NUTRITION INTERVENTION/MNT Interventions/MNT ! Food and Nutrient - PowerPoint PPT Presentation

NUTRITION INTERVENTION/MNT

Interventions/MNT ! Food and Nutrient Delivery ! Total Parenteral Nutrition (TPN) ! Nutrition Education ! TPN and CL diet

HD #3 ! Consult ordered by MD ! Estimated needs: ! Energy : 2000-2300 kcal (Harris Benedict x 1.3-1.5) ! Protein : 111-133 g (1.5-1.8 g/kg) ! Recommended TPN initiation ASAP

MNT Goals ! Short-Term ! Initiate TPN as soon as clinically appropriate as determined by GM and nutrition support teams. ! Long-Term ! Provide adequate energy, protein, fluid, and electrolytes based on pt’s condition and estimated needs. " Tolerate TPN @ goal rate " Electrolytes within normal limits " CBGs 110-150 mg/dL

HD #3 ! # Na and $ K ! Free water deficit of 3.2 L ! Repletion with 80 mEq KCl in isotonic solution ! Percutaneous biliary drain placed

HD #4 % Pt remains in ICU % Lab values % Na # , K $ , Mg and Phos normal % Free water deficit of 3.2 liters ! I & O: 8423/3685 ! Biliary drain: 500 ml since placement ! NGT: 2000 ml ! Gatorade for comfort

HD #4 – Nutrition Rx ! GM and nutrition support team agreed to TPN % Conservative TPN orders entered: % 15% AA + 40% D @ 20 ml/hr x 12 hrs 40 ml/hr x 12 hrs, no lipids % Standard electrolytes; mvi, trace elements Provision : 35% of calorie needs 54% of minimum protein needs 240 g dextrose ! Monitor electrolytes q 24 hours for possible refeeding

Suggested Guidelines for TPN ! SCCM guidelines ! Avoid lipids the 1 st week in the ICU ! Provide 20 kcal/kg ! Refeeding Risk ! No or very poor intake >5-10 days ! Unintentional wt loss >10-15% past 3-6 months ! BMI <18.5 ! Malnourished pts, initiate TPN as soon as possible following admission and adequate resuscitation

Suggested Guidelines for TPN: Refeeding Risk ! Replete phos if <2.0 or Mg <1.5 before initiation ! Start hypocaloric TPN ! 15 kcal/kg or 50% of estimated needs ! Monitor K, Mg, and phos after starting TPN ! Replete aggressively if necessary ! When lytes stable and WNL, gradually increase TPN to goal kcals (over 2-7 days)

Refeeding Syndrome ! Normal conditions glucose is preferred fuel ! Absence of oral intake, glycogen can provide energy ! Initial starvation period ! Glycogen stores are depleted, AA mobilized from muscle and FA from adipose tissue " Provide glucose and glycerol for gluconeogenesis ! Gluconeogenesis from lactacte and pyruvate

Refeeding Syndrome ! Prolonged starvation ! Rate of proteolysis decreases ! BMR slows by 20-25% ! Peripheral tissues and most organs adapt to using FA as fuel source ! Brain switches to ketones and decreases reliance on glucose " Decreased need for glucose spares muscle mass

Electrolyte Imbalances ! Cause of electrolyte imbalances when nutrition is provided, namely CHO ! Insulin secretion promotes glucose uptake into cells ! Phos, K, Mg follow glucose into cells ! Already depleted electrolyte pool coupled with shift into cells is very dangerous ! Complications ! Respiratory ! Cardiac ! Neurological

Electrolyte Imbalances ! $ phos exacerbated by increased need for phosphorylated intermediates ! Impaired oxygen release from hemoglobin ! Increased demand for K during repletion ! Mg essential for normalizing potassium and phosphorus levels ! Required for over 300 metabolic pathways

NUTRITION MONITORING/ EVALUATION

HD #5 % PICC line placed % TPN started @ 6am ! Lab values ! K and Phos normal, Mg # ! Na # and Cl #& ! Free water deficit of 2.2 L ! I & O: 7640/7545 ml ! Biliary drain: 460 ml ! NGT: 4350 ml ! Pt autodiuresing

HD #5 ! TPN reordered for day 2 ! Dextrose decreased to 30% ! Rate increased to 50 ml/hr ! No lipids ! NaCl removed due to elevated lab levels Provision = 48% of calorie needs 81% of minimum protein needs 180 g dextrose

HD #6 ! Pt transferred out of ICU ! Lab values ! K dropped to 2.6 despite aggressive repletion ! Na # , CO2 #& ! Mean CBG of 190 ! Free water deficit of 4.4 L " D5 ! NS with 40 mEq K @100 ml/hr ! I & O: 4440/6500 ! Poor I & O being recorded

HD #6 ! TPN reordered for day 3 ! Decreased dextrose from 30% to 20% ! Rate increased to 65 ml/hr ! Sodium acetate removed, 30 mEq potassium acetate added ! Potassium chloride increased to 30 mEq Provision = (with 1 L D5W) 58% of calorie needs 88% of maximum protein needs 200 g dextrose

Why the electrolyte abnormalities? ! Possible refeeding? ! NGT suction losses ! Potassium ! Fluid ! Percutaneous biliary drain ! Bile salts " 95% of bile salts are reabsorbed from the terminal ileum and returned to the liver via the portal system

Metabolic Alkalosis ! Gastric secretions rich in HCl ! HCl reaches duodenum and stimulates bicarbonate secretion by pancreas ! No net gain or loss of hydrogen/bicarbonate ions ! When HCl lost through NGT suction: ! No pancreatic secretion stimulation ! Net bicarbonate gain = metabolic alkalosis " Volume depletion maintains alkalosis " Hypokalemia 2/2 alkalosis and renal loss of K ions from stimulation of aldosterone secretion

HD #7 % K $ , Na # , Mg #& % Free water deficit of 4.4 L % Requiring K repletion of 60 mEq via IVF & % CBGs <150 % I & O: 9401/10,055 ml % Recs for weekend TPN ! Wait on lipids until fluid status and electrolytes stable ! Decreased magnesium sulfate, rate still @ 65 ml/hr Provision = (including calories from D5W @ 200 ml/hr) 90% of calorie needs 88% of maximum pro needs 396 g D

HD #10 ! Resolving free water deficit ! D5W @ 200 ml/hr changed to LR @ 250 ml/hr ! K normalized ! CBGs >200, started on 8 units Glargine ! I & O: 10,600/11,500 ml ! Diet order = full liquid ! TPN @ goal rate ! Added lipids; electrolytes stable and pt off D5

Labs After TPN Initiation Date Lab Range HD#5 HD#6 HD#7 HD#8 HD#9 HD #10 Na 131-142 147 (H) 154 (H) 155 (H) 148 (H) 142 144 (H) 2.6 (L) ' 3.5 K 3.5-5.0 2.7 (L) 3.1 (L) 2.8 (L) 3.3 (L) 4.2 Mg 2.0-2.6 3.1 (H) N/A 2.9 (H) 2.6 2.3 2.2 PO4 2.5-4.5 3.7 2.5 3.1 3.3 3.0 2.7 Cl 96-106 111 (H) 110 (H) 112 (H) 106 100 105 CO2 21-32 27 36 (H) 35 (H) 36 (H) 35 (H) 32

Maintenance Potassium Requirements ! TPN ! 75 mEq potassium chloride ! 15 mm potassium phosphate ! 15 mEq potassium acetate ! IVF ! Upwards of 80 mEq/day of potassium

TPN Regimen Date Dex Pro Lipid Rate Volume Kcal Kcal/kg Pro/kg HD#5 240 g 54 g 0 g 20 ml x 12 hrs, 720 ml 705 9.5 0.7 40 ml x 12 hrs HD#6 180 g 90 g 0 g 50 ml/hr x 24 hrs 1200 ml 972 13.1 0.8 HD#7 200 g 117 g 0 g 65 ml/hr x 24 hrs 2560 ml 1168 15.7 1.5 HD#8 396 g* 117 g 0 g 65 ml/hr x 24 hrs 6564 ml* 1814* 24.5* 1.5 HD#9 HD#10 315 g 135 g 45 g 75 ml/hr 2004 ml 2020 27.3 1.8 *Including provision from D5 @ 200 ml/hr

HD #12 ! Tissue diagnosis by endoscopic ultrasound with fine needle aspiration ! Non-resectable metastatic cancer " Involvement of vasculature and biliary tree ! Stent placed at site of obstruction ! Unable to place tube beyond duodenal obstruction for EN access ! Pt remains on TPN

Outcome ! 20 day hospital stay ! Full liquid diet, could not tolerate solid food ! Home hospice vs. SNF hospice ! Pt could not tolerate clamping of NGT (N/V) ! Transferred to SNF hospice (comfort care) ! Free water deficit resolved ! K stable with continued aggressive repletion ! Both short and long term nutrition goals were met ! Pt passed away on May 14 th

Key Events and Issues ! HD 4 pt requested Gatorade for comfort, TPN orders entered ! Provided nutrition education specific to clear liquids and TPN ! HD 5 TPN was initiated ! HD 6 performed NFPE ! HD 10 TPN goal rate reached ! HD 12 pt diagnosed with non-resectable metastatic cancer ! HD 14 TPN d/c ! HD 20 pt transferred to SNF hospice

Discussion & Summary ! Interdisciplinary collaboration ! Free water deficit ! Electrolyte losses ! Did not re-feed bile ! Careful I/O monitoring ! NGT drain ! Biliary drain ! Significant urine output

References Academy of Nutrition and Dietetics Nutrition Care Manual. 1. OHSU Suggested Guidelines. 2. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 3. 12 th ed. St. Louis, MI: Saunders Elsevier; 2008. Pronsky ZM, Crowe JP. Food-Medication Interactions. 16 th ed. 4. Bichrunville, PA: Food Medication Interactions; 2010. Jensen et al. Starvation and disease related malnutrition. 5. JPEN 2010; 34 (2): 155-159. McClave, S, Martindale, R et al. Guidelines for the Provision 6. and Assessment of Nutrition Support Therapy in the Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN. 2009. 33(3): 277-316. Parrish CR et al. Nutrition Issues in Gastroenterology. Much 7. Ado About Refeeding. Practical Gastroenterology 2005. Dickerson RN et al. Guidelines for the intravenous 8. management of hypophosphatemia, hypomagnesemia, hypokalemia and hypocalcemia. Hosp Pharm, 200;35:1201-1206 .