deficiency in TOTAL ENERGY INTAKE

muscle wasting (Somatic=skeletal)

adipose tissue wasting

maintain visceral protein (albumin & transferrin)

ex: famine

OK energy intake 

low protein intake

in CATABOLIC conditions -burns, trauma, infection

DEPLETES visceral proteins

Preserves adipose

What things do you inquire about when doing a nutritional intake history?

(3)

APPETITE

MEAL CONTENT

DIETARY HISTORY

When assessing nutritional status, do you look for during a physical exam?

(5)

1. Temporary wasting
2. loss of muscle mass
3. evidence of excess fluid
4. pedal andd pre-sacral edema
5. ascites ( may be alcoholic or have CHF)

male = 50 + 2.3( inches over 5ft)

femal = 45 + 2.3(inches over 5 ft)

What is the equation for % of IBW ?

                 ABW   x 100

                 IBW

When do you consider a person to be

 "moderately malnurished"

When do you consider a person to be

 "severly malnurished"

How can you measure body fat?

Locations?

Anthropometric measurements

1. Tricep Skin Fold Thickness
2. Mid-arm circumference
3. Arm muscle circumference

What labs do you look at for nutrition status?

Albumin

Transferrin

Tranthyretin

Nitrogen balance

What is the range & half life

for

 albumin?

3.5 - 5 g/dL

half life = 20 days

What is the range  & half life

for

transferrin ?

250 - 430 MG/dL

half life = 7 days

What is the range and half life

 for

transthyretin (pre-albumin)?

17-42mg/dL

half life = 2 days

Put in order of half life

transferrin, albumin, transthyretin

transthyretin (pre-albumin) 2 days

transferrin - 7 days

albumin - 20 days

dehydration

anabolic steroids

insulin

infection

• over hydration
• edema
• renal problems
• nephrotic problems
• thyroid/ adrenal / pituitary hormones
• poor dietary intake
• impaired digestion
• burns
• CHF
• cirrohis
• trauma
• sepsis

What can cause value of 

transthyretin (pre-albumin) to decrease?

cirrohis

hepatitis

stress

surgery

inflammation

HyPER thyroid

cystic fibrosis

renal problem

zinc deficiency

pregnancy

iron deficiency

hypoxia

chronic blood loss

estrogen

What can cause a decrease in transferrin?

chronic infection

cirrohis

burns

enteropathus

nephrotic syndrome

cortisone

testosterone

N_in - N _out  = Protein(g) - (N_{urine +} 4 g)

6.25

6.25g protein produces 1g Nitrogen

(N_{urine +} 4 g)  =  N_out

If the nitrogen balance is negative,

What do you do?

patient put under tent to collect all of gases released

measure CO2 to oxygen ratio

usually done in ICU

carb metabolism releases CO2

Calculation:

75 yr old male

weight = 67kg

ht= 5' 9"

What is his fluid requirement?

2205 ml/day

10 kg x 100ml/day = 1000 ml

10kg x 50ml/day = 500 ml

47 kg x 15ml/day = 705ml

1st 10 kg  = 100ml/kg

2nd 10 kg = 50ml/kg

additional kg = 20ml/kg   if < 50 yrs

                      = 15ml/kg  if over 50 yrs

Calculation:

75 yr old male

weight = 67kg

ht= 5' 9"

What is his basal energy expenditure?

BEE _male= 66 + (13.7 x wt_kg) + (5 x ht_cm) - 6.8(age)

BEE = 66 + (13.7 x 67kg) + (5 x175.26cm) - (6.8 x 75 yrs)

= 1350.2 kcal/day

1350.2 - 15% = 1147.7kcal

Which of the following are excreted by the kidneys...

Na, Cl, PO4, Mg, K, Ca

Calculation:

35 yr female

ht: 64"

wt: 140 lbs

has severe burns - injury factor = 1.85

-activity factor (oral) = 1.2

What is her BEE?

BEE _female= 655 + (9.6 x wt_kg) + (1.7 x ht_cm) -

4.7(age)

BEE _female= 655 + (9.6 x 63.6_kg) + (1.7 x 162.6_cm) -

4.7(35 yrs)

= 1377.4 x 1.85 x 1.2 = 3058 kcal

(no discount when burns, trauma, or infection)

Calculation:

Find Nitrogen balance..

Patient given 53 g of amino acids

Nurse collected 30g of nitrogen in urine

N_in = 53 g amino acids =8.48 g Nitrogen

         6.25g AA/1g N

N_out = 30g_{urine Nitrogen} + 4 g = 34 g

= 8.48 - 34 = -25.52g 

   NEG Balance = give more AA or more calories or both

Calculation:

Find Nitrogen balance..

Patient given 67 g of amino acids Nurse collected

4.2g of nitrogen in urine

N_in = 67 g amino acids = 10.72 g Nitrogen

         6.25g AA/1g N

N_out = 4.2g_{urine Nitrogen} + 4 g = 8.2 g

= 10.72 - 8.2 =  + 2.52g 

POSITIVE balance w/ no errors (> 5g)

TLC (total lymphocyte count)

= WBC (cells/mm³) - %lymphocytes/100

Protein requirements:

NPC : N ratio

1.  renal failure

2. severe stress

3. normal renal; moderate stress

renal failure:                       350-400 :1

severe stress:                     80 -100:1

Normal renal; mod stress      150:1

Non-protein calories = # g N

150

Ex:    150:1 = NPC:N           

What are the Na , K, and Cl meq required....

 per 24hrs?

per 100mls?

Na & Cl  = 1 - 1.7 meq/kg/24 hr

K= 0.9 - 1.3mew/kg/24 hrs       

Na & Cl = 3 meq

K = 2 meq

What are the TPN requirements for .....per 1 L?

Mg

K

Ca

P

Ca  5meq

Mg  8meq

K  20 - 40 meq

P  10-15 mMol

Patient is HyPO-albumic,  

What will happent to the serum calcium values?

you see 0.8 decrease Calcium

 for every 1 g albumin decrease

other IV fluids  Na, Cl, & K

additives

Amino acids - acetate, Cl, Na, P

Drugs -

antibiotic, Shol's soln, Mg antacids, Al OH₂ bind P

no more than 60 % of non-protein calories

or

2.5-3 g fat/kg/day MAX

Zinc

Copper

Chromium

Manganese

Iodine

B1 - thiamine

B2 riboflavin

B3 - niacin

B6 - pyridoxine

Folic acid

B12 - Cyanocobalamin

have prolonged PT (prothrombin time)

optional treatment

optional

for those w/ prolonged PT & NOT on oral anticoags

2-4mg weekly

What are some GI disorders that indicate use of TPN?

• IBS
• chronic vomiting
• chronic diarrhea
• GI fistulas
• Pancreatitis
• Mal-absorption (short bowel syndrome)
• develop abnormalities
• mechanical/function obstruction

What hypermetabolic states require TPN?

(3)

Burns

severe trauma

Long Bone fracture

patient selection for  Parenteral nutrition

when Enteral nutrition is....

inadequate

impossible

hazardous

inadvisable

Renal failure

Hepatic insufficiency

cardiac disorder

psycho problem (anorexia )

malignancy

mucositis

after surgery that prevents enteral feeding for several days

When should patient get CENTRAL TPN?

if they can NOT use enteral route for

at least 5 days

What clinical settings is TPN recommended?

• GI - malabsorption of nutrients

           -small bowel disease

           -intractable vomiting

           - severe diarrhea

           - radiation enteritis

• pancreatitis (mod-severe)
• high dose chemo, bone marrow transplant, radiation
• severe malnourished (early TPN w/ in 1-3 days)
• severe catabolic - 50% + burns, multisys trauma, sepsis, severe IBS

Person has function GI tract

do you recommend TPN

Person under minimal stress and trauma

is well-nourished

Do recommend TPN if GI is usable in 10 days?

1. Isoleucine
2. Leucine
3. Lysine
4. Methionine
5. Phenylalanine
6. Threonine
7. Tryptophan
8. Valine

How many calories do you get from

anhydrous dextrose (IV)

carbs

fat

protein

anhydrous dextrose = 3.4 cal/g

carbs (dietary) = 4 cal/g

fats = 9 cal/g

protein = 4 cal/g

reduce dextrose (carbs)

carb metabolism creates CO2

Peripheral  TPN require a

MAX of ______ % dextrose

If a patient is fluid restricted

what kind of TPN is recommended?

Patient is getting enteral feeding

how do you prevent diarhhea?

start @ 1/2 strength for 24 hrs

then increase

What 2 additives can interact if added

close together?

superior vena cava

can also use subclavian or jugular to reach superior vena cava

What are the advantages of

Central TPNs?

Cheaper than Peripheral

max caloric intake

ok for volume restricted patients

long term catheter maintence

(use if needed for more atleast 5 days)

What are the advantages of

Peripheral TPNs?

short term use

no central catheter needed

decreased sepsis w/ catheter

avoid hyperosmol problems

What are the disadvantages for a

Central TPN?

sepsis @ catheter is a problem

hyperosmol side effects

hazardous catheter insertion

What are the disadvantages to

peripheal TPNs?

not for fluid restricted

need to rotate veins

caloric intake limited

 thrombophlebitis

fat is higher cost (increases calories)

1.  Assure proper catheter placement w/ chest x-ray

        - run D10W or D5W until confirmed @ 50ml/hr

2.  infuse @ constant rate w/ infusion pump

3.  gradually advance dextrose

      - day 1  = 1000cal

      - day 2  = 2000 cal

      - day 3 = 2500 -3000 cal 

  ***control hyperglycemia before advancing

Central TPN

patient does not have glycosuria

What is the serum glucose level?

CENTRAL TPN

Patient has glycosuria

What do you do?

control w/ insulin

or

give less dextrose and increase FAT

quick method

• reduce rate by 50% 1-2 hrs
• reduce rate again by 50 % 1-2 hrs
• d/c

if less than 1000 calories no need to taper

caution if on insulin (IV or Sub Q) may need dextrose

*** reduce downward and increase enteral calories

rebound hyPOglycemia

b/c have increased insulin production due to increased dextrose

Metabolic complications of TPN

related to Glucose and fat

• post infusion hyPOglycemia
• EFAD (essential fatty acid defic)
• hyperglycemia
• ketoacidosis
• hyperLipidemia
• hyperosmol syndrome

Metabolic complications of TPN

related to

acid-base and nitrogen

metabolic ACIDOSIS

hyper-ammonia (premies, infants, patient w/ liver failure)

azotemia

Metabolic complications of TPN

related to

fluids and minerals

hyper / hypo    Na, Mg, K, PO4, Ca

under / over  hydration

trace element deficiency

Metabolic complications of TPN

related to vitamins

hyper /hypo D

hyper A

hypo K

hypo B's

Metabolic complications of TPN

related to

"other problems"

refeeding syndrome

metabolic bone disease

How often do you moniter

urine glucose?

How often do you moniter

Serum glucose

serum electrolytes

BUN

initially  daily

Stable:  3 times a week

How often do you moniter

weight

what 5 things are monitered

 WEEKLY once patient is stabilized?

1. Bilirubin, liver enzymes
2. CBC - Hgb, Hct, WBC
3. PT
4. Mg²⁺
5. albumin

If patient is" glucose intolerant"

how often should you check their serum glucose?

Q 6hrs finger stick (Visidex) or lab