CLINICIAN’S POCKET REFERENCE - PART 4 pptx

TABLE 11–1 (Continued) Diet Guidelines Indications Clear liquid <7 g low-quality protein (continued) <1 g dietary fiber <1 g fat/day This diet is inadequate in all nutrients and should not be used >3 d without supplementation Low-fiber Foods that are low in indigestible carbohydrates Management of acute radiation enteritis and inflammator y Decreases stool volume, transit time, and bowel disease when narrowing or stenosis of the gut frequency lumen is present Carbohydrate Calorie level should be adequate to maintain or Diabetes mellitus controlled achieve desirable body weight diet (ADA) Total carbohydrates are limited to 50–60% of total calories Ideally fat should be limited to ≈30% of total calories Acute renal failure Protein (g/kg DBW) 0.6 For patients in renal failure who are not undergoing dialysis Calories 35–50 Sodium (g/day) 1–3 Potassium (g/day) Variable Fluid (mL/day) Urine output + 500 Renal failure/ Protein (g/kg DBW) 1.0–1.2 For patients in renal failure on hemodialysis Hemodialysis Calories (per kilogram DBW) 30–35 Sodium (g/d) 1–2 Potassium (g/d) 1.5–3 Fluid (mL/d) Urine output + 500 (continued) 207 TABLE 11–1 (Continued) Diet Guidelines Indications Peritoneal dialysis Protein (g/kg DBW) 1.2–1.6 For patients in renal failure on peritoneal dialysis Calories (per kilogram DBW) 25–35 Sodium (g/d) 3—4 Potassium (g/d) 3–4 Fluid (mL/d) Urine output + 500 Liver failure In the absence of encephalopathy do not restrict Management of chronic liver disorders protein In the presence of encephalopathy initially restricted protein to 40–60 g/d then liberalize in increments of 10 g/d as tolerated Sodium and fluid restriction should be specified based on severity of ascites and edema Low lactose/ Limits or restricts mild products Lactase deficiency Lactose-free Commercially available lactase enzyme tablets are available on the market Low-fat <50 g total fat per day Pancreatitis Fat malabsorption Fat/cholesterol Total fat >30% total calories Hypercholesterolemia restricted Saturated fat limited to 10% of calories <300 mg cholesterol <50% calories from complex carbohydrates Low-sodium Sodium allowance should be as liberal as possible Indicated for patients with hyptertension, ascites, and to maximize nutritional intake yet control symptoms edema associated with the underlying disease “No-added salt” is 4 g/d; no added salt or highly salted food; 2 g/d avoids processed foods (ie, meats) <1 g/d is unpalatable and thus compromises adequate intake 11 208 11 Diets and Clinical Nutrition 209 11 interobserver variability and are generally not useful unless performed by an experienced eval- uator. Absolute lymphocyte count is sometimes used as a marker of visceral proteins and im- munocompetence. Visceral protein markers, such as prealbumin and transferrin, may be helpful in evaluating nutritional insult as well as catabolic stress. Although the most com- monly quoted laboratory parameter of nutritional status is albumin, the albumin concentration often reflects hydration status and metabolic response to injury (ie, the acute phase response) more than the nutritional state of the patient, especially in patients with intravascular volume deficits. Due to its long half-life, albumin may be normal in the malnourished patient. Preal- bumin is superior as an indicator of malnutrition only because of its shorter half-life. Use of these serum proteins as indicators of malnutrition is subject to the same limitation, however, because they are all affected by catabolic stress. Table 11–2, page 210, lists the parameters for identifying potentially malnourished patients; however, no single criterion should be used to assess a patient’s nutritional status. Patients can generally be classified as mildly, moderately, or severely nutritionally depleted based on these parameters. NUTRITIONAL REQUIREMENTS Determining the patient’s nutritional requirements is one of the first steps in prescribing a modified diet order or supplementation for a patient. The following list provides guidelines for estimating nutritional needs. Monitoring the patient’s progress and adjusting nutritional goals on the basis of clinical judgment is important for ensuring that the patient’s specific needs are being met. Caloric needs can be determined by one of two means: the Harris–Benedict BEE and the “rule of thumb” method. Caloric Needs A patient’s caloric needs can be calculated by the following methods: Harris–Benedict BEE For men: BEE = 66.47 + 13.75 (w) + 5.00 (h) − 6.76 (a) For women: BEE = 655.10 + 9.56 (w) + 1.85 (h) − 4.689 (a) where w = weight in kilograms; h = height in centimeters; and a = age in years. After the BEE has been determined from the Harris–Benedict equation, the patient’s total daily maintenance energy requirements are estimated by multiplying the BEE by an ac- tivity factor and a stress factor. Total energy requirements = BEE × Activity factor × Stress factor Use the following correction factors: Activity Level Correction Factor Bedridden 1.2 Ambulatory 1.3 Level of Physiologic Stress Correction Factor Minor operation 1.2 Skeletal trauma 1.35 Major sepsis 1.60 Severe burn 2.10 11 TABLE 11–2 Parameters Used to Identify the Malnourished Patient Parameters Measurement/Interpretation Usefulness/Limitations ANTHROPOMETRIC MEASUREMENT Actual body weight (ABW) compared “Rule-of-thumb” method to deter mine IBW with ideal body weight (IBW) Step 1 For men: IBW (lb) = 106 lb for 5 ft of height, plus 6 lb for each inch of height over 5 ft For women: IBW (lb) = 100 lb for first 5 ft of height plus an additional 5 lb for each inch over 5 ft Step 2 % IBW = ABW × 100 IBW % of IBW 90–110 Normal nutritional status 80–90 Mild malnutrition 70–80 Moderate malnutrition <70 Severe malnutrition Actual body weight compared with % UBW = ABW × 100 usual body weight (UBW) UBW % of UBW 85–95% Mild malnutrition 75–84% Moderate malnutrition <75% Severe malnutrition (continued) 210 11 TABLE 11–2 (Continued) Parameters Measurement/Interpretation Usefulness/Limitations BIOCHEMICAL PARAMETERS Serum albumin 3.5–5.2 g/dL Normal Routinely available 2.8–3.4 g/dL Mild depletion Valuable prognostic indicator: depressed levels 2.1–2.7 g/dL Moderate depletion predict increased mor tality and morbidity <2 g/dL Severe depletion Inexpensive Large body stores and relatively long half-life (approximately 20 d) limit usefulness in evaluating short-term changes in nutritional status Transferrin (TFN) 200–300 mg/dL Normal Frequently available 150–200 mg/dL Mild visceral depletion Depressed levels predict increased mor tality 100–150 mg/dL Moderate depletion and morbidity <100 mg/dL Severe depletion Smaller body pool and shor ter half-life (8–10 days) than serum albumin TFN can be calculated from the total iron- If TFN is calculated from TIBC, levels will be binding capacity (TIBC) as follows: increased with the presence of iron defi- TFN = (0.8 × TIBC) − 43 ciency or chronic blood loss Levels are increased during pregnancy Levels are decreased if iron stores are increased as a result of hemosiderosis, hemochromatosis, thalassemia (continued) 211 11 TABLE 11–2 (Continued) Parameters Measurement/Interpretation Usefulness/Limitations Prealbumin 16–30 mg/dL Normal Half-life is 2 d. Thus is more sensitive indicator 10–15 mg/dL Mild depletion of acute change in nutritional status than is 5–10 mg/dL Moderate depletion albumin or TFN <5 mg/dL Severe depletion Not routinely available Levels are quickly depleted after trauma or acute infection. Also decreased in response to cirrhosis, hepatitis, and dialysis, and there- fore, should be interpreted with caution Absolute lymphocyte count 1400–2000 Mild depletion May not be valid in cancer patients. Not used (calculated as WBC × % 900–1400 Moderate depletion by some nutritionists lymphocytes) <900 Severe depletion 212 “Rule of Thumb” Method • Maintenance of the patient’s nutritional status without significant metabolic stress requires 25–30 Cal/kg body weight/d. • Maintenance needs for the hypermetabolic, severely stressed patient or for support- ing weight gain in the underweight patient without significant metabolic stress re- quires 35–40 Cal/kg body weight/d. • Greater than 40 Cal/kg body weight/d may be needed to meet the needs of severely burned patients. Protein Needs Maintenance requirements for nonstressed patients are 0.8 g of protein per kilogram of body weight. Repletion requirements of the nutritionally compromised patient are 1.2–2.5 g of protein per kilogram of body weight. DETERMINING THE ROUTE OF NUTRITIONAL SUPPORT Once nutritional support is indicated, the route for administration is chosen. Enteral supple- mentation by mouth or tube and parenteral nutrition are the main routes for providing nutri- tional support. Enteral Supplementation and Tube Feeding Enteral nutrition encompasses both supplementation by mouth and feeding by tube into the GI tract. If the patient’s oral intake is inadequate, every effort should be made to increase in- take by providing nutrient-dense foods, frequent feedings, or oral supplements. If such at- tempts are unsuccessful, tube feeding may be indicated. In addition, patients who have a functioning GI tract but for whom oral nutrition intake is contraindicated should be consid- ered for tube feedings. If the GI tract is functioning and can be used safely, tube feedings should be ordered in- stead of parenteral nutrition when nutrition support is necessary because it • Is more easily absorbed physiologically • Is associated with fewer complications than TPN • Maintains the gut barrier to infection • Maintains the integrity of the GI tract • Is more cost-effective than TPN • Contraindications to tube feeding can be found in Table 11–3. Parenteral Nutrition Parenteral nutrition usually offers no advantage to the patient with a functioning GI tract. Because it does not achieve greater anabolism nor provide greater control over a patient’s nutritional regimen, parenteral nutrition is indicated only when the enteral route is not us- able; therefore, the following rule applies: If the gut works, use it. Some patients, because of their disease states, cannot be fed enterally and require par- enteral feedings. Enteral nutrition is to be avoided in the situations noted in Table 11–3. TPN is typically used in these patients and is discussed in detail in Chapter 12. Although parenteral nutrition can be given either via central veins (TPN) or by periph- eral veins (PPN), the tonicity of the fluid required to administer all nutritional requirements 11 Diets and Clinical Nutrition 213 11 214 Clinician’s Pocket Reference, 9th Edition 11 intravenously requires central administration, and thus PPN may be used as a supplement, but is not adequate to provide all nutritional requirements. PRINCIPLES OF ENTERAL TUBE FEEDING The factors involved in choosing the route for enteral nutrition include the projected dura- tion of feeding by this method, GI tract pathophysiology, and the risk for aspiration. Nasally placed tubes are the most frequently used. Patient comfort is maximized by using a small- bore flexible tube. When enteral feedings are started, it is often important to assess gastric residual volumes. The small-bore tubes do not allow for aspiration of residual volumes, however, which may be significant if gastric emptying is questionable. Thus, larger bore tubes are often used to start, and, once feeding tolerance is ensured, the tube is changed to a small-bore tube, which can be left in place comfortably for prolonged periods. Feeding di- rectly into the stomach (as opposed to the bowel) is often preferable because the stomach is the best line of defense against hyperosmolarity. Patients at risk for aspiration require longer tubes into the jejunum or duodenum. Types of feeding tubes and placement procedures are discussed in detail in Chapter 13, page 272. When long-term feeding is anticipated, a tube enterostomy is usually required. PEG tubes can usually be placed without general anesthesia. Patients with tumors, GI obstruc- tion, adhesions, or abnormal anatomy, however, may require open surgical placement. A je- junal feeding tube may be threaded through a PEG for small-bowel feeding. The placement of a needle catheter or Witzel’s jejunostomy during surgery generally allows for earlier post- operative feeding with an elemental formulation than waiting for the return of gastric emp- tying and colonic function. Enteral Products A variety of enteral products and tube feedings are available (see Table 11–4, page 215, for some examples). Check the enteral formulary for the specific products available in your fa- cility. TABLE 11–3 Contraindications to Tube Feeding Complete bowel obstruction GI bleeding High-output (>500 mL/d) enterocutaneous fistula or fistula not located in the proximal or distal GI tract Hypovolemic or septic shock Ileus Inability to obtain safe enteral tube feeding access Poor prognosis not warranting invasive nutritional support Severe acute pancreatitis Severe intractable diarrhea Severe intractable nausea and vomiting Severe malabsorption Anticipated duration of tube feeding therapy <5 d 11 TABLE 11–4 Composition of Some Commonly Available Enteral Formulas Component (per 100 kcal) kcal/ Protein Fat Carbohydrates Na + K + mOsm/ Product mL (g) (g) (g) (mEq) (mEq) kg Meal replacements Require normal proteolytic and lipolytic function. Contain lactose. Compleat B 1.00 4.00 4.00 12.0 5.20 3.40 390 Lactose-free Provides proximal absorption. Requires normal proteolytic and lipolytic function. Low residue. Ensure 1.06 3.70 3.70 14.5 3.60 4.0 450 Ensure Plus 1.50 5.50 5.30 19.7 4.90 5.90 600 Isocal 1.06 3.70 3.80 14.4 2.40 2.60 300 Magnacal 2.0 3.5 4.0 12.5 2.20 1.60 590 Osmolite 1.06 3.70 3.80 14.4 2.40 2.60 300 Sustacal 1.00 6.10 2.30 13.8 4.10 5.40 620–700 Travasorb MCT 1.00 4.90 3.30 12.2 1.50 4.50 312 Elemental formulas Provide rapid proximal absorption. Indicated for pancreatic-biliar y dysfunction, selective malabsorption, fistu- las, and short bowel syndrome (SBS). Low residue. Nutrients predigested. Peptamen 1.0 4.0 3.9 12.7 2.20 3.21 270 Reabilan 1.0 3.15 4.30 13.2 3.05 3.20 350 Reabilan HN 1.33 4.36 4.30 11.9 3.26 3.18 490 Vital HN 1.00 4.20 1.00 18.8 2.70 3.40 450 Vivonex TEN 1.00 3.82 0.28 20.5 2.00 2.00 630 Vivonex 1.00 2.04 0.15 22.6 2.00 3.00 550 (continued) 215 11 TABLE 11–4 (Continued) Component (per 100 kcal) kcal/ Protein Fat Carbohydrates Na + K + mOsm/ Product mL (g) (g) (g) (mEq) (mEq) kg Special metabolic May require vitamin-mineral supplement if used as principal source of nutrition. Amin-Aid 2.00 1.90 4.70 37.3 >1 >1 850 Glucerna 1.0 4.18 5.57 9.37 4.03 4.0 375 Pulmocare 1.5 4.17 6.14 7.04 3.80 2.95 490 Hepatic Aid II 1.17 4.30 3.60 16.8 >1 >1 560 Travasorb Hepatic 1.10 2.90 1.40 20.9 1.9 2.9 690 Travasorb Renal 1.35 2.30 1.80 27.1 >1 >1 590 Fiber-containing Nutritionally complete tube feeding that may help maintain nor mal bowel function and useful in patients who demonstrate intolerance to low-residue feedings. Enrich 1.1 3.62 3.39 14.3 3.35 3.94 480 (1.3 g fiber) Jevity 1.06 4.20 3.48 14.4 3.81 3.77 310 (1.36 g fiber) Note: Formulation of products at the time of publication. Actual components may var y slightly. 216 [...]... diameter) 3 4 5 6 34 7 32 8 9 30 10 11 28 13 12 14 24 26 22 15 16 19 20 17 18 241 Needle Gauge 3 French = 1.0 mm = 039 in 18 French = 6 mm = 236 in 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 Inches 1 1 2 Centimeters 2 3 4 5 3 6 7 4 8 9 10 5 11 A FIGURE 13–1A: French catheter guide and needle gauge reference (Courtesy Cook Urological.) 12 13 6 14 15 13 242 13 Clinician’s Pocket Reference, 9th Edition... 5-, 1 0-, 20-mL Needles: 1 8-, 2 0-, 2 2-, 25-gauge 1% Lidocaine (with or without epinephrine) Adhesive tape INSTRUMENT TRAY Scissors Needle holder Hemostat Scalpel and blade (No 10 for adult, No 15 for children or delicate work) Suture of choice ( 2-0 or 3-0 silk or nylon on cutting needle; cutting needle best for suturing to skin) French Catheter Scale in French units (1 French = 1/3 mm diameter) 3 4. .. Table 11–7 1 1 2 24 Clinician’s Pocket Reference, 9th Edition TABLE 11–7 Commonly Used Infant Formulas Formula Human milk Donor Maternal Breast milk fortifiers Standard formulas Isoosmolar Enfamil 20 Similac 20 SMA 20 Higher Osmolality Enfamil 24 Similac 24 & 27 SMA† 24 & 27 Low Osmolality Similac 13 1 1 Soy formulas ProSobee (lactoseand sucrose-free) Isomil (lactose-free) Nursoy (lactose-free) Indications*... 200 IU 60 µg 40 0 µg 5 µg Abbreviation: MVI–12 = multivitamin infusion–12 Pyridoxine (B6) 4 mg Dexpanthenol 15 mg Vitamin E (α tocopherol) 10 IU Thiamine (B1) 3 mg Riboflavin (B2) 3.6 mg Niacin 40 mg 12 232 Clinician’s Pocket Reference, 9th Edition TABLE 12–3 Suggested Trace Element Dosing Trace Element Parenteral Dose per Day Zinc Copper Selenium Chromium Manganese 2.5 4. 0 mg* 0.5–1.5 mg 20 40 mg 10–15mg... platelets b PT and PTT c SMA-7 and SMA-12; in particular check phosphate, glucose, and routine electrolytes (Na, K, Cl) d Urinalysis e Baseline weight 12 2 34 12 Clinician’s Pocket Reference, 9th Edition 2 Order the type of TPN desired along with the additives and supplements Medications are generally not added to TPN solutions except insulin and H2 receptor blockers A 0.2 2- m filter should be used with... cases can be provided within 24 h of prescribing If a formula change is necessary based on a change in patient status, discontinue the TPN and replace it with D10W at the same rate until a new bag of TPN can be provided 12 230 Clinician’s Pocket Reference, 9th Edition TABLE 12–1 Typical TPN Solutions for Adults Component CAA Dextrose Na K Ca Mg PO4 Cl Solution 1 4. 25% (42 .5 g/L) 25% (250 g/L, 850 Cal/L)... fat) A 1. 2- m filter should be used with three-in-one TPN 3 Nursing orders: a Check urine for sugar and acetone every 6-8 h, house officer should be called if sugar is >2+ or acetone is present b Take vital signs every shift c Change tubing and deep-line dress every other day (or per hospital procedure) d Weigh patient every other day e Monitor daily fluid balance 4 Laboratory monitoring: a SMA-7 daily... infusion-12 (MVI-12) The contents of 2 vials is added to 1 L of TPN solution daily (Table 12–2) In addition to MVI-12, 5–10 mg of vitamin K (phytonadione) must be given IM weekly Vitamin K may also be added to the TPN and given as a 1-mg IV dose daily Several manufacturers sell a trace element supplement that conforms to the AMA group’s guidelines Each milliliter contains 1.0 mg zinc, 0 .4 mg copper, 4. 0... solution per liter 1 2 3 4 5 6 7 8 27.5 g protein/L × 2 L = 55 g protein/ 24 h Recall that 1 g of nitrogen = 6.25 g of protein Nitrogen input = 55 g protein/6.25 g protein per gram N = 8.8 g Patient voided 22.5 dL urine/ 24 h with UUN 66 mg/dL Nitrogen lost in urine = 22.5 dL × 66 mg/dL = 148 5 mg, or about 1.5 g Add 4. 0 g for nonurine nitrogen loss Nitrogen output = 1.5 g + 4. 0 = 5.5 g Nitrogen balance... mEq/L 6 mEq/L 15 mMol/L 45 mEq/L Solution 2 4. 25% (42 .5 g/L) 12.5% (125 g/L, 42 5 Cal/L) 50 mEq/L 50 mEq/L 6 mEq/L 6 mEq/L 15 mMol/L 45 mEq/L Abbreviation: CAA = crystalline amino acids 12 Amino acid formulas are supplied as CAA or SAA in concentrations ranging from 3.5–15% These are diluted by the pharmacy to varying concentrations to provide for the necessary protein dose (2.75%, 4. 25%, etc) The final . 5.30 19.7 4. 90 5.90 600 Isocal 1.06 3.70 3.80 14. 4 2 .40 2.60 300 Magnacal 2.0 3.5 4. 0 12.5 2.20 1.60 590 Osmolite 1.06 3.70 3.80 14. 4 2 .40 2.60 300 Sustacal 1.00 6.10 2.30 13.8 4. 10 5 .40 620–700 Travasorb. vitamin-mineral supplement if used as principal source of nutrition. Amin-Aid 2.00 1.90 4. 70 37.3 >1 >1 850 Glucerna 1.0 4. 18 5.57 9.37 4. 03 4. 0 375 Pulmocare 1.5 4. 17 6. 14 7. 04 3.80 2.95 49 0 Hepatic. predigested. Peptamen 1.0 4. 0 3.9 12.7 2.20 3.21 270 Reabilan 1.0 3.15 4. 30 13.2 3.05 3.20 350 Reabilan HN 1.33 4. 36 4. 30 11.9 3.26 3.18 49 0 Vital HN 1.00 4. 20 1.00 18.8 2.70 3 .40 45 0 Vivonex TEN 1.00 3.82