Nutritional Support

Definitions

• Shock: Shock occurs when there is not enough blood flow to the body’s organs and tissues. As a result, organs and tissues do not receive enough oxygen and waste products build up. 
• Refeeding syndrome: Occurs when food is reintroduced to patients who have been extremely malnourished. It can lead to organ failure and is marked by biochemical abnormalities.
• ARDS: Adult respiratory distress syndrome (ARDS), a condition in which lung function is impaired because fluid has been built up in the lungs because the lung’s cells have been injured. 
• Pancreatitis: Inflammation of the pancreas.
• Respiratory quotient: The ratio of the volume of carbon dioxide produced to the volume of oxygen used. It is a measure that can be used to measure a person’s basal metabolic rate.
• Ileus: Obstruction of the gastrointestinal tract.
• Pulmonary edema: Fluid buildup in the lungs typically caused by an increase in pressure in the blood vessels of the lungs.
• Sepsis: Acute inflammation of the whole body

Pathophysiology

Describe the physiologic and biochemical changes which occur during the post-operative period for a patient having major surgery. How might this effect plans for nutrition support?

After major surgery patients may suffer from surgical trauma and experience physiological changes that lead to delayed gastric emptying and an increased risk of both nausea and vomiting. As a result, patients are often placed on elemental diets after major surgery. Elemental diets require little or no digestion and elemental diets are readily absorbed. However, patients receiving elemental feedings or no feeding for several days are at risk of catabolism, the loss of body cell mass, and delayed wound healing. Therefore nutrition support plans for patients after surgery must strongly consider the risk of malnutrition and the further complications of inadequate nutrition.

Describe the physiologic and biochemical changes which occur during sepsis/septic shock. How might this effect plans for nutrition support?

A patient with sepsis/septic shock will have a high temperature, rapid heart beat, rapid respiratory rate, and a change in white blood cell count and ultimately sepsis will lead to damage of the body’s organs. As the body adjusts to sepsis, muscle breakdown and gluconeogenesis occurs. Nutritional support is important during sepsis to enable protein synthesis and lessen muscle breakdown and gluconeogenesis.

What effect can malnutrition have on respiratory function? How might this effect plans for nutrition support?

Malnutrition can reduce respiratory function by decreasing respiratory muscle strength and the immune function of the lungs. Patients with respiratory function are often in a hyper metabolic state. Patients will require enough calories to match their energy expenditure which will likely be increased due to decreased respiratory function. 

What is bacterial translocation and why is it significant?

Bacterial translocation is the migration of bacteria across the intestinal border. This is significant for nutritional support because patients may be at heightened risk for bacterial translocation if they are receiving nutrition support and the GI track is not being stimulated.

Nutritional Management

Describe the different routes for administration of enteral feedings (PEG, NG and PEJ). Include indications for each route of administration in your description.

• PEG: A PEG is a feeding tube used to treat patients who require nutrition support for a long period of time. The feeding tube is placed directly into the stomach.
• NG: Nasogastric feeding tubes are inserted through the nose into the stomach. This is the most common form of enteral support and is used when the GI tract is still functional. 
• PEJ: A PEJ is a jejunal extension tube that is passed through the PEG tube in order to extend the site of feeding into the small intestine. This type of feeding tube is preferred in situations such as when a patient has delayed gastric emptying or when feeding can not occur directly into the stomach because of surgery.

Review the enteral feeding formulary for your institution and discuss appropriate enteral feeding formula use for each route. (You may want to do this in chart form.)  

Discuss re-feeding syndrome. Include in your discussion, the role of phosphorus in respiratory function. What are some possible consequences of over feeding a patient who requires mechanical ventilation?

In refeeding syndrome patients have low biochemical levels of phosphate, potassium, magnesium, and sodium. The biochemical abnormalities occur as a result of switching from a state of starvation (in which the body adapts to utilizing stored energy sources) to the reintroduction of food and use of carbohydrate as a main source of energy. Phosphorus is necessary for muscle contractions in the body. If phosphorus levels are low, body organs like the lungs which must contract in order for proper functioning will be unable to operate appropriately. If a patient is overfed their CO2 production will increase and will need to be removed. If the lungs are not functioning properly due to for example decreased phosphorus levels, then minute ventilation will need to be used to remove the excess CO2. This makes it complicated when monitoring patients on minute ventilation. Caloric intake should be matched to energy expenditure.

What is propofol (Diprivan)? What is the nutritional application of propofol?

Propofol is a drug used before surgery to relax patients and put them to sleep. It also contains 1.1kcal/mL and is often given alongside nutrition support. A patient receiving propofol should be monitored closely to ensure that overfeeding does not occur. The total kcals provided from the Propofol, a lipid based solution, should be counted for in the nutrition prescription.

What is the rationale for using MCT oil in the diets of patients with malabsorption syndrome?

MCT oil is used in patients with malabsorption syndrome because it is more readily absorbed than long chain triglycerides. They do not require bile salts or pancreatic lipase for absorption.

Nutrition Support Calculations

Pt. A is a 80 year old F admitted to the ICU with CHF. Ht: 5’5” Wt: 50 kg. She required intubation secondary to pulmonary edema. A naso-jejunal feeding tube has been placed. You are consulted to suggest an appropriate feeding. Calculate the appropriate feeding. Calculate calorie and protein needs and write a feeding prescription for this patient.

Kcal: 2062 kcal/d @ 25 kcal/kg – 2625 kcal/d @ 35 kcal/kg and stress factor:1.5
Protein: 75g/d @1.5 g/kg – 100 g/d @ 2 g /kg
Prescription: NJ: Pulmocare @ 237 mL + 50 mL H20 via NJ Q4H @ 125 mL/hr with flush 50mL H2O Q 4hr: Tvol: 1716mL Tcal: 2130kcal/d

Pt. B is a 74 year old M s/p severe CVA 7 days ago. Ht: 68” Wt: 160 lbs. He is NPO x 1 week. A PEG was placed yesterday. You acre consulted to suggest an appropriate feeding. Calculate his calorie and protein needs. Write a diet prescription for this patient.

Kcal: 2362 kcal/d @ 25 kcal/kg – 3308 kcal/d @ 35 kcal/kg and stress factor: 1.3
Protein: 109 g/d @ 1.5 g/kg – 145 g/d @ 2.0 g/kg
Prescription: PEG: 2 Cal HN @ 237 mL + 75 mL H2O via PEG Q4H @ 125 mL/hr with flush 75 mL H2O Q4H; Tvol- 2062 mL/d; Tcal- 2850 kcal/d

 Click here to view the Nutrition Support chart review.

INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Nutrition Support

CHARTING TYPE: Not specified 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

List out the medications by their generic name so they are easily recognized by other dietitians and to save space on the assessment form

Do not exceed .8 g/kg for protein because the patient has chronic renal failure

When recommending a change always state that you will consult with the MD

The MD will more than likely maintain the fluid, protein, and calories at the same level because the patient is overweight and has chronic renal failure

Use N/A for food preferences and allergies for all tube feeding patients

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

The patient was in a vegetative state and was therefore unreceptive to nutrition education. The patient’s family was also not present. For this assessment I did not agree with Mr. Harris (the dietitian I was working with on the case) about an appropriate protein level. I felt as though the patient should be receiving at least 1 g/kg because his GFR indicated 1 g/kg was an appropriate level and because he had a stage 3 pressure ulcer. I felt as though the 57kg the patient was receiving was too low. Mr. Harris and I also disagreed about placing N/A for food allergies. I believed that a patient may still be able to have an allergy to a component of their tube feeding and therefore stating none known would be more appropriate than N/A. 

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

The MD did not increase the calories or protein for this patient. He believed that increasing protein would be too big of a strain for the patient considering his chronic renal failure. The MD also did not increase kcals because the patient was currently overweight.