Post-operative patients
Residents admitted from skilled nursing facilities or nursing homes
Depression in the elderly
Uncontrolled diabetes mellitus (diabetic ketoacidosis)
Chronic malnutrition:
Marasmus
Kwashiorkor
Prolonged hypocaloric feeding
Morbid obesity with profound weight loss
Prolonged fasting (including patients with non-nutritional IV fluids)
High-stress patient not fed for >7 days
Hunger strikers
Victims of famine
Table 1.5 Summary Guidelines to Prevent Complications of the Refeeding Syndrome (20)
1) Anticipate patients at risk for refeeding syndrome.
2) Check baseline electrolytes before initiating nutrition support and replace
any low levels promptly however, do not withhold nutrition support until
serum levels are corrected, rather replete electrolytes concurrently with
the nutrition support provided.
3) Initiate nutrition support, including total calories and fluids, slowly this
does not mean that the enteral or parenteral nutrition has to progress
slowly to meet the refeeding level that has been predetermined.
Example: If a refeeding level of 20 kcal/kg is appropriate (which equates
to a continuous tube feeding rate of 45 ml/hour of a 1 kcal/ml product),
there is no need to also start enteral nutrition slower than this, as the
amount of refeeding calories the patient is to receive in 24 hours has
already been accounted for.
4) Consider additional sources of calories, such as dextrose in IV fluids,
glucose or lipid calories from medications, etc. and include these in total
calories.
5) Unless hemodynamically unstable, keep sodium-containing fluids to ~ 1
liter/day initially.
6) Monitor electrolytes daily for at least 3 days and replace any low levels as
needed. Be wary of the malnourished patient in renal failure with elevated
serum electrolytes secondary to decreased clearance, as they may be a
late refeeder.
7) Be prepared for accelerated refeeding and the need for aggressive
electrolyte replacement in the hyperglycemic patient while glucose control
is improved.
8) Routinely administer vitamins to malnourished patients, especially
thiamin; consider a loading dose prior to initiation of nutrition support.
9) Increase calories cautiously in a stepwise manner. Continue to monitor
electrolytes as calories are increased.
10) Outline a plan for nutrition advancement (especially if patient is to be
discharged) to prevent the patient from remaining on refeeding levels
longer than necessary, thereby delaying improvements in nutritional
status over time.
B.
C.
V.
Age
Activity level
Current nutritional status
Current metabolic and disease states
Individualized goals
The following section will provide a brief overview of the determination of nutritional
requirements including calories, protein and fluid for the hospitalized patient.
Calorie Requirements:
Estimating energy expenditure in hospitalized adult patients is challenging. If available,
indirect calorimetry can be used to measure energy expenditure using gas exchange (see
following section). Frequent measurements are required to appropriately identify a patients
energy expenditure (22). When indirect calorimetry is not possible, there are many possible
predictive equations (see ADAs Evidence Analysis Library at www.adaevidencelibrary.com)
(38). Most of these predictive equations are based on a single indirect calorimetry study per
patient. The high degree of variability of an acutely ill patients energy needs from day to day
limits the ability to make strong conclusions regarding the superiority of any prediction equation
over another. More importantly, whichever method (indirect calorimetry or predictive equation) is
used, the optimal energy provision for hospitalized patients has yet to be determined (22).
Significantly underfeeding or overfeeding is harmful; (23, 24) however, there is no evidence that
feeding a patient the calories they are burning based on indirect calorimetry (or based on any
predictive equation) will improve outcome. Acutely ill patients remain catabolic despite meeting
or exceeding full calorie expenditure (25, 26). In fact, there is evidence that feeding critically ill
patients 100% of predicted energy needs may be harmful (27). For a discussion regarding
permissive underfeeding of obese patients, please refer to the guidelines published in 2009 for
the provision and assessment of nutrition support therapy by ASPEN and the Society for Critical
Care Medicine (SCCM) (39).
At UVAHS, the calories per kilogram method is most often used to estimate a patients
caloric needs to simplify calculations:
TABLE 1.7 CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS
*See page 8-9
Patients at risk for refeeding* 15-20 kcal/kg
20-30 kcal/kg
Adults (18-65)
Elderly (65+)
25 kcal/kg
15-20 kcal/kg AdjWt
Obese or Super obese
*Calorie requirements may vary based on degree of stress and need for
repletion
Other factors:
Pregnancy: Add 300 kcal/day
Lactation: Add 500 kcal/day
11
Clinical judgment should be used to individualize each patients estimated needs, and
frequent monitoring and evaluation of nutrition interventions should occur to make adjustments
as needed based on patient response.
3.
TABLE 1.8
RESPIRATORY QUOTIENT INTERPRETATION
SUBSTRATE/MEASUREMENT CONDITION
R.Q.
_______________________________________________________________________
Lipogenesis (overfeeding)
Carbohydrate oxidation
Mixed substrate oxidation (appropriate feeding)
Protein oxidation
Fat oxidation (underfeeding)
Ketosis
1.001.20
1.00
0.85
0.82
0.71
0.670.70
1.5-2.0 g/kg
1.5 g / kg AdjWt 2.0 g/kg IBW
2.0 2.5 g/kg
0.8-1.3 g/kg *
12
4.
There are more than 30 predictive equations to estimate energy needs for burn
patients. At UVA, patients with >20% TBSA burn are provided kcals and protein based on the
guidelines below:
Energy Requirements = 30-35 kcal/kg
Protein requirements = 2.0-2.5g protein/kg
Note: once grafting has taken place, calorie and protein requirements will decrease
Additional Needs (35):
Vitamin C = 500 mg BID
Zinc Sulfate = 220 mg (limit to 2 3 weeks)
Beta Carotene = 25,000 IU x 5 days
Therapeutic Multivitamin/Mineral
IV selenium, copper and zinc - awaiting further research to determine
specific amounts.
FLUID REQUIREMENTS:
Fluid requirements will vary among patients and may increase or decrease from normal
needs under a number of conditions including the following:
TABLE 1.10 Potential Source of Fluid Excess or Loss in Hospitalized Patients (20)
Intake
Maintenance IV fluids
Medications given via IV drip
Water flushes given with crushed
medications
Water flushes to keep tubes
patent
Water contained in tube feedings
or PN
Output
Chest tubes
Percutaneous drains
Biliary /Pancreatic
Wound drainage
Ostomies/Stool/Urine
Naso/oro gastric tube suction
Excessive drooling/Sialorrhea
(cerebral palsy, Downs syndrome,
undetermined neuromuscular
disorders or those following a head
injury or stroke
Fistulas
Insensible losses
Increased insensible losses including:
Burns
Tracheostomies
Fever
Kinair beds
13
TABLE 1.11
ESTIMATING ADULT FLUID REQUIREMENTS
1.
By caloric intake (36):
1ml/calorie
2.
Fluid requirements
35 ml/kg/day
30 ml/kg/day
25 ml/kg/day
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition
2001;17:632-637.
Matz R. Precipitation of refeeding-associated electrolyte abnormalities with intravenous hydration.
[Letter to editor] Am J Med 1999;107:302.
Mallet M. Refeeding Syndrome. Age & Aging 2002;31:65-66.
University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR,
Krenitsky J, McCray S). University of Virginia Health System Nutrition Support Traineeship,
2003.
Detsky AS et al. What is the subjective global assessment on nutritional status? JPEN.
1987;11:8-13.
Reid CL. Poor agreement between continuous measurements. The use of energy expenditure
and routinely used prediction equations in intensive care unit patients. Clin Nutr. 2007;26(5):64957.
Talpers SS, Romberger DJ, Bunce SB and Pingleton SK. Nutritionally associated increased
carbon dioxide production. Excess total calories vs high proportion of carbohydrate calories.
Chest 1992;102(2):551-5.
Casper K, Matthews DE and Heymsfield SB. Overfeeding: cardiovascular and metabolic
response during continuous formula infusion in adult humans. Am J Clin Nutr 1990;52(4):602-9
Frankenfield DC, Smith JS and Cooney RN. Accelerated nitrogen loss after traumatic injury is not
attenuated by achievement of energy balance. JPEN J Parenter Enteral Nutr 1997;21(6):324-9.
Streat SJ, Beddoe AH and Hill GL. Aggressive nutritional support does not prevent protein loss
despite fat gain in septic intensive care patients. J Trauma 1987;27(3):262-6.
Krishnan JA, Parce PB, Martinez A, Diette GB, and Brower RG.
Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to
clinical outcomes. Chest. 2003;124: 297305.
Hester DD, Lawson K. Suggested guidelines for use by dietitians in the interpretation of indirect
calorimetry data. JADA. 1989;89:100-101.
French SN. Nutritional assessment via indirect calorimetry. Tech Notes. Medical Graphics
Corporation; 1987;1-12.
Harris JS, Benedict FG. A Biometric Study of Basal Metabolism in Man. Carnegie Institute of
Washington, 1919.
Long CL, Schaeffel N, Geiger JW, et al. Metabolic response to injury and illness: Estimation of
energy and protein needs from indirect calorimetry and nitrogen balance. JPEN. 1979;3:452.
Weinser RG et al. Handbook of Clinical Nutrition. St. Louis, MO:CV Mosby Co; 1989;130-179.
Herndon D, Tompkins R. Support of the Metabolic Response to Burn Injury. Lancet.
2004;363:1895-1902.
Lefton J. Specialized Nutrition Support for Adult Burn Patients. Support Line. 2003;25: 19-24.
Dickerson, R. Estimating energy and protein requirements of thermally injured patients: Art or
Science? Nutrition. 2002; 18:439-442.
Berger, MM, et al. Trace element supplementation after major burns modulates antioxidant status
and clinical course by way of increased tissue trace element concentrations. Am J Clin Nutr
2007;85:1293-1300.
Randall HT. Fluid electrolyte and acid base balance. Surg Clin North Amer. 1976;56:1019.
Water requirements in enteral support. Support Line. Dietitians in Nutrition Support: A Dietetic
Practice Group of the ADA; 1989;11.
American Dietetic Association Evidence Analysis Library. Available at
www.adaevidencelibrary.com. Updated 1/4/11. Accessed 3/3/11.
McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J
Parenter Enteral Nutr. 2009; 33: 277. Available at http://pen.sagepub.com/content/33/3.toc.
Accessed 3/3/11.
15
SECTION 2.
INTRODUCTION
The gastrointestinal tract (GI) is the most effective way to feed the patient. If the
patient has at least a partially functioning gut, but is unable to meet his nutritional needs via the
oral (po) route, then enteral nutrition therapy via tube feeding should be considered. Enteral
nutrition (EN) promotes the usual physiologic integrity of the GI tract, has less risk of harm (line
infections, sepsis) and is more economical than parenteral nutrition.
Table 2.1 Benefits of Enteral Nutrition (compared with Parenteral Nutrition) (1)
Stimulates immune barrier function
Physiologic presentation of nutrients
Maintains gut mucosa
Attenuates hypermetabolic response
Simplifies fluid/electrolyte management
More complete nutrition than parenteral nutrition
o iron, fiber, glutamine, phytochemicals, etc. are not provided.
Less infectious complications (and costs associated with these complications)
? Stimulates return of bowel function
Less expensive
TABLE 2.2
INDICATIONS FOR INITIATION OF ENTERAL NUTRITION (1)
Indication
Examples
Oral intake is contraindicated
Dysphagia, mechanical ventilation,
mandibular fractures, head & neck surgery,
neurological impairment, demyelinating
diseases such as amyotrophic lateral
sclerosis, muscular dystrophy, etc.
Inability to meet markedly increased
Burns, trauma, radiation therapy,
nutritional needs with oral intake
chemotherapy, sepsis/infection, closed head
injury
Inability to meet basic nutritional needs with Anorexia, cancer, head and neck tumors
oral intake alone
Need to bypass part of the GI tract to allow
enteral nutrition
16
TABLE 2.3
Type of Formula
Standard, high protein
(Promote, Promote with
Fiber*)
Calorie dense (Jevity 1.5*,
TwoCal HN*, Osmolite 1.5)
Elemental /Semi-Elemental
(Vivonex RTF, Perative*)
Low-Electrolyte/Volume
Restricted
(Nepro*)
Kcal/mL
Protein
1 kcal/mL
High, intact
1.5 or 2.0
kcal/mL
Moderate, intact
1 kcal/mL,
1.3 kcal/mL
Peptides and
Amino acids
1.8 kcal/mL
Low, intact
Special Considerations
Used most frequently at
UVAHS; high
protein:calorie ratio
Provides high amount of
calories when reduced
volume is desired
Low fat, Low cholesterol
Simple carbohydrate
Lowest K, Magnesium, P
formula, concentrated;
appropriate when fluid or
electrolyte restriction is
needed
*contains fiber
Note: All formulas are gluten-free, lactose-free and low sodium. These formulas are listed on the adult
enteral formulary at UVA as of 9/2008. Subject to change.
17
2.
b.
Intermittent feeding: Check prior to each feeding and if residuals are more
than 500 mL, hold tube feeding for 1 hour and contact house officer.
b.
Irrigate the feeding tube with at least 30 mL water before and after administering tube
feeds to ensure patency. Additional water to meet fluid needs is recommended on an
individual basis.
2.
3.
Following directions, select desired formula, method of delivery, strength and rate.
4.
5.
18
Nasoduodenal/
Nasojejunal
Hypercatabolism in presence of
at least partially functional GI
tract
Functional GI tract with a
proximal obstruction
Esophageal injury or
obstruction
Gastrostomy
Jejunostomy
*For patient comfort and to decrease the risk of sinusitis, nasal Salem sumps used for
feeding should be changed to a small-bore nasoenteric feeding tubes.
19
INTERMITTENT
Not recommended for postpyloric feeding tubes
NOCTURNAL
Long-term feeding for patients
who dont tolerate intermittent
feedings, who have a small
bowel feeding tube, or to
supplement daytime po intake
Allows daytime mobility
TUBE FEEDING PROGRESSION (See EPIC Orders for Enteral Tube Feeding)
Initiation:
Standard protocol for initiation of continuous feeds for non-surgical patients: Start full
strength formula at 50 ml/hour x 4 hours, advance by 15 ml/hour every 4 hours until goal
of _______ ml/hour is reached.
Standard protocol for initiation of bolus feeding: Give 125 ml x 1 feed, increase by 125
ml/feed until goal of ______ ml/feed is reached. Allow at least 3 hours between feedings.
Note: intermittent feeding is not for use with post-pyloric feeding tubes.
Residual Checks:
Do not check residuals with post-pyloric feeding tubes.
If not contraindicated, place patient on the right side before checking residuals.
If residuals > 500 ml, hold feeds for 1 hour then recheck. If <300 ml at recheck, then
restart feeds using initial rate and progress per orders. If continues > 500 ml, notify the
physician.
Notify physician if feedings held twice in 24 hours.
Return up to 250 ml gastric residuals to the patient.
20
Tube dislodgment
Gastroesophageal reflux
Nasopharyngeal
irritation/breakdown
Luminal obstruction
(clogged tube)
Aspiration of
formula
21
COMPLICATIONS
II.
POSSIBLE CAUSE
POSSIBLE MANAGEMENT
Gastrointestinal
Diarrhea
Medications (sorbitol
elixirs, antibiotics, Shohls
solution, magnesium-containing
antacids, laxatives, cathartic
agents, Lactulose)
C. difficile
Bacterial contamination
Improper administration
Fat malabsorption
Constipation
C. difficile toxin
Inactivity
Encourage ambulation if
possible
GI obstruction
Colonic dysmotility
Drug induced
Post op
Other
22
COMPLICATION
POSSIBLE CAUSE
Bloating
Vomiting/Nausea
Rapid formula
administration
Delayed gastric emptying
III.
POSSIBLE MANAGEMENT
Calorie dense formula
Prokinetic agent
Post pyloric tube
Initiate feedings at a lower
rate and gradually advance
Consider post pyloric tube
Monitor residuals
Verify correct tube
placement
Prescribe anti-emetics/
antinauseants, prokinetics
Post pyloric tube
Slower infusion
Prokinetic agent
Consider change to a
calorically dense formula to
decrease volume
Post pyloric tube
Metabolic
Hyperglycemia
Hypoglycemia
Dehydration or
Hypernatremia
Diabetes
Hypercatabolism
Stress/Trauma
Corticosteroids
Sepsis
23
COMPLICATION
Hyponatremia
Hyperkalemia
Hypokalemia
POSSIBLE CAUSE
Hyperphosphatemia
Hypophosphatemia
Fluid overload
Hypotonic formula
Excessive production of
antidiuretic hormone (SIADH)
Cerebral salt wasting
Poor perfusion (CHF)
Metabolic acidosis
Excessive potassium intake
Decreased excretion
Renal insufficiency
Potassium-sparing meds
Refeeding syndrome
Diuretics
Excessive losses
(i.e. from diarrhea or NG
drainage)
Insulin therapy
Volume overload
Metabolic alkalosis
Renal insufficiency
Refeeding syndrome
Insulin therapy
Phosphate binding antacids
Calcium carbonate
supplements
24
POSSIBLE MANAGEMENT
Phosphate binder
Reduce phosphorus intake
Monitor propofol infusion
for Phos-containing
meds (Fleet enemas contain
phos)
Monitor serum levels
Provide adequate
phosphorus and/or
supplement
Hyperglycemia
Lipogenesis
Fluid and fat gain rather than lean body mass gain
Fatty liver
Immunosuppression (with excessive lipid and linoleic acid intake)
Increased minute ventilation (VE)
Excessive CO2 production impairing pulmonary status/vent wean
Prolonged underfeeding may lead to loss of lean tissue, skin breakdown, inadequate
wound healing and immune dysfunction.
Use of Blue Dye (11)
In the past, blue dye or food coloring was sometimes added to tube feedings as an
indicator of aspiration. This practice has not been shown to be an effective method to monitor
for or prevent aspiration pneumonia. In addition, studies have shown that critically ill patients
may have increased gut permeability, making them susceptible to absorption of the dye into
systemic circulation. When absorbed, blue food dye can act as a mitochondrial toxin causing
unfavorable outcomes, up to and including death. Methylene blue can be used to help
diagnosis enterocutaneous fistulas or during bedside swallow evaluations.
DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS
Medications are often administered through enteral feeding tubes. Information
concerning drug-nutrient interactions during enteral feedings is limited, particularly regarding
bioavailability and absorption. Medications given by the enteral route (bypassing the usual
location of absorption) may cause what appears to be formula intolerance and/or result in less
than optimal drug absorption (12). General guidelines for administering medications with tube
feedings are as follows (Table 2.7):
25
2.
Flush the feeding tube with 20-30 ml of warm water or appropriate volume before and after
giving medication through the tube.
3.
If more than one medication is being given at the same time, give each medication separately
and flush the tube with 5 ml of warm water between medications.
4.
Use liquid preparation if possible (if patient does not have diarrhea).
5.
If a tablet form must be used, be sure it is finely crushed and dispersed in warm water.
6.
7.
8.
Consider tube site placement. Drugs that depend on gastric secretions for
breakdown/absorption may need to be substituted or given by an alternate method if tube
placement is in the duodenum or jejunum.
9.
Medications may be given via NG, OG, ND, PEG or J tubes. Do not give crushed medications
via small bore ( 12 French) NJ or J tube, if at all possible, to prevent clogging.
10.
Check with the pharmacist if in doubt about availability of medication in liquid form or whether
tablets may be crushed and administered via feeding tubes.
SECTION 3.
Parenteral nutrition (PN) support is used to nourish patients who either are
already malnourished or have the potential for developing malnutrition and who
are not candidates for enteral support (1). Parenteral nutrition provides
intravenous carbohydrates in the form of dextrose, protein in the form of amino
acids, lipids in the form of triglycerides, and vitamins, minerals, trace elements
and fluid.
PERIPHERAL PARENTERAL NUTRITION (PPN):
Peripheral Parenteral Nutrition is defined as supplementation via a peripheral
vein and is a temporary route for the administration of dilute nutrient solutions.
Sensitivity of peripheral veins to hypertonic solutions limits the caloric density of
formulations that may be used. Solutions with an osmolality of greater than 900
mOsm generally require central access (1, 2).
PPN is used only for a short time (up to 2 weeks) because (1):
The lack of peripheral venous sites that can withstand long-term high
osmolality infusion
May not meet patients calorie and protein needs
Indications:
PPN may be used in the following conditions:
Partial or total nutrition support for patients who are not able to ingest
adequate calories orally or enterally, and whose therapy is likely to be less
than 7 days.
When central-vein parenteral nutrition is not feasible or desirable.
Contraindications:
Because of the lower concentration of nutrients, PPN is not the optimal choice for
feeding patients with the following conditions:
Long-term Access:
Peripherally Inserted Central Catheter Line (PICC line), which is passed via
the antecubital vein, and advanced into the central venous system (5).
Long-term access may be obtained using a catheter that is tunneled into the
subclavian vein subcutaneously away from the insertion site.
Long term catheters that are tunneled under the skin, may reduce the
incidence of infection. Access ports may also be inserted under the skin.
Examples: Groshong, Hickman, Port a cath.
Placement of long term IV access may be surgical or non surgical
depending upon the type of catheter used. Implantable devices are inserted
surgically, whereas percutaneous catheters do not require surgical
intervention.
28
29
Requirements:
Minimum: 1 mg/kg/minute 1440 mg/kg/24hrs
Maximum: 5 mg/kg/minute 7200mg/kg/24hrs OR 7 g/kg/day OR 24
dextrose kcal/kg/day.
*Note: Per minute calculations are based on 24 hour infusions; not on
nocturnal or cyclic infusions, where infusion rates are generally higher.
Solutions:
Commercially prepared dextrose solutions are available in concentrations
ranging from 5% - 70% (D70W Used at UVA). Solutions with final
concentrations greater than 10% must be administered into a central vein
because of the high osmolarity.
Consequences of excess CHO administration:
Hyperglycemia
Glucosuria
Synthesis and storage of fat
Hepatic steatosis
Increased carbon dioxide production impairing pulmonary status/vent
wean
2. PROTEIN (1, 2, 7)
Requirements:
30
Crystalline amino acids are currently the protein source for commercial
formulas. Amino acids are available in concentrations of 3 15%. Amino
acid solutions of 3% and 3.5% (without added electrolytes) are nearly
isotonic, making them acceptable for peripheral administration. Standard
amino acid solutions are usually comprised of 40 50% essential amino
acids and 50 60% non-essential amino acids.
At UVA: 10% Travasol amino acid solution is used and is customized
according to the protein needs of patients.
2. FAT (1, 8, 9)
IV lipids are also referred to as IV fat emulsions (IVFE)
B. MICRONUTRIENTS:
1. VITAMINS (2)
Parenteral vitamin requirements differ from enteral requirements
because of differences in efficiency of absorption and utilization of
nutrients administered via the parenteral route, and physiochemical
stability in the parenteral solutions.
Because of instability when mixed with PN solutions, vitamins are
added just prior to administering the solution.
Optimal vitamin intakes for seriously ill and septic patients are
unknown.
32
AMA
Recommended
Amount
FDA
Recommended
Vitamin A
3300 IU
1 mg / 3300 units
Multi-Vitamins added to
standard PN solution at
UVA
(MVI-ADULT, 10 ml/day)
3300 USP units
Vitamin D
200 IU
Vitamin E
10 IU
10 mg / 10 units
10 USP units
Vitamin K
150 mcg
150 mcg
Ascorbic acid
100 mg
200 mg
200 mg
Folic Acid
0.4 mg
600 mcg
600 mcg
Niacin
40 mg
40 mg
40 mg
Riboflavin (B2)
3.6 mg
3.6 mg
3.6 mg
Thiamin (B1)
3 mg
6 mg
6 mg
Pyridoxine (B6)
4 mg
6 mg
6 mg
Cyanocobalamin
(B12)
Pantothenic acid
5 mcg
5 mcg
5 mcg
15 mg
15 mg
15 mg
Biotin
60 mcg
60 mcg
60 mcg
Amount
TABLE 3.3 Daily Parenteral Trace Element Supplementation for Adults (13)
Trace
Element
Zinc
Copper
Chromium
Selenium
Manganese
Previous Guidelines
(AMA - 1979) 1
Recent
Recommendations2
( ASPEN-2004)
2.5-4 mg
0.5-1.5 mg
10-15 mcg
No guideline
150-800 mcg
2.5-5 mg
0.3-0.5 mg
10-15 mcg
20-60 mcg
60-100 mcg
mg = milligrams
Concentrated
Multitrace 5
(1mL)
used at UVA
5 mg
1 mg
10 mcg
60 mcg
500 mcg
NonConcentrated
MTE- 5 (2.5mL)
2.5 mg
1 mg
10 mcg
50 mcg
250 mcg
mcg = micrograms
3 ELECTROLYTES (2)
34
TABLE 3.4
Electrolyte
Recommendations or
Requirements
Sodium
70 100 mEq/day
63 mEq/day
Chloride
70 100 mEq/day
Potassium
70 100 mEq/day
Calcium
10 20 mEq/day
8.1 mEq/day
Magnesium
15 20 mEq/day
18 mEq/day
Phosphorus
40-60 mEq/day
18 mMol/day
Acetate
0 60 mEq/day
53 mEq/day
Vitamin K
Vitamin C
Copper
Selenium
Famotidine
Vitamin B12
Manganese
Iron dextran
C. FLUIDS
Standard rate at UVA is 75 ml/hour. See section on PN calculations to calculate
minimum flow rates.
PN SCHEDULES:
35
TABLE 3.5
Provides:
Macronutrients:
750 Dextrose calories/day
300 Protein calories/day
500 Fat calories/day (250 mL of 20%
lipid per day)
Provides:
Macronutrients:
400 Dextrose calories/day
300 Protein calories/day
500 Fat calories/day (250 mL of 20%
lipid per day)
The differences between standard CPN and PPN are in the dextrose and total calories and have been
underlined.
36
37
TABLE 3.6 GASTROINTESTINAL COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION (OR LACK OF
ENTERAL NUTRITION) (4)
Complication
Fatty liver
Cholestasis
Gastrointestinal
mucosal atrophy
Possible Etiology
Delivery of
carbohydrate in excess
of hepatic oxidative
capacity
Overfeeding of calories
and/or fat
Excess infusion of
amino acids
Essential fatty acid
deficiency
Carnitine deficiency
Symptoms
Elevation of liver
enzymes within 1 to
3 weeks post PN
initiation
Progressive
increases in serum
total bilirubin
Elevated serum
alkaline phosphatase
In vitro, presence of
enteric bacteria in
mesenteric lymph
nodes
Development of
enteric bacteremia
and sepsis without
clear source
38
Treatment
Reduce
carbohydrate
delivery
Cyclic PN
Rule out other
causes
Begin enteral
nutrition if possible
Prevention
Use mixed
substrate
solutions
Avoid
overfeeding
Avoid glucose
infusion > 5 7
mg/kg/minute
Enteral nutrition
as tolerated
(trophic feedings)
Avoid overfeeding
Rule out other
causes
Early use of
gastrointestinal
tract
Transition to
enteral/oral
feedings as
tolerated
Early use of
gastrointestinal
tract
References
1. Madsen H, Frankel EH. The Hitchhikers Guide to Parenteral Nutrition Management for
Adult Patients. Practical Gastroenterology 2006; XXX(7):46-68.
2. Gottschlich, MM, ed. Nutrition Support Core Curriculum: A Case Based Approach. Silver
Spring, MD: American Society of Parenteral and Enteral Nutrition; 2007.
3. Tighe MJ, Wong C, Martin IG, et al: Do heparin, hydrocortisone, and glyceryl trinitrate
influence thrombophlebitis during full intravenous nutrition via a peripheral vein? JPEN
19:507-509, 1995.
4. University of Virginia Health System Nutrition Support Traineeship Syllabus (Parrish CR,
Krenitsky J, McCray S). Parenteral Module. University of Virginia Health System Nutrition
Support Traineeship Syllabus, 2003.
5. Baumgartner TG. Parenteral macronutrition. In: Baumgartner TG, ed.
Clinical Guide to Parenteral Micronutrition. Fujisawa USA, Inc; 1997: 41.
6. Evans N. The role of total parenteral nutrition in critical illness: Guidelines
and recommendations. AACN Clinical Issues. 1994;5:476-484.
7. Miles J, Klein J. Should protein be included in calorie calculations for a TPN
prescription? Nutrition in Clinical Practice. 1996;11:204-206.
8. Hise ME, Brown JC. Lipids. In: Gottschlich, MM, ed. Nutrition Support Core Curriculum:
A Case Based Approach. Silver Spring, MD: American Society of Parenteral and Enteral
Nutrition; 2007:54-57.
9. Lowrey T, Dunlap A, Brown R, Dickerson R, Kudsk K. Pharmacologic
influence on nutrition support therapy: Use of propofol in a patient receiving
combined enteral and parenteral nutrition support. Nutrition in Clinical
Practice. 1996;11:147-149.
10. Parenteral multivitamins products; drugs for human use; drug efficacy study
implementation; amendment (21 CFR 5.70). Federal Register. April 20, 2000; 65:2120021201.
11. Fuhrman MP, Hammond KA, et.al. The Science And Practiceof Nutrition
Support. Dubuque, Iowa: American Society of Parenteral and Enteral Nutrition; 2001: 94.
12. M.V.I. Adult UNIT VIAL, Manufacatured by: AstraZeneca, Westborough MA;
January 2004.
13. Fessler TA. Trace Element Monitoring and Therapy For Adult Patients Receiving Long
Term Total Parenteral Nutrition. Practical Gastroenterology. 2005;25:44-65.
14. ODonnell K, Radigan, A. Hypermanganesemia in an Acute Care Setting.
Nutrition in Clinical Practices. 2003;18:374-376.
15. Skipper A, Marian MJ. Parenteral Nutrition. In: Gottschlich MM, ed. Nutrition Support
Dietetics Core Curriculum. 2nd Ed. Silver Spring, MD. American Society of Parenteral and
Enteral Nutrition, 1993:111.
16. Evans JN. The role of total parenteral nutrition in critical illness: guidelines and
recommendations. AACN Clincal Issues. 1994;5:476-484.
17. Lee V. Liver Dysfunction Associated with Long Term Parenteral Nutrition:
What are the options? Practical Gastroenterology 2006. XXX(12):49-68.\
18. Jeejeebhoy. Management of PN induced cholestasis. Practical Gastroenterology 2005;
XXIX(2):62-68.
19. Hamilton C, Seidner D. Metabolic Bone Disease in the Patient on Long-Term Parenteral
Nutrition. Practical Gastroenterology 2008; XXXII(1):18-32.
39
APPENDIX
40
APPENDIX 1.
Lab Parameter
BUN
Elevated with:
7 18.7 mg/dl
Dehydration
Renal disease
Increased protein metabolism
Starvation
Stress
Diabetes
Fever
Acute myocardial infarction
G I bleed
Congestive heart failure
Urinary obstruction
Higher in elderly:
8.4 25.7 mg/dl
Creatinine
CO2 (Bicarbonate)
22 29 mmol / L
Metabolic alkalosis
Respiratory acidosis
Emphysema
Vomiting
*This list is not all inclusive. For example, drug effects not listed.
41
Decreased with:
Liver failure
Increased protein synthesis
- Late pregnancy
- Infancy
Acromegaly
Nephrotic syndrome
Overhydration
Malabsorption
Low protein, high CHO diets
Metabolic acidosis
Respiratory alkalosis
Hyperventilation
Fever
Lack of oxygen
APPENDIX 1.
Lab Parameter
Serum Osmolarity
BUN + Glucose
2.8
18
Serum Glucose
74 99 mg/dl
*This list is not all inclusive. For example, drug effects not listed.
42
Diabetes mellitus
Cushings syndrome
Acromegaly
Hemochromatosis
Pheochromocytoma
Burns, shock
Acute pancreatitis
Wernickes encephalopathy
Dehydration
Sepsis
Overfeeding
Corticosteroids
Blood draw contaminated with
PN (can confirm with a finger
stick)
Liver disease
Neoplasms
Pancreatic disorders
Adrenal insufficiency
Hypothyroidism
Fluid overload
Severe sepsis
APPENDIX 1.
Lab Parameter
Hematocrit (HCT)
Elevated with:
Women: 35 47%
Men: 40 52%
Dehydration
Polycythemia
Hemorrhage
Anemia
Fluid overload
Advanced age
Late Pregnancy
Women: 12 16 gm/dl
Men: 14 18 gm/dl
Dehydration
Polycythemia
Hemorrhage
Iron deficiency anemia
Malnutrition
Advanced age
Late pregnancy
Renal failure
Fluid overload
83 95 fL
Macrocytosis
- Folate deficiency
- Vitamin B 12 deficiency
- Excess alcohol intake
Hemochromatosis
Microcytosis
- Advanced iron deficiency
- Blood loss
Iron malabsorption
Lead poisoning
Decreased with:
**This list is not all inclusive. For example, drug effects not listed.
43
APPENDIX 1.
Lab Parameter
Sodium
Elevated with:
Decreased with:
Dehydration:
Diabetes Insipidus
Osmotic diuresis
GI losses
Renal disease
Severe exercise
Adrenal insufficiency
Extreme sweating
Diuretics
Diabetic acidosis
Malabsorption
Excessive GI losses
( diarrhea, vomiting, etc)
SIADH
Potassium
Hemolysis
Burns, shock
Crush injuries
Excess supplemental potassium
Renal failure
Diabetic ketoacidosis
Dehydration
Hyperglycemia
Acidosis
Blood draw contaminated with PN
Refeeding Syndrome
Starvation
Excessive GI losses
(diarrhea, vomiting, etc)
Hypomagnesemia
Cushings syndrome
Diuretics
Amphotericin
Chloride
98 107 mmol / L
Dehydration
Renal failure
Excessive GI losses
(diarrhea, vomiting, etc)
Excess urinary losses
*This list is not all inclusive. For example, drug effects not listed.
44
APPENDIX 1.
Lab Parameter
Calcium
Elevated with:
Decreased with:
Cancer
Renal disease
Vitamin D intoxication
Hyperparathyroidism
Renal calculi
Prolonged Immobilization
Hypoparathyroidism
Renal disease
Osteomalacia
Steatorrhea
Rickets
Hypomagnesemia
Phosphorous
Hemolysis
Renal disease
Healing fractures
Vitamin D deficiency
Skeletal disease
Magnesium
Renal failure
Diabetic acidosis
Hypothyroidism
Addisons disease
Dehydration
Overuse of magnesium
supplements or antacids
Hemolysis
Rickets
Insulin injections
Malnutrition
Malabsorption
Refeeding syndrome
Chronic diarrhea
Alcoholism
Pancreatitis
Renal disease
Hepatic cirrhosis
Toxemia of pregnancy
Hyperthyroidism
Malabsorption
Ulcerative colitis
K- depleting diuretics
Refeeding syndrome
Absorption decreased by
phytates, oxalates,
phosphates
Check ionized calcium
*This list is not all inclusive. For example, drug effects not listed.
45
APPENDIX 2.
Fe
(mg)
*Others
60
0.4
90
40
0.3
60
200
60
0.6
200
1.5
12
0.2
60
10
10
0.8
60
10
10
12
100
250
60
Folate
(mg)
C
(mg)
0.4
12
1.05
4.5
100
21.4
4.1
1.7
20
10
3.6
40
15
150
1.2
1.3
10
10
1.5
1.7
20
400
30
3.4
20
Amt.
A
(IU)
D
(IU)
E
(IU)
B1
(mg)
B2
(mg)
Niacin
(mg)
B5
(mg)
B6
(mg)
B12
(mcg)
1
tablet
5000
400
30
1.5
1.7
20
10
1
tablet
5000
400
60
3.4
20
40
1
tablet
2500
400
15
1.05
1.2
13.5
Liquid multivitamin
5 ml
5000
400
10
10
15 ml
1300
400
30
1.5
10ml
3300
200
10
1
tablet
1
tablet
1
tablet
4000
400
5000
Product/Form
Therapeutic
multivitamin tablet
Therapeutic high
potency vitamins
with minerals
Childrens
Chewable
Multivitamin
46
APPENDIX 3.
Vitamin
Form
Dose
Vitamin A
Composition
1 each
25,000 IU
1 ml
50,000 IU/ ml
Injection
2 ml
100,000 IU
Capsule
1 each
50,000 IU
Drops (Drisdol)
0.25 ml
2000 IU
Tablet
1 each
Vitamin D2 Ergocalciferol
Vitamin D3 Cholecalciferol
Capsule
Calcitriol -active
form (Calcijex or
Rocaltrol)
Liquid
0.25 mcg,
2 mcg
Injection
1 mcg/ml
1 mcg
Capsule
1 each
Drops
0.3 ml
15 IU
Tablet
1 each
5 mg
Injection
0.5 ml
1 ml
1 mg
10 mg
Tablet
1 each
Tablet
1 each
100 g
Injection
1 ml
1000 g
Tablet
1 each
500 mg
Syrup
5 ml
500 mg
Vitamin E
(Aquasol E)
Vitamin K
Vitamin B6
Vitamin B12
(Cyanocobalamin)
Vitamin C
(Ascorbic acid)
47
Vitamin C (cont.)
Vitamin B Complex
Injection
1 ml
1 each
3 mg B1, 3 mg B2,
20 mg B3, 0.5 mg B6,
1 g B12,
5 mg Panthothenic acid,
60 mg Desiccated liver,
60 mg Debittered
Brewers yeast
100 mg
Thiamin
Tablet
1 each
Thiamine HCl
Niacin
Injection
Tablet
1 ml
1 each
100 mg
250 mg
Niacin ER (Niaspan)
Tablet
1 each
500 mg
Nicotinic Acid
Tablet
1 each
Folic Acid
Tablet
1 each
1 mg
Injection
1 mL
5 mg
APPENDIX 4.
Vitamin
50 mg & 100 mg
Form
Dose
Composition
Calcium Acetate
Capsule
1 each
667 mg
Calcium Carbonate
Liquid
2.5 ml
4 mL
625 mg
1g
Calcium Oyster
Shell w/ Vit. D
(Oscal 250)
Tablet
1 each
250 mg
Tablet
1 each
500 mg
Syrup (liquid)
5 mL
1.8 g
Calcium Oyster
Shell
Calcium Glubionate
48
Vitamin
Form
Dose
Composition
Ferrous sulfate
Tablet
1 each
300 mg
Ferrous gluconate
Tablet
1 each
300 mg
Iron dextran
Injection
1 mL
50 mg
Zinc Sulfate
Capsule
1 each
220 mg
Injection
1 mL
1 mg
Chromium
Injection
10 mL
40 mcg
Powder
1 packet
P-250 mg/mol
Na-160 mg
K+-280 mg
Powder
1 packet
P-250 mg
K+-556 mg
Tablet
1 each
500 mg
Liquid
5 mL
1000 mg
Capsule
1 each
140 mg
Tablet
1 each
400 mg
Magnesium Sulfate
Injection
1 ml
1 gm
Potassium Acetate
Injection
1 mL
2 mEq
Potassium Chloride
Capsule
1 each
10 mEq
Powder
1 scoop
20 mEq
Liquid
Liquid
1 ml
1g
Phosphorus
Phos-Nak (Na,
Phos, K+)
Neutrophos-K (K+,
Phos)
Magnesium
Gluconate
Magnesium Oxide
Potassium Iodine
49
APPENDIX 5
CONVERSION INFORMATION
mg
Conversion factor
Conversion Factors For Major Minerals
1 mEq Na = 1 mmol Na = 23 mg Na
1 g Na = 43 mEq Na = 43 mmol Na
1 mEq K = 1 mmol K = 39 mg K
1 g K = 26 mEq K = 26 mmol K
1 mEq Ca = 0.5 mmol Ca = 20 mg Ca
1 g Ca = 50 mEq Ca = 25 mmol Ca
1 mEq Magnesium = 0.5 mmol Magnesium = 12 mg Magnesium
1 g Magnesium = 82 mEq Magnesium = 41 mmol Magnesium
1 mmol Phos = 2 mEq HPO3 = 31 mg Phos
1 mEq Cl = 1 mmol Cl = 35 mg Cl
1 g Cl = 29 mEq Cl = 29 mmol Cl
APPENDIX 6
Body Fluid
pH
Sweat
Gastric
Pancreas
Ileostomy
Bile
Diarrhea
Normal stool
Urine
Blood
750
2000 - 3000
2500
varies
500 - 750
varies
30-50
40-65
135-155
120-130
135-155
25-50
5
10
5
10
5
35-60
70-90
50-70
35-50
30-45
90
-
45-55
100-140
55-75
50-60
80-110
20-40
1.2-3
7-8
7
7
varies
200
varies
n/a
5
30-80
138
10
30-80
4.5
25
10
50-100
103
varies
4.5-8
7.4
Used with permission from the University of Virginia Health System Nutrition Support Traineeship
Syllabus (Parrish CR, Krenitsky J, McCray SF). University of Virginia Health System Traineeship, 2003.
Adapted from:
Willcutts K, Scarano K, Eddins CW. Ostomies and Fistulas: A Collaborative Approach. Practical
Gastroenterology 2005; XXIX(11):63-79.
Frietag & Miller (eds) Manual of Medical Thrapeutics 23rd ed, Little Brown and
Co 1982.
Grant JP. Handbook of Total Parenteral Nutrition. 2nd ed. Philadelphia: W.B. Saunders Co; 1992: 174.
Pemberton, LB; Pemberton DK, and Cuddy PG. Treatment of Water, Electrolyte and Acid-base Disorders
in the Surgical Patient. McGraw-Hill, Inc. Health Professions Division, 1994.
51
Appendix 8
Appendix 9
Pancreatic Enzyme Replacement Therapy
Pancreatic enzyme activity is measured in lipase units. The number in the product name
indicates the amount of lipase. Pancreatic enzyme medications are available in varying
strengths.
Name of Product
Creon 6,000
Creon 12,000
Creon 24,000
Guidelines for Dosing:
1,000 2,000 units of lipase / kg / meal
OR
500 4,000 units of lipase / gram of dietary fat (Becker, JADA 2001)
Dose should not exceed 2,500 units of lipase / kg / meal (Borowitz Peds Gastro 2002)
or 10,000 units of lipase / kg / day (Pankrease info)
High doses have been associated with fibrosing colonopathy (FitzSimmons NEJM 97)
52
Appendix 11
Section of Bowel
Duodenum
Jejunum
Ileum
Colon
53
54
55
56