Bernard, MD Assistant Professor of Surgery Division of General Surgery University of Kentucky Lexington, KY. Edmiston Jr., PhD lektor i kirurgi Department of Surgery Medical College of Wisconsin Milwaukee, WI.
Molly McMahon, MD Associate Professor of Medicine
Scott Whittaker, MD
Trujillo, MS, RD Nutritional Science Research Group Division of Cancer Prevention National Cancer Institute National Institutes of Health Rockville, MD. Corkins, MD, CNSP, FAAP Assistant Professor of Pediatrics James Whitcomb Riley Children's Hospital/Indiana University School of.
Patricia Fuhrman, MS, RD, LD, FADA, CNSD
Schneider, RPh, MS, FASHP klinični profesor in direktor Latiolais Leadership Program Division of Pharmacy Practice in.
Frederick Schwenk II, MD Professor of Pediatrics
Background
How To Use This Manual
Contents of Manual
In these disease-specific chapters, the authors describe the unique aspects of the conditions, including the pattern and mechanism of nutritional depletion, unique nutritional requirements, and potential complications of nutritional support that require specific monitoring. The remaining four chapters focus on practices related to specific sites of nutrition care delivery and ethical issues relevant to nutrition support.
Integration of Nutrition Support into Patient Care
Certification
Accreditation
Clinical Pathways
Acknowledgements
Background: The Nutrition Care Process
Nutrition Screening
Nutrition Assessment
If the patient has at least ONE of the following diagnoses, circle and proceed to Part E to consider the patient AT NUTRITIONAL RISK and stop here. If the patient has at least ONE of the following symptoms, circle and go to section E to consider the patient AT NUTRITIONAL RISK and stop here.
Weight history
Balance or recalibrate the scale and place the patient in the center of the base of the scale. If <80% of ideal body weight, continue to section E to consider the patient's NUTRITIONAL RISK and stop here.
Nurse assessment
Repeat the procedure with the patient in the chair and subtract the chair weight from the total weight. Compare the patient's current weight for height with the ideal body weight chart on the back of this form.
History
- Nutrition Support Decision Making
Clinical pathways and algorithms for providing parenteral and enteral nutritional support in adults. Silver Spring, MD: A.S.P.E.N.; 1998. The Science and Practice of Nutrition Support. Dubuque, IA: American Society for Parenteral and Enteral Nutrition/Kendall Hunt.
Birth to 36 months: Boys
L ength-for-age and Weight-for-age percentiles
Birth to 36 months: Girls
Head circumference-for-age and Weight-for-length percentiles
2 to 20 years: Boys
Stature -for-age and Weight-for-age percentiles
AGE (YEARS)
2 to 20 years: Girls
AGE (YEARS)13
Body mass index-for-age percentiles
STATURE
Weight-for-stature percentiles: Boys
Weight-for-stature percentiles: Girls
Introduction
Nutritional Goals
This goal is based on correcting nutritional or metabolic deficiencies arising from a disease or treatment so that the outcome is improved. This is the goal in markedly catabolic patients (eg, severely injured patients). b) To maintain body weight and lean body mass.
Overall Nutritional Requirements
Among these, only PUFA (omega-3 and omega-6) are essential components of the diet, as humans cannot synthesize them. Recent attention to PUFA is due to their immunomodulatory effects: anti-inflammatory effects in the omega-3 series and pro-inflammatory effects in the omega-6 series, through modulation of various prostaglandins, thromboxanes, leukotrienes and lipoxins.29 Other PUFA functions include alteration in membrane fluidity , additional immunomodulatory effects through intracellular signal transduction and changes in gene expression, and modifications of the intestinal bacterial ecosystem due to a presumed disruption of the wall membrane.29 They are also important for development. and maintenance of the eye and brain.
Nutritional Requirements for Health and Disease (Enteral and Parenteral Nutrition)
Approaches to estimating BMR or REE differ depending on the number of variables included (e.g. age, sex, weight, height). The World Health Organization equations are two examples of energy expenditure estimates based on weight, age, and/or gender (see Tables 2-3 and 2-4).45–47. However, many older adults are underhydrated due to impaired thirst mechanisms and the inability to obtain or consume fluids themselves, making attention to intake and output data critical in this population.58 On the other hand, it may sometimes be necessary to limit fluid. in sick elderly people due to underlying conditions such as congestive heart failure. a) Daily electrolyte requirements for generally healthy people receiving PN or EN, as published by A.S.P.E.N. are shown in Table 2-15.36,38Note that some of these values for enteral electrolytes differ slightly from the AI and RDA values recently published by the IOM and shown in Table 2-12. b) The needs of ill patients receiving these therapies can be very different, especially if organ dysfunction is present, necessitating close clinical and laboratory monitoring of these patients.
Selection of Enteral Feeding Route (Figure 3-1)
In this chapter, we discuss how to choose among the several enteral access routes and tubes available.
Short-Term Nonsurgical Prepyloric Tubes
If the patient begins to cough or cannot speak, the tube should be withdrawn because it may be in the trachea. Auscultation of air puffs over the midepigastrium was used to document passage of the tube into the stomach.
Short-Term Nonsurgical Postpyloric Tubes
Short-Term Surgical Pre- and Postpyloric Tubes
Tube placement should be checked every 8 hours during continuous feeds and before each intermediate feed. If the tube is accidentally removed, it should be replaced as soon as possible; the tract may be closed within hours of the incident.
Selection of Infusion Equipment 50,51
SECTION I Fundamentals of Nutrition Support Practice and Management .. a) Maturation of the canal generally occurs after 2 to 3 weeks in the adult patient and 6 weeks in the pediatric patient. Some manufacturers have developed tubing that prevents free flow of the formulation when the kit is disconnected from the pump.
Composition and Characteristics of Enteral Formulations
Numerous commercially prepared enteral formulations are available and include standard formulations and specialty products designed to provide nutritional support for specific disease states. Feeding of enteral formulations supplemented with glutamine has been associated with improved microbial colonization patterns, reduced bacterial overgrowth, and improved clinical outcome.11 (3) Like L-glutamine, L-arginine is considered an essential.
Adult Enteral Formulations
However, evidence has accumulated to favor the use of enteral nutritional support in patients with pancreatitis when specialized nutritional support is warranted. The fat content ranges from approximately 38% to 55% of total calories. f) These products are nutritionally complete and provide 100% of the RDA in ≤1 L. g) Formulations designed for patients with Acute Respiratory Distress Syndrome (ARDS) also contain borage and sardine oil.
Pediatric Enteral Formulations
Since MCTs are transported via the portal system rather than the lymphatic system, they may minimize lymphatic flow. a) The high MCT formulation is isotonic, with an osmolality of 350 mOsm per kg of water. The protein content of the formulation is 35 g/L. d) Carbohydrate sources include corn syrup solids and sucrose.
Infant Enteral Formulations
This formulation is intended for use in infants consuming cow's milk or soy. protein allergies. It is also commonly used in infants with severe malabsorption. a) These formulations have osmolalities ranging from 320 to 500 mOsm per kg of water.
Preterm Infant Enteral Formulations
Before changing the nutrient density of formulations, several implications of changing the formulation must be considered. You can increase the nutrient density of colostrum by adding powders or concentrated liquids to full-term infant formulas.
Reducing Contamination of Enteral Formulations
Soluble fiber reduces the incidence of diarrhea in septic patients receiving total enteral nutrition: a prospective, double-blind, randomized, controlled trial. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.
Benefits, Indications, and Contraindications for Enteral Feedings
Complete mechanical obstruction of the gastrointestinal tract below the duodenum, or pseudo-obstruction that cannot be resolved, is a contraindication to enteral feeding. The etiology, severity, and location of acute gastrointestinal bleeding, as well as the need for immediate gastrointestinal evaluation and treatment, are determining factors in the feasibility of enteral feeding.
Implementation of Enteral Feedings
Protocols for introducing tube feeding vary and should be individualized to meet the needs of the patient and the realities of the healthcare environment. Bolus feedings can be started at 25% of the target volume, divided over the desired number of daily feedings.
Monitoring and Management of Enteral Feedings
If poor tolerance of the enteral regimen is demonstrated, the bottle feeding volume or concentration should be reduced. The amount of gastric residue obtained depends on the amount and time of the last feeding, the medications and the location of the feeding tube tip.
Complications and Management of Enteral Feedings 46–58
Insertion of the following instruments into the feeding tube is generally used as a last resort to plug the tube and should only be performed by experienced practitioners. For patients with impaired gastric motility, the use of promotility agents such as metoclopramide and erythromycin should be considered.
Transitioning from Enteral Nutrition Support
In: Current Issues in Enteral Nutrition Support: Report of the First Ross Conference on Enteral Devices.Columbus, OH: Ross Products;. Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions.
Central Venous Access: General Principles
The development of central venous access devices is closely linked to the development of total parenteral nutrition. Today, the use of central venous access has become a standard for a variety of intravenous (IV) therapies.
Central Venous Catheter Placement
Warfarin should be discontinued the day before CVC placement, and prothrombin time should be checked on the day of catheter placement. Infusions of unfractionated heparin should be stopped 4 hours before the procedure.3 Treatment with low molecular weight heparin should be stopped 12 hours before the procedure.
Central Venous Catheter Features
The need for additional laboratory evaluations is based on the clinic's assessment. 3 Neutropenia has been identified as a significant risk factor in the placement of tunnel CVCs. 5. For example, polytetrafluoroethylene, polyurethane and polyethylene have a ratio of 0.75, compared to 0.38 for silicone catheters. a) Catheter length is dependent on the site of insertion.
Central Venous Catheter Types 1,12,13
Central Venous Catheter Selection
Type: Single infusion or multiple infusions differentiate the need for single and multi-lumen catheters. Most patients requiring PN at home can be managed with a single-lumen catheter, nightly PN infusion, and other intravenous medications around the scheduled PN infusion.
Central Venous Catheter Care and Maintenance
Peripheral Access 19
Central catheters are not recommended for PN administration due to the risk of upper extremity thrombosis. Midline catheters can be used for up to 4 weeks and midclavicular catheters for 2 to 3 months.19 6.
Infusion Delivery Devices
Central catheters, often called extended-dwell peripheral catheters, are advanced about 5 to 7 inches into a vein, and midclavicular catheters involve placing the distal tip at the axillary and subclavian junctions. The basic types commonly used for PN administration are ambulatory infusion devices and inpatient infusion devices.
Infusion Delivery Device Selection Criteria 20–22
A thorough understanding of the available nutrient products used in the PN mixture is necessary to formulate a safe and clinically appropriate end product. The many factors that affect the end product include concentration, composition and pH of base solutions; stability of base solutions; microbial growth potential; and compatibility of nutritional components.
Formula Design
The electrolyte composition of PN mixtures is also dependent on the compatibility of each electrolyte with the other components of the PN mixture (see Section II.B). a) Sodium is available as the chloride, acetate, bicarbonate, phosphorus or lactate salt. Order of Mixing: The order in which the components of a PN mixture are combined can affect the overall stability of the final product.
Compatibility Issues
100 A.S.P.E.N. Nutrition Support Practice Manual 2nd Ed. © 2005 A.S.P.E.N. www.nutritioncare.org. . i) Add the vitamins last, as close as possible to the time of administration of the PN supplement. Estimation of osmolarity: The osmolarity of a formulation can be estimated by summing the osmolar contribution of each component of the PN formulation and dividing by the total volume (in liters) of the formulation.
Stability Issues
Coadministration or mixing of medications known to be incompatible with PN should be avoided.33 In the absence of reliable information on the compatibility of a specific drug with PN, the medication should be administered separately from the PN.33. Once the vitamins have been added, the PN mixture should be administered within 24 hours to limit loss of potency.
Microbial Growth Potential
Vitamins should be added as the last ingredient when preparing a PN mixture (see section I.D). Batch addition of ascorbic acid has caused degradation, resulting over time in the formation of oxalic acid.
Automated Compounding
Continuous coalescence occurs, with total, irreversible separation of the oil and water phases and unusable TNA. Periodic observation by the user of the device to ensure that it is functioning properly.
Off-Site Compounding Centers
Ordering PN Formulations
Labeling PN Formulations
Physician Orders
PARENTERAL NUTRITION (PN) - ADULT
CENTRAL 2-in-1 Dextrose _____ g
Dextrose _____ g
- Background
- Situations in Which PN Is Commonly Used
- Initiation of PN
- Administration of PN
- Monitoring and Management of PN
- Complications of PN
- Transitional Feeding and Discontinuing PN 44,45
- Enteral Incompatibilities. Every available dosage form has the potential to cause undesirable effects or incompatibilities
- Medication Administration via Enteral Feeding Tubes
- Parenteral Considerations. Patients receiving parenteral nutrition (PN) are often treated concomitantly with medications,
- Effects of Medications on Clinical Laboratory Values
- Effects of Drugs on Nutrition and Metabolism
- Overview of HIV Infection and AIDS
- Nutritional Aspects of HIV Infection
- Nutritional Assessment in HIV Infection
- Goals of Nutritional Therapy and Nutrition Decision Making
- Nutritional Management in HIV Infection
- Nutritional Alterations in Patients With Cancer
- Nutritional Assessment of Patients With Cancer
- Food Intake: As compared to my normal intake, I would rate my food intake during the past month as
- Symptoms: I have had the following problems that have kept me from eating enough during the past two weeks (check all
- Physical (See Worksheet 4)
Drug binding in the undernourished: a study of the binding of propranolol to alpha-acid glucoprotein. HIV in the United States at the turn of the century: an epidemic in transition.
Scored Patient-Generated Subjective Global Assessment (PG-SGA)
Recommendations for nutritional triage: the additive score is used to define specific nutritional interventions, including patient &. family education, symptom management, including pharmacological intervention, and appropriate nutritional intervention. food, nutritional supplements, enteral or parenteral triage). 2-3 Patient and family education by dietitian, nurse, or other physician with pharmacological intervention as indicated by symptom review (Box 3) and laboratory values, as appropriate.
Metabolic Demand (See Worksheet 3)
A patient's willingness to eat can also be adversely affected by financial constraints, depressed psychological state, and poor attitude. Knowledge of the patient's hydration status is also important for accurate interpretation of body weight.
Criteria for Intervention and Goals of Therapy
There is insufficient evidence to support the claim that improvements in nutritional status will result in improved patient outcomes. In addition, there was a significant decrease in treatment delays compared to that in fed patients receiving enteral nutrition. f) Overall, PN appears to improve nutritional status but not clinical outcome. g) The duration of PN supply required to achieve nutritional supplementation is difficult to predict.
Nutritional Management
However, extra iron should be avoided in patients undergoing multiple blood transfusions, and folate supplements should not be given with methotrexate therapy. Adequate calories, protein, and micronutrients must be provided to support growth along the NCHS growth curves.
Patient and Caregiver Education Internet Resources
Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutritional assessment tool in patients with cancer. Eur J Clin Nutr. The effect of an oral nutritional supplement enriched with fish oil on weight loss in patients with pancreatic cancer.Br J Cancer.
Indications for Transplantation. Organ transplantation is indicated for individuals who have organ failure that is no longer “cur-
Immunosuppression
Nutritional Factors Influencing Postoperative Outcomes
Monitor blood sugar and need for long-term diabetes diet and hypoglycemic agents Avoid high sodium foods. Monitor blood sugar and need for long-term diabetes diet and hypoglycemic agents Limit fat intake to <30% of calories during long-term phase; maintain a healthy weight.
Nutrient Requirements
Nutrition Goals for Posttransplant Maintenance Phase
Optimizing nutritional support, supplementation with oral bicarbonate, prevention of renal osteodystrophy, and treatment of anemia before transplantation may help stabilize growth.91 (1) The use of recombinant human growth hormone before. transplantation in patients with chronic renal failure has been shown to result in improved growth.91. Patients with noncholestatic liver disease require 100% to 120% of the RDA for calories, 2.2 to 2.5 g of protein per kg per day for infants and the RDA for protein for children aged 1 year to 18 years.
Enteral Nutrition
178 A.S.P.E.N. Nutrition Support Practice Manual 2nd Ed. © 2005 A.S.P.E.N. www.nutritioncare.org. . as older children92; however, there are reports of significant catch-up growth in children of pubertal age. e) Recipients of lung and intestinal transplants require more immunosuppression than other organ transplants. In pancreas transplant recipients with urinary drainage of exocrine secretions, losses may be as high as 2 to 3 L/day.
