* NUTRITION

Heba Anees El Shesheni ,

BSc.pharm, BCNSP

objectives

* Discuss appropriate indications for the use of enteral

and parenteral nutrition (EN and PN).
* Recommend a patient-specific EN formula, infusion
rate, and monitoring parameters.
* Recommend a patient-specific PN formula and
monitoring plan based on the type of intravenous
access, nutritional needs, comorbidities, and clinical
condition.
* Discuss strategies for preventing complications
associated with EN and PN.

*ENTERAL

NUTRITON

* Indication and Timing

Enteral nutrition is used in

hemodynamically stable patients

at risk of malnutrition
in whom it is anticipated that oral feedings
will be inadequate for at least 12 weeks.

Malnutrition is associated with poor wound

healing and
increased risk of infection

* EN Contraindications
* 1. Complete intestinal obstruction
* 2. GI fistula
* 3. Extreme short bowel
* 4. Severe diarrhea or vomiting
* 5. Hemodynamic instability or intestinal ischemia
* 6. Paralytic ileus
* Positive bowel sounds are not required for EN initiation

promotes gut motility

EN

*EN administration routes

* 1. Orogastric tubes

* preferred in patients with nasal/facial trauma or sinusitis

* uncomfortable for alert patients.

* 2. NG tubes

* most common tubes for short-term enteral access

* used for stomach decompression in addition to feeding.
* a. Prolonged use can cause sinusitis or nasal mucosal ulceration.
* b. Patients with a gastric ileus will not tolerate NG feedings and will
have an increased risk of aspiration.

* 3. Nasoduodenal tubes

* smaller and more flexible than NG tubes.

* a. Ideally, the tip is placed past the pyloric sphincter to improve tube
feeding tolerance and prevent aspiration.
* b. Tubes will clog if not flushed appropriately.
* c. Suitable for patients with a gastric ileus.

*EN administration routes

* 4. Nasojejunal tubes

* advanced into the fourth portion of the duodenum or past the

ligament of Treitz.

* 5. Gastrostomy tubes

* PEG tubes for percutaneous endoscopic gastrostomy

* placed through the abdominal wall into the stomach for patients
requiring long-term feeding.

* 6. Jejunostomy tubes

* placed through the abdominal wall into the jejunum usually to

facilitate immediate postoperative or post injury feeding.

EN delivery

* 1. Gravity control
*

delivery with tubing that is fitted with a roller clamp to allow

infusion into the stomach as desired.

* 2. Continuous infusion

* using an enteral feeding pump is usually used in hospitals

* reduced risk of aspiration compared with bolus feedings
* must be used for duodenal or jejunal feedings

* 3. Cyclic feedings

* are administered continuously for 1012 hours (overnight) to

facilitate patient mobility during the daytime.

* 4. Intermittent bolus feedings

* 100300 mL for 3060 minutes every 46 hours

* only used for feeding tubes ending in the stomach.

EN benifits

* 1. Lower risk of infection than PN.

* 2.Early administration of EN is associated with decreased
infection and shorter length of stay.

* 3. GI mucosal atrophy occurs with an absence of EN

* increased risk of bacterial translocation because gut bacteria can
cross the weakened intestinal barrier.

* EN Formulations
* 1. Typically contain carbohydrate, fat, protein, electrolytes,
water, vitamins, and trace elements in varying amounts
* 2. Intact or polymeric formulas

* used in patients with normal digestive processes

* typically contain 11.2 kcal/mL. Examples include Osmolite and
Isocal.

* a. These are generally inexpensive and an appropriate first

choice for many patients.
* b. Some polymeric formulas are concentrated for patients
requiring fluid restriction and contain 2 kcal/mL.

* Magnacal, TwoCal HN, and Deliver 2.0.

* c. Some polymeric formulas are designed for oral

administration and are used to supplement the patients diet.

* Boost and Ensure.

* EN Formulations
* 3. Elemental formulas

* Easily digested by patients with impaired digestive capacity or

malabsorption
* more expensive than polymeric EN.
* Peptamen, Vital HN, and Vivonex TEN.

* 4. Some EN contains fiber for patients with constipation.

* Ultracal and Jevity.

* 5. Disease-specific EN
* a. EN for patients with renal failure

* concentrated (i.e., 2 kcal/mL to adhere to fluid restrictions)

* can contain reduced amounts of protein and electrolytes (for

nondialysis patients)
* or more protein and moderate electrolytes (for dialysis patients).

Magnacal Renal and Nepro.

* EN Formulations
*b. Some EN products designed for patients with respiratory

failure
* more calories from fat (40%55% of total calories)
* fewer from dextrose to reduce the production of.
* excessive CO2 production is primarily caused by
overfeeding with total calories rather than the total amount
of dextrose; therefore, these more expensive formulations
may be unnecessary as long as the patient is not being
overfed
* Pulmocare, Respalor, and NutriVent.
* c. EN for patients with diabetes
* more calories from fat
* fewer calories from carbohydrates
* added fiber to improve glycemic control.
* Glucerna.

* EN Formulations
* d. EN for patients with hepatic failure and hepatic
encephalopathy

* more branched-chain AA and less aromatic AA, which may

improve encephalopathy (controversial).
* NutriHep

* e. EN for highly stressed patients (e.g., trauma, burn injury,

acute respiratory distress syndrome, sepsis)

* enhanced with protein, arginine, glutamine, omega-3 fatty acids,

nucleotides, or beta-carotene.
* designed to enhance immune function and clinical outcomes.
* Impact, Glutamine, and Oxepa.

* EN Complications
* 1. Improper tube placement or displacement
* 2. Clogged feeding tubes

* a. Prevent by flushing feeding tube before, between, and after

the administration of each drug.
* b. Unclog feeding tubes with warm water, cola, pancreatic
enzymes, or sodium bicarbonate.

* 3. Nasopharyngeal erosions, epistaxis, tracheoesophageal

fistula
* 4. Sinusitis
* 5. Electrolyte abnormalities are most likely to occur in
patients who develop refeeding syndrome

* EN Complications
*6. Aspiration pneumonia
* a.

Administering EN past the pyloric valve using a duodenal feeding

tube can prevent aspiration pneumonia.
* b. Prevent by
* keeping the head of bed elevated at 3045 degrees.
* by initiating EN at a slow rate (e.g., 20 mL/hour) and advance every
46 hours as tolerated to goal rate.
* monitoring gastric residuals and discontinuing infusion if gastric
residual volume is greater than 250500 mL.
* i. Prevent delays in gastric emptying using an EN formula with less
fat.
* ii. Gastric motility can be increased with metoclopramide (520 mg
intravenously every 6 hours) and/or erythromycin (250 mg
intravenously every 68 hours administered until tolerating EN for
at least 24 hours); can combine metoclopramide and erythromycin,
but monitor for diarrhea and tachyphylaxis
* iii. Avoid prolonged use of promotility agents because of increased
risk of adverse effects.

* EN Complications
*7. Diarrhea

* a. More common with elemental products because of a higher osmolarity

* b. Consider other causes of diarrhea such as
*

antibiotic use, infection, lactose intolerance, magnesium, and sorbitol in liquid

preparations.

*8. Constipation can be prevented by

* adding fiber
* metoclopramide.

*9. Dehydration
*10. Hypernatremia occurs when patients are given insufficient
water while receiving EN.

* a. Patients require about 1 mL of water for each calorie.

* b. Hypernatremia typically occurs in patients with altered mental status.
* c. Calorie-dense (i.e., 1.5 or 2 kcal/mL) EN formulas have less water than
products containing 1 kcal/mL and therefore require additional water to
prevent hypernatremia.

* EN Monitoring
*1. Blood glucose concentration
*2. Head of bed elevation to 3045 degrees
*3. Gastric residuals are checked

* infusion rate is generally held or reduced if the residual amount exceeds 250

500 mL (applies to gastric tube feedings only, not small bowel)

* According to the SCCM and ASPEN guidelines, holding EN for gastric residual
volumes less than 500 mL in the absence of other signs of intolerance should be
avoided.

*4. GI tolerance

* a. Abdominal pain and/or distension

* b. Stool frequency and volume
* c. Gastric residuals
* d. Nausea/vomiting/diarrhea

*5. Prealbumin weekly.

* Exception: Not recommended in critically ill patients because it reflects acutephase response rather than nutritional status

*6. Serum sodium and other electrolytes

*7. Wound healing is a sign of adequate nutritional therapy.

*Developing EN Regimen

* Drug administration using

Enteral access

* 1. Liquids are preferable, and they should be diluted with 23 times

the medication volume, with sterile water for irrigation.
* 2. Diarrhea can occur with medications having a high osmolality
(e.g., medications mixed in sorbitol).
* 3. Flush with 20 mL of water before and after drug administration.
* 4. Do not crush sustained-release or enteric-coated pills.
* 5. Mix crushed tablets or capsule contents with 1015 mL of sterile
water for injection, and administer each drug separately.
* 6. May need to discontinue tube feedings before and after drug
administration temporarily to prevent reduced bioavailability (e.g.,
fluoroquinolones, phenytoin, warfarin, bisphosphonates)
* 7. Consider feeding tube location and subsequent drug absorption
(e.g., for efficacy; antacids need to be administered into the
stomach, not the duodenum).

*PARENTERAL
NUTRITON

* PN is the administration of intravenous

nutrition in patients with a nonfunctioning
or inaccessible GI tract in which the
duration of PN is anticipated to be at least 7
days (i.e., it is anticipated that the patient
will be unable to be fed orally or enterally
for at least 7 days)

* Indications for parenteral

* 1. Severe pancreatitis

nutrition

* 2. Peritonitis
* 3. Severe inflammatory bowel disease (e.g., Crohn disease,
ulcerative colitis)

* 4. Extensive bowel resection (e.g., short bowel syndrome) causing

malabsorption or

maldigestion

* 5. Complete bowel obstruction

* 6. Severe intractable vomiting or diarrhea
* 7. Inability to meet full nutritional needs by enteral route alone (can
use PN as supplement to EN)

* Intravenous infusion of PN
1. PN is usually administered through a central line.
* peripherally inserted central catheter or PICC
* Hickman
* Port-a-Cath
* 2. Peripheral access
* the osmolarity must not exceed 900 mOsm/L.
* the need for PN is expected to be less than 2 weeks.
* a. Final dextrose concentration should be 10% or less.
* b. Final AA concentration should be 2.5%4%.
* c. Ca++ concentration should be 5 mEq/L or less.
* d. K+ concentration should be 40 mEq/L or less.

* Intravenous infusion of PN
* In hospitalized patients, PN is typically administered as a

continuous infusion, which should be completed within 24 hours.

* Ambulatory patients may prefer a cyclic PN in which the PN is
usually infused for 12 hours overnight.
* Infusions are generally better tolerated by patients if they are
removed from the refrigerator 3060 minutes before infusion.

*Types of PN admixtures
* 2-in-1 refers to PN in which all nutrients are mixed in the same

intravenous bag, except for lipids.

* a. Lipids are infused separately no faster than 0.1 g/kg/hour.
* b. Rapid administration of lipids is associated with headache, fever,
nausea, hypertriglyceridemia, dyspnea, cyanosis, flushing,
sweating, and back or chest pain.
* c. Lipid infusion time should be less than 12 hours because of the
potential for microbial growth after this time (growth is reduced
when lipids are mixed with dextrose and AA, as in the 3-in-1 below,
because of reduced pH and increased osmolarity).
* d. Administration tubing for a 2-in-1 should be changed every 72
hours; lipid tubing should be discarded after use (no longer than 12
hours).

*Types of PN admixtures
* 3-in-1 refers to PN in which all nutrients are mixed in the same

intravenous bag to form a lipid emulsion.

* a. Stability of a 3-in-1 depends on the pH, which is primarily
determined by the final concentration of AA (maintain between
2.5% and 4%).
* b. Do not add concentrated dextrose directly to a lipid emulsion
when mixing (see order of mixing below).

* c. Avoid excessive amounts of Ca++ and magnesium (see

recommended doses below).

* d. Administration tubing for a 3-in-1 should be changed every
24 hours.

*2-in-1 PN Compared with 3-in-1 PN

Nutritional components
of PN formulae

* 1. Dextrose
* 70% and contains 3.4 kcal/g.
* Glycerol (or glycerin) provides 4.3 kcal/g, and it is used in
premixed parenteral products
* 2. Fat emulsion
* 10% or 20% and contains about 10 kcal/g
* 30% formulation for compounding in 3-in-1 only
* 3. AA
* 3%20% and provide 4 kcal/g
* 4. Electrolytes are added to maintain physiologic serum
concentrations.
* 5. Multivitamins and trace elements are added on the
basis of the recommended daily amount.

*Order of Mixing
* 1. Add dextrose, AA, sterile water
* 2. Add phosphate.
* 3. Add other electrolytes (except Ca) and trace minerals.
* 4. Mix well to ensure phosphate is evenly distributed and to

prevent precipitation with Ca.

* 5. Add Ca.
* 6. Observe for precipitates or contaminants.
* 7. Add lipid if 3-in-1 formulation. (Note: Do not mix dextrose
and lipids directly because the low pH of dextrose can
destabilize the lipid emulsion.)
* 8. Add vitamins last, as close to the time of PN administration
as possible in acute care settings, or just before infusion in
patients receiving home PN.

Factors affecting Ca , P
risk of Ca++ and phosphate precipitation.
* 1.Factors increasing risk the
solubility
* a. Increasing pH (more basic)

* b. Increasing Ca++ ( 6 mEq/L) or phosphate( 30 mmol/L ) concentration.

* CaCl should never be used in compounding PN formulations.
* c. As the temperature increases.
* PN should be refrigerated if not administered within 24 hours of
compounding.
* If refrigerated, PN should be administered within 24 hours of rewarming.
* 2. The final concentration of AA should be at least 2.5% or higher to prevent
Ca++ and phosphate precipitation.
* a. AA form soluble complexes with Ca++ and phosphate.
* b. AA provide a buffer system to maintain a lower pH of the PN in an
acceptable range to prevent Ca++ or phosphate precipitation.
* 3. A 1.2-micron filter (used for a 3-in-1 PN) may not prevent the embolism of
a calcium phosphate precipitate, but it should be used anyway to reduce the
risk.
* 4. Order of mixing additives
* 5. The PN should be agitated often during compounding to ensure adequate
mixture into solution.

* Medication additives in PN
* 1. Medications should not be added to PN if it can be avoided.
* 2. Do not add the following to PN:

* Ceftriaxone (precipitates with Ca)

* phenytoin (can change the pH of PN)
* medications containing propylene glycol or ethanol as diluents (e.g., furosemide,
diazepam, lorazepam, digoxin, phenytoin, etoposide)
* iron dextran (trivalent cations destabilize the lipid emulsion in 3-in-1 PN
formulations)

* 3. Incompatible drugs should be administered through a separate

intravenous catheter or a separate lumen of a central venous catheter, if

possible.
* 4. If an incompatible intravenous drug needs to be administered through
the same intravenous catheter as the PN
* the PN should be stopped
* followed by a compatible flush before and after drug administration.
* The volume of flush should be sufficient to clear the entire catheter of PN
and of drug (typically around 10 mL if flushing the port closest to the
* 5. Only regular insulin is compatible with PN

*PN Complications
* 1. Catheter-related infections are primarily caused by Staphylococcus aureus

and Candida albicans.

* 2. Catheter insertion complications (e.g., pneumothorax, incorrect placement)
* 3. Peripheral venous thrombophlebitis
* risk is increased by day 4 of catheterization
* site should be rotated every 3 days.
* 4. Fluid imbalance
* 5. Acid-base imbalances
* usually related to the patients underlying condition
* excessive chloride salts in the PN can cause a metabolic acidosis
* excessive acetate salts in the PN can cause a metabolic alkalosis.
* 6. Hyperglycemia can lead to nosocomial and wound infections.
* 7. Gut atrophy
* 8. Overfeeding
* hepatic steatosis
* hypercapnia (elevated CO2), hyperglycemia, and azotemia.
* 9. Essential fatty acid deficiency
* Symptoms include skin desquamation, hair loss, impaired wound healing,
hepatomegaly, thrombocytopenia, fatty liver, and anemia.
* Can occur within 13 weeks of a lipid-free PN

*PN Complications
*10. Refeeding syndrome
*can occur in acutely (can include critically ill patients) or
chronically malnourished patients by initiating EN or PN.

* a. Characterized by hypophosphatemia, hypokalemia,

hypomagnesemia
* b. Can cause cardiac dysfunction, respiratory dysfunction, and death

*Prevention of refeeding syndrome:

* i. Identify patients at risk (e.g., anorexia, alcoholism, cancer,

chronically ill, poor nutritional intake for 12 weeks, recent

unintentional weight loss, malabsorption).
* ii. Initially, provide less than 50% of caloric requirements; then,
advance over several days to desired goal.
* iii. Supplement vitamins before initiating PN as well as K , phosphate,
and magnesium (if needed); monitor daily for at least 1 week; and
replace electrolytes as needed (many patients will need aggressive
electrolyte replacement during the first week of PN).
+

*PN Complications
*11. Hepatobiliary disorders
* Steatosis
* Cholestasis
* gallbladder sludge or stones.

*a. Steatosis (or fatty liver) is associated with overfeeding

and a transient elevation in aminotransferase

concentration. Although it is usually benign, it can progress
to fibrosis or cirrhosis in patients receiving long-term PN.
*b. Cholestasis usually occurs in children, but it can also
occur in adults receiving long-term PN and can progress to
cirrhosis and liver failure; a conjugated bilirubin
concentration greater than 2 mg/dL is the primary sign.
*c. Gallbladder stasis is associated with the development of
gallstones, sludge, and cholecystitis and is more
attributable to a lack of EN than to PN administration.

*PN Complications
* 12. Aluminum toxicity
* More likely to occur in patients on long-term PN or in those

with renal dysfunction (aluminum is renally eliminated)

* Accumulates in bone and interferes with bone Ca++
uptake, causing osteopenia
* Neurotoxicity
* Aluminum contaminates many intravenous electrolytes and
intravenous fluids.
* See drug labels for amount of aluminum content.
* 13. Osteoporosis and osteomalacia
* can occur in patients receiving long-term PN
* associated with higher protein doses (causes increased Ca++
excretion) and chronic metabolic acidosis (because of
insufficient acetate).

* Monitoring patients on PN
*

Monitor for
*1. Infection (temperature, WBC, intravenous access site).
*2. Peripheral vein thrombophlebitis and/or infiltration (if peripheral
access); symptoms include pain, erythema, and tenderness or a
palpable cord at the site of the peripheral vein; treat by removing
catheter.
*3. Fluid status (weight, edema, vital signs, input and output,
temperature).
*4. Nutritional status

* a. Prealbumin is very useful in monitoring the effects of long-term nutrition support

in patients who are not critically ill.
* i. Values

* (a) Normal range 1640 mg/dL

* (b) Moderate malnutrition 1116 mg/dL
* (c) Severe malnutrition is less than 11 mg/dL.

* ii. Goal for malnourished patients is an increase of at least 35 mg/dL/week until

within normal range.
* b. Serum albumin (normal 3.55 g/dL) is a poor predictor of nutritional status
because it has a long half-life and concentrations fluctuate during illness.

* Monitoring patients on PN
* 5. Hyperglycemia and hypoglycemia.

* a. A common blood glucose goal is 150 mg/dL or less.

* b. Regular insulin
* (initially 0.050.2 unit of dextrose per gram) can be added to

the PN for patients using a consistent dosage.

* c. For patients with hyperglycemia or fluctuating insulin dosages,
insulin can be supplemented separately from the PN, although
this practice varies by practitioner.
* d. Abrupt discontinuation of PN
* usually tolerated in nondiabetic patients
* rebound hypoglycemia may occur in other patients
* avoid by gradually tapering off PN over 12 hours
* check blood glucose 30 minutes to 1 hour after discontinuing
PN
* If PN (centeral)is discontinued abruptly, can avoid rebound
hypoglycemia by administering 5% or 10% dextrose

* Monitoring patients on PN
* 6. Electrolyte and acid-base imbalances.

* a. For metabolic alkalosis, Na+ and K+ can be administered as the chloride salts.
* b. For metabolic acidosis, Na+ and K+ can be administered as the acetate salts
(acetate is converted to bicarbonate).
* c. For respiratory acid-base disorders, correct the underlying cause or adjust the
ventilator settings as needed.

*7. Triglyceride concentrations

* withhold lipids in patients with a concentration greater than 400 mg/dL.

* When calculating lipid requirements, account for any drugs mixed in a
lipid emulsion (e.g., propofol, clevidipine).

*8. Hepatic function.

*9. Patient readiness for oral or EN support.

* a. Well-nourished, relatively healthy patients can change immediately

from PN to oral/EN.
* b. Elderly, debilitated, and/or malnourished patients may need a
transition period in which oral or EN feedings are gradually increased,
coinciding with a reduction in PN.

THANK
YOU