1. Is the nasogastric feeding route appropriate for this patient? Why or why not?

No, the nasogastric feeding route is not appropriate for this patient. This patient is at high risk
for aspiration and regurgitation due to his decreased level of alertness and lapses of
consciousness. However, enteral feeding is still necessary in this case because he is unable to
have oral food route (eat properly) due to his broken jaw and decreased level of alertness.
Taking into consideration his functional gut, nasoduodenal feeding route is the optimal route. A
nasoduodenal tube feeding should also be appropriate because it will be relatively for short
term (less than 4 weeks) until his jaw has recovered.

2. What daily intake of kcals, protein, and fluids would you recommend for this patient and why?
Show calculations for estimated needs, give recommendations as kcal/d, g protein/d

Estimated Energy Requirements (EER)= REE x activity factor x injury factor (MSJ equation)
REE: (10 x weight (kg)) + (6.25 x height (cm)) – (5 x age) + 5
REE: (10 x 71kg) + (6.25 x 180 cm) – (5x 35 yo) + 5 = 1660 kcal
Activity factor: 1.2 (confined to bed) , stress factor 1.3 ( skeletal trauma)
EER= 1660 x 1.2 x 1.3= 2,589.6 kcal/d approximately 2600 kcal/day

Protein:
Due to wound healing and injuries, the patient’s protein needs should be elevated to 1.5
g/kg/day.

1.5g/kg x 71kg = 106.5 g/day; approximately 106 g/day

Fluid: 1 mL/kcal x 2600 kcal = 2600 mL/day

3. Based on the needs of this patient, describe three desirable characteristics for the type of
formula you would recommend.

Based on patient’s needs, the desirable formula is polymeric not hydrolyzed since he does not
have any digestive problems and have a normal absorptive capacity. Also, it should contain high
energy (concentrated formula) so that it can meet his caloric needs. Also, high in proteins so it
can meet his increased protein needs due to his injury and catabolic state.
High nitrogen polymeric formula is suitable in this case as it have high protein content and 1-2
kcal/cc
It’s better to have 2-4% of calories from linoleic and linolenic acids and designed to meet DRIs
for vitamins and minerals, thus nutritionally complete.

4.
a) Based on the enteral formula you selected in the question above, what daily total
volume of formula would meet Mr. R’s estimated caloric needs? Show calculations.
 Goal 2600 kcal
The formula provides 1 kcal/cc so it provides 2600 cc/day
b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr
infusion? Show calculations.
2600/24 = 108 ml/hour is the hourly rate to meet Mr. Rabih’s needs
c) Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what
else is needed and how it would be added to the current tube feeding. Show
calculations.
His fluid needs are 2600 ml and it can be reached by tube feeding 2600 cc, and the
hourly rate 108 cc/hour is adequate (max tolerated rate 125cc/hr)
If the fluid’s needs were not met, extra water via tube could be added or extra fluid is
obtained by tube flush
5. Which type of PN support do you recommend – central or peripheral? Justify your answer.

Central Vein feeding is recommended, as it is usually used when patient is unable to tolerate
enteral feeding for more than 5-7days, with stress and elevated metabolic rate (hyper-
metabolism from multiple bone fractures and head injury), it is also used when the patient
requires higher caloric needs. Because the patient is receiving all of his nutrition parentally and
has high nutritional needs, the solution has a high osmolality. Peripheral parental nutrition
solutions must be limited to < 900 mOsm/L to avoid thrombophlebitis of the vein. Central access
allows a higher osmolality formula because it is a high flow area (large central vein, usually
superior vein cava). Second, central access allows multiple administrations in which fluid,
nutrients and medication could all be administered at one time. Peripheral parental nutrition is
restricted not allowing additional components like medications

6. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of the
patient’s total kcal needs. Show calculations

10% emulsion =1.1 kcal/ml

20% of caloric needs = 20% of 2600 = 520 kcal
1ml - - - - > 1.1 kcal
X < - - -- - - 520 kcal
X= 520 x1 /1.1 = 473 ml

7. The MD wants the dextrose and amino acid solution to be a total volume of 2 L/day. (The
volume of lipid emulsion is separate from this 2 L)
a) Determine the final amino acid concentration of this solution, which would supply 110 g
protein/day. Show calculations.
110 g protein/ 2000 mL x 100% = 5.5%
the final amino acid concentration of this solution is 5.5 %
b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals
from CHO and as grams of dextrose. Show calculations.
20% lipids = 520 kcal
Protein = 110 g x 4 kcal/g = 440 kcal
 CHO calories = total calories – (calories of prot + calories of fat) = 2600 -520-440 = 1640
kcal
1 g of dextrose has 3.4 kcal
1 ------ > 3.4

X < -- -- - - 1640

X= 1640 x 1 /3.4 = 482.35 approximately 483 g of dextrose

c) Determine the final dextrose concentration of the solution. Show calculations.

(483 g /2000ml) x 100=24.15% dextrose solution

d) If the PN solution had to be made from a starting stock solution of D50W (500 g
dextrose in 1 L of water), what volume of this stock D50W would be needed to provide
the grams of dextrose that you calculated in question 9b above? Show calculations.
500g ------ > 1 l

483 g -- -- -> x

X = 483 x 1/500 = 0.966 L or 966 ml of D50W

e) Compare the grams of dextrose to be provided in this solution with the maximum
glucose infusion rate for Mr. Rabih of 5 mg/kg BW/min. Would you make any changes to
the PN solution based on this information? Explain your rationale. If so, how would you
change it?
Rate = dextrose in mg / patient’s weight in kg / minutes of infusion = (483 x
1000)/71/(24 x 60) = 4.73 mg/kg/ min < 5 mg/kg/min
No, I would not make any changes to the PN solution because the calculated rate of
dextrose is below the maximum tolerated rate. However, I would monitor the patient to
make sure he reacts well to this infusion rate and tolerates it.

f) Mr. Rabih develops hyperglycemia while on PN support. Describe an action you would
recommend to help lower blood glucose and achieve metabolic control of the patient.

1) Lower the amount of dextrose given. It is possible that the ratio of dextrose in
the solution is high (rate was near the maximum of 5) and if we were to reduce
the % of dextrose and increase the ratio of either lipid or protein we could still
provide adequate energy while reducing blood glucose.
2) Consider adding exogenous insulin to the solution to bring down blood glucose.