NUTRITIONAL & METABOLIC SUPPORT

(2004)

PHILIPPINE SOCIETY OF PARENTERAL

AND ENTERAL NUTRITION
Philippine Society of Parenteral & Enteral Nutrition
c/o UST Dietary Department, 3/F Medicine Building,
University of Santo Tomas Hospital, España Manila
Tel #: 7499794

Officers

President Jonathan M. Asprer, M.D.

Vice President Luisito Llido, M.D.
Secretary Marianna S. Sioson, M.D.
Treasurer Edel G. Navarrette, R.N.D

Board of Trustees
Eliza Mei Perez-Francisco, M.D.
Edmon Gutierrez, RPh
Jesus Fernando Inciong, M.D.
Victoria Manuel, M.D.
Eduardo Santos, M.D.
Reynaldo Sinamban, M.D.
Rey Resurrecion, M.D.

Advisory Board
Samuel Ang, M.D.
Cenon Cruz, M.D.
David Dy, M.D.
Claver C. Ramos, M.D.
NUTRITIONAL AND METABOLIC SUPPORT CPM 9th EDITION

Algorithm for Nutritional and Metabolic Support

1

Critically ill
patient
(stressed/injured)


Nutritional Screening
& Assessment

3 4 5





Weight Laboratory:
History & Physical
Anthropometry Serum albumin
exam
MAMC or (transferrin,
SGA (subjective
Triceps Skin Fold prealbumin)
global assessment)
Physiologic Function Total lymphocyte count
(Muscle strength)

6 7


Values/ Y Give normal diet or feed according

Responses  to the prescribed diet
normal?

8 N


Evaluate nutritional demands:

Requirement for fluids, calories,
protein, fat, electrolytes, vitamins &
trace elements

9 10


Oral Y Feed according to the

ingestion  prescribed diet
ok?

11 N 12


Consider
GIT Y Enteral
functional?

Nutrition
and PPN
13 N


14

GIT dysfunction Y
expected to persist  Consider
TPN
for >7 days?

15 N


Consider
PPN Figure 1

296
CPM 9th EDITION NUTRITIONAL AND METABOLIC SUPPORT

Algorithm for Nutritional Support

Figure 2: WHEN TO GIVE PRE-OPERATIVE NUTRITIONAL SUPPORT

Screening:
All Surgical Patients Body Mass Index (BMI)
BMI ≤18


Assessment of Risk for Serum albumin
Nutritional Complications Total lymphocyte count
SGA (subjective global assessment)


Moderate to Severe
Malnutrition


7 - 10 Days Combined enteral &
Nutritional Support parenteral nutrition, as tolerated

Surgical
Patients

2 3 4


Y Enteral Nutri­
Nutritional  Functioning  Go to Figure 3B
 tion/Oral Formula
Assessment GI tract?
Supplements

N
5 6 7


PN for
Parenteral Y
Nutrition
 more than 4  Central PN  Go to #9
weeks?

N
8 9


GI function Y
Enteral Nutri­  Go to Figure 3B
returns? tion

10 N


Go to #7

Figure 3. Selection of Route of Delivery

297
NUTRITIONAL AND METABOLIC SUPPORT CPM 9th EDITION

Enteral Nutri­
tion

2 3 4 5


Tube feeding Risk for pulmonary Y

Y
for more than  Enterostomy  aspiration?  Jejeunostomy
4 weeks?

N N
6 7


Nasoenteric 
Gastrostomy
tube

8 9 10 11



Risk for pulmo­ Nasoduo­

Y denal or GI function Y Standard for­
nary aspiration?   
Nasojejunal normal? mula
tube

N N
12 13 14



Nasogastric Specialty Formula toler­

formula  ance
tube

15 16 17


Progress to
Y more complex
Go to #10 Adequate?  diet and oral
feedings as
tolerated
N
18


PN Supple­
menta­tion

19


Figure 3B
Progress to
Total Enteral
Feedings

298
CPM 9th EDITION NUTRITIONAL AND METABOLIC SUPPORT

algorithm for Nutrition Support Management Protocol

1

Hospitalized
Patients

2


Patient Screen­
ing

4
3


1. Develop a
nutrition
Is patient at Y care plan.
risk? 
2. Implement
a nutrition
care plan.
5


Patient Moni­
toring

6 7 8


Patient Reas­
Are there Implemen-
N sessment and
changes in Y tation of Nutri­
patient's
 Updating of 
tion Care Plan
Nutrition Care
status?
Plan
N
9 10 11 12



Evaluation of
Terminate ther­
Care Setting
apy as goals In patient care still Y Acute In Pa­
(Progres­   tient Care
are achieved required?
sion Towards
Goals)
N
13 14 15





Discharge
Admit Patient Go to #4
Planning

Figure 4

* Organization of Nutrition Support Services for Hospitalized Patients

Adapted by PhilSPEN (From: ASPEN Board of Directors)
299
NUTRITIONAL AND METABOLIC SUPPORT CPM 9th EDITION

110 242
238
234
230
225
100 222
218
3'7" 1.1 214
Weight 210
3'9" 206
202
1.2 90 198
Height 194
4'1" 190
188

4'3" 1.3 182

80 178
174
4'5" Body Mass Index 170
166
4'7" 1.4 40 162
158
OBESE 70 154
4'9" (ABOVE 30) 30 150
146
1.5 OVERWEIGHT 27
142
138
(Above 27 - 30) 60 134
5'1"
25
24 130
23 126
22
5'3" 1.6 NORMAL 21
122
116
BMI 20
114
5'5" (18.5 - 27) 18.5 50 110
106
102
5'7" 1.7 15
98
94
40 90
5'9" UNDER 86
82
WEIGHT 78
1.8 (BELOW
10 74
70
18.5) 30 66
6'1" 62
58
54
6'3" 1.9 50
20 46
42

6'5"
38
34
30
26
6'7" 2.0 10 22

Body mass Index (BMI) Nomogram

Determine patient’s BMI by measuring the height and weight and plotting a line
connecting the two values. The interpretation is indicated therein.

300
CPM 9th EDITION NUTRITIONAL AND METABOLIC SUPPORT

Nutritional and Metabolic Support

Compiled and edited by:
Jonathan M. Asprer, M.D.

Nutritional and metabolic support refers to the provision • Fatigue/diminished mental activity
of adequate calories and protein to supply the increased • Weakness or loss of strength
metabolic demands of critically ill patients subjected • Hair loss, texture; keratomalacia
to stress and/or injury in the intensive care setting. It • Cheilosis, glossitis
involves a close colla­boration between the physician and • Skin rash, petechiae bruising
allied health professionals to pres­cribe and implement • Muscle wasting
nutritional support. Thus, the diagnosis and treatment • Hepatomegaly
of the nutritionally challenged hospitalized patient is • Edema
the focus of clinical expertise on a multidisciplinary • Peripheral neuropathy
level. • Gastrointestinal function

Nutritional Screening and Assessment Anthropometrics

Nutritional screening and assessment can be done with Ideal Body Weight
readily available and relatively inexpensive methods. Adult Females
Four key questions should be addressed for a nutritional 100 lb (45 kg) for the first 60 inches (152 cm) + 5 lbs
assessment: (2.3 kg) for every inch >60.
1. Was the patient normally nourished prior to this Adult Males
disease? 106 lb (48 kg) for the first 60 inches (152 cm) + 6 lbs
2. Is the patient at risk for developing morbidity or (2.7 kg) for every inch >60.
mortality?
Percent of Usual or Ideal Body Weight
3. What is the cause of under/overnutrition?
Significant potential for malnutrition:
4. Is the patient likely to respond to nutritional treat­
(a) >5% weight loss in 1 month
ment?
(b) >7.5% weight loss in 3 months
Nutritional assessment is only useful if there is an effec­ (c) >10% weight loss in 6 months
t­ive treatment; it is not enough to assess and identify
Mid-Arm Muscle Circumference (MAMC)*
mal­nutrition. Outcomes are improved and cost saved
MAMC (cm) = MAC (cm) -3.14 (triceps skin fold in cm)
only when appropriate intervention follows. There is
1. Assess skeletal mass
subs­tantial evidence that nutritional therapy including
2. Compare with normal values
nutri­tional assessment and appropriate nutritional inter­
<5th % = depletion
ven­tion improves health outcomes, lowers costs, saves
5-25th % = at risk for obesity
lives, and reduces morbidity. Such early nutritional
<85th % = at risk for obesity
assess­ment and appropriate nutritional intervention
must be accepted as essential for quality healthcare Muscle Function
delivery. Muscle function testing is not usually useful as an initial
screening tool but may be useful in serial assessments.
Proper nutritional assessment should evaluate anthro­
Improvements in hand grip strength measured by dy­
pometric and laboratory data in addition to a compre­
namometry or respiratory muscle strength (peak inspira­
hensive history and physical examination. Every
tory and expiratory pressures) are useful.
hospitalized patient should have a basic nutritional
assessment within 48 hours of admission and ideally, Triceps Skin Fold Thickness*
every 10 days thereafter. 1. Assess fat stores
2. Compare with normal values
History and Physical Examination * Not routinely used because of operator-dependent vari­
A simple clinical assessment based on a com­pre­hensive ability; unreliable indicator of short-term res-ponse to
history and a thorough physical examination re­veals a nutritional therapy.
surprisingly adequate assessment of nutritional status.
Laboratory Measurements
Some of the more important data include:
• Unusual dietary habits Nitrogen Balance
• Medications/vitamin and mineral supplementation • Often helpful in determining whether sufficient pro­
• Dysphagia/odynophagia tein and/or calories are being provided.
• Abdominal pain/distention/diarrhea g protein/d
• Bone pain N1(g) = 6.25
• Muscle pain, cramps, or twitching The average protein is approximately 15% nitrogen,
• Numbness, paresthesias in extremities hence 6.25 is used as the denominator.
301
NUTRITIONAL AND METABOLIC SUPPORT CPM 9th EDITION

To calculate nitrogen output. and measurement of inspired O2 and expired CO2

• Use 24-hour total urine nitrogen (TUN) or urine urea using the Weir equation.
nitrogen (UUN). TUN is preferable. UUN represents,
on the average, only 80-90% of TUN. Situations In Which Metabolic Measurements May Be
• Daily fecal N losses in patients without mal­absorption Unreliable
or protein-losing enteropathy during paren­teral nutri­ • FiO2 >60%
tion ranges between 0.3-0.8 g/day or approximately • Hyperventilation
8 mg/kg/day. • Poor patient cooperation (agitated or sleeping)
Indirect Calorimetry • Bronchopleural fistula, endotracheal tube cuff
(requires specialized equipment in the form of a “meta­ leak
bolic cart”) • PEEP, PEFR
Measures the basal energy expenditure (BEE) re- • Tremor, seizures
quired to fuel basic life functions at rest in a neutral
Visceral Proteins
thermic environment, 10 or more hours after eating.
• Helpful in estimating caloric requirements, es­pecially Albumin
in patients who are significantly under­weight or Normal (3.5-5.0 g/dL)
overweight, (with significant fluid retention) or sig­ Mildly depleted (3.0-3.5 g/dL)
nificantly catabolic. Moderately depleted (2.5-3.0 g/dL)
• BEE is estimated from known values of heat produced Severely depleted ( <2.5 g/dL)
by the combustion of carbohydrate, fat, and protein • Most widely available laboratory examination
• More useful as a prognosticator of risk for nutrition-
Methods of Measuring Skinfolds and Circumferences associated complications than as an actual indicator
of nutrition status
Skin folds • Poor indicator of short-term changes in visceral
1. Start at the anatomic site as defined (the midpoint pro­tein status and may be unreliable after fluid resus­
between the acromial and olecranon processes of citation and in certain medical conditions, due to
the scapula and the ulna, respectively. The arm fluxes induced by shifts in body fluid compartments
should hang relaxed at the patient's side).
• Should not be used to monitor adequacy of nutri­tional
2. Lift the skin and fat layer from the underlying
repletion once therapy has been initiated
tissue by grasping the tissue with the thumb and
forefinger. • Non-nutritional factors may elevate albumin levels
3. Apply calipers about 1 cm distal from the thumb (eg. albumin infusion, dehydration, renal failure,
and forefinger, midway between the apex and the anabolic steroids) while others may depress albumin
base of the skinfold. levels (eg. pregnancy, severe burns, protein-losing
4. Continue to support the skinfold with the thumb and enteropathy, nephrotic syndrome, edema, hepatic
forefinger for the duration of the mea­sure­ment. insufficiency, neoplastic disease, severe infections,
5. After 2 to 3 seconds of caliper application, read trauma, or post surgery)
skinfold to the nearest 0.5 mm. Pre-albumin (Not normally available outside a research
6. Measurements are then made in triplicate until
context)
readings are within ± 1.0 mm; results are then
Normal (18-24 mg/dL)
averaged.
Mildly depleted (16-18 mg/dL)
Circumferences Moderately depleted (14-16 mg/dL)
1. The tape should be maintained in a horizontal posi­ Severely depleted ( <14 mg/dL)
tion touching the skin and following the contours
of the limb, but not compressing the underlying • 1.9 day half life
tissue. • More sensitive marker than albumin for assessing
2. Measurements should be made to the nearest mil­ rapid nutritional changes, although subject to similar
limeter, in triplicate, and then averaged, as previ­ non-nutritional factors.
ously described for skinfolds. • May be elevated in renal failure and suppressed in
• Integumental losses, in the absence of large wounds hepatic failure.
or burns, range between 7 mg/kg/day for women • Pre-albumin and nitrogen balance measurements are
and 8 mg/kg/day for men the preferred parameters in the assessment of total
Nitrogen balance = N intake (I) - Noutput (0) or N1 - (UUN + 4) body protein status.
• Unfortunately, not widely available locally
For anabolism, + N balance of at least 4-6 g is
required. Transferrin (usually available only in a research con­
text)
• Achievement of positive N balance requires not Normal (200-250 mg/dL)
only sufficient protein or amino acids, but adequate
Mildly depleted (170-200 mg/dL)
calories as well.
Moderately depleted (140-170 mg/dL)

302
CPM 9th EDITION
Severely depleted ( <140 mg/dL)
• May be elevated due to iron deficiency anemia, as an
acute phase reactant, during pregnancy, or during the
use of oral contraceptives.
• May be suppressed in renal and hepatic failure despite
adequate protein status.
• Although a significant relationship exists between
serum transferrin concentration and nutritional sta­
tus, the variation in concentration may lend a greater
usefulness in population studies rather than in the
individual patient.
• Not widely available locally.
Immune Function
Total Lymphocyte Count
TLC = WBC x % Lymphocytes
Normal (1600-4000 per mm3)
Mild depletion (1200-1600 per mm3)
Moderate depletion ( 800-1200 per mm3)
Severe depletion (<800 per mm3)
• May be depressed by non-nutritional factors inclu­ding
chemotherapy, radiation therapy, gluco­cor­ticoids, and
viral infections.
Delayed Hypersensitivity Skin Tests
• Commonly used antigens include candida and inter­
mediate strength purified protein derivative (PPD). A
5-mm response or greater at 24-48 hours is considered
a positive response.
• May be affected by non-nutritional factors including
corticosteroids, T-cell deficiency, cancer, immuno­
suppressive medications.
Subjective Global Assessment (SGA)
A. History:
1. Weight Change:
Over-all loss in past 6 months ­­____ kg;
% Loss ______;
Change in past two weeks _____ increase ______
no change _____ decrease _____
2. Dietary intake change relative to normal
No change ____
Change: duration _____ weeks _____
Type: suboptimal solid diet _____full liquid
diet _____ hypocaloric diet ____starvation _____
3. Gastrointestinal symptoms
None _____ nausea ____ vomiting ____
diarrhea _____ anorexia ____
4. Functional Capacity
No dysfunction _____
Dysfunction: duration _____ weeks _____
Type: working sub-optimally _____
ambulatory ____ bedridden _____
5. Disease and its relationship to nutritional
requirements
Primary Diagnosis: _____________
Metabolic Demand/Stress: no____low ____
moderate ____ high ____
NUTRITIONAL AND METABOLIC SUPPORT
B. Physical (for each specify: 0 = normal, 1+ = mild,
2+ = moderate, 3+ = severe)
Loss of subcutaneous fat (triceps) _______
Muscle wasting (deltoids) ___________
Ankle edema ______ Sacral edema _____
Ascites ________
C. Subjective Global Assessment Rating:
Well Nourished A_________
Suspected or moderately B_________
malnourished
Severely Malnourished C_________
Nutritional Requirements
Caloric Requirements
Actual caloric requirements can only be estimated in the
absence of indirect calorimetry. The formulas shown are
helpful in making the appropriate estimations.
Harris Benedict Equation
Estimates basal metabolic rate (BMR):
Males: 66.47 + 13.75 (wt, kg) + 5 (ht, cm) - 6.76
(age, yr)
Females: 65.51 + 9.56 (wt, kg) + 1.85 (ht, cm) - 4.68
(age, yr)
Multiply result by “activity” factors of 1.2 - 1.5 to cor­
rect for physical activity and disease stress.
These values are derived from studies on young healthy
adults, so the formula may be inaccurate in critically ill
patients. In trauma, or with infected or mechanically
ventilated patients REE values obtained by indirect
calorimetry have been shown to vary by as much as
70-140% of those predicted by the Harris Benedict
equation. In acutely ill surgical patients, the Harris
Benedict equation may overestimate caloric re-quire­
ments by as much as 59%. Each degree (oC) increase in
body temperature increases the REE by 7-13%. When in
doubt, it is more advisable to underfeed than to overfeed,
as this tends to place the patient under considerable
metabolic stress.
Mechanical ventilation and medications such as barbi­
turates, muscle relaxants such as pancuronium and beta
blockers such as propranolol, may decrease metabolic
rate. Metabolic rate is usually increased signi­ficantly
in patients with major burns because significant energy
must be used to maintain body tem­perature.
However, the REE usually declines during con­va­
lescence. Care must be taken not to undernourish or
over­feed patients.
Caloric Requirements by Weight (IBW) or Preferred
Body Weight
Maintenance (25-35 kcal/kg)
• Non-hospitalized patients usually require 25-30
kcal/kg
• Hospitalized patients require 30-35 kcal/kg
303
NUTRITIONAL AND METABOLIC SUPPORT
Rebuild Lean Body Mass (35-40 kcal/kg)
• In patients who are severely underweight, REE is
often depressed and actual body weight should be
used in preference to IBW in the initial days of nutri­
tional support to avoid both overfeeding or inducing
the refeeding syndrome (hypophosphatemia).
Calorie: Nitrogen Ratio
Sufficient non-protein calories (i.e., dextrose, lipid) must
be administered to enable the efficient use of protein
synthesis and to prevent the catabolism of skeletal muscle
and exogenous amino acids for use as a calorie support
with subsequent development of kwashiorkor. Protein
provides 5.65 kcal/g. However, when the water dilution
of protein and the energy lost in the form of urea are
considered, protein supplies only 1 kcal/g. Therefore,
protein becomes a poor and expensive glucose source
when sufficient dextrose calories are not provided.
Optimal non-protein calorie: nitrogen ratio is 100-
120:1.
Protein Requirements
Protein requirements can be estimated in the absence
of nitrogen balance determinations.
• 0.6-0.8 g/kg/day in healthy humans
• 0.8-1.0 g/kg/day in hospitalized patients
• 1.1-1.5 g/kg/day for protein repletion
• >1.5 g/kg/day only in severe burns and protein-los­
ing enteropathy. Excess protein will not result in
greater tissue synthesis.
• 0.55 g/kg/day minimum in renal failure or hepatic
failure in the absence of dialysis
• Add 6-9 g/day for hemodialysis
• Add 12-16 g/day for peritoneal dialysis (1.2-1.4
g/kg/d)
Fat Requirements
• Minimum fat content of the diet is 24% of total calo­
ries consisting of linoleic acid in order to prevent
essen­tial fatty acid deficiency (EFAD) with scaly skin
rash, hair loss, hepatomegaly and possibly anemia,
thrombocytopenia, osteoporosis, and poor wound
healing.
• Most lipid emulsions are typically 50% linoleic
acid.
• Medium chain triglycerides (MCT) do not provide
essential fats.
• Biochemical evidence of EFAD may occur within two
weeks of the provision of lipid-free TPN although
clinical deficiency does not develop for about six
weeks.
Electrolyte, Vitamin, and Trace Element Require­
ments
Requirements may vary depending on underlying
pathology and the need to replace deficient states or to
304
CPM 9th EDITION
prevent toxicity. For most patients receiving parenteral
nutrition, standard electrolyte, vitamin and trace element
solutions will provide daily patient needs if adequate
calories are infused. Likewise, most enteral products are
designed to meet the RDA for electrolytes, vitamins, and
trace elements if adequate amounts to provide optimal
caloric intake are provided.
Fluid Requirements
Maintenance Fluid
1500 mL + 20 mL/kg for every kg >20 kg
• Increases by 10% for every 1oC of fever.
• May be decreased significantly in cirrhosis, congest­
ive heart failure, pulmonary edema, ARDS, or renal
failure.
Replacement Fluid
Extraneous fluid losses (e.g., nasogastric or enteric
suction, biliary or fistula drainage, diarrhea or emesis)
should be replaced with a separate intravenous solution
in amounts equal to measured losses every 8 hours.
Weight gain of >1-2 kg/wk is probably related to fluid
retention.
For patients on TPN, fluid retention may also occur.
Extraneous fluid and electrolyte losses should be re­
placed with ordinary intravenous electrolyte solutions
when possible.
Parenteral Nutrition
Indications
In general, total parenteral nutrition (TPN) is indicated in
any condition where the small intestine is dys­functional,
obstructed, or inaccessible or the colon is severely
dysfunctional or obstructed, and these condi­tions are
expected to persist for a minimum of 7 days.
Specific Indications
• Intractable vomiting
• Severe diarrhea
• Short bowel syndrome
• Severe mucositis/esophagitis
• Unduly prolonged ileus
• Intestinal obstruction
• “Bowel rest” for enterocutaneous fistula, anasto­motic
leak
• Preoperatively, only in cases of severe malnutrition,
otherwise surgery should not be delayed.
Contraindications
• Intraoperative parenteral nutrition is relatively con­
traindicated since there is no demonstrated efficacy.
Should intraoperative fluid resuscitation be required,
the risk of inadvertently increasing the parenteral
nutrition infusion rate could have poten­tially seri­
ous problems. Severe metabolic and/or electrolyte
disturbances may occur rapidly in the perioperative
CPM 9th EDITION
period.
• Parenteral nutrition is not indicated in patients who
have a gastrointestinal tract capable of ade­quate
nutrient absorption, whenever parenteral duration
is expected to be less than 7 days, in mildly malnou­
rished pre-op patients, or for patients in whom the
disease prognosis is not improved by the use of paren­
teral nutrition. On the other hand, the nutri­tional as­
sessment for nutritional support should be considered
within the first 24 hours; do not wait 7 days.
• PN may not be appropriate in hemodynamically un­
stable patients or in patients with severe pulmo­nary
edema or fluid overload; neither for those with anuria
but not receiving dialysis nor those with profound
metabolic or electrolyte disturbances.
Total Parenteral Nutrition (TPN)
• The high osmolality (>900 mOsm) of most TPN
solutions requires administration into large veins
with high blood flow in order to avoid phlebitis.
The catheter tip should rest in either the superior or
inferior vena cava.
• To limit the risk of infection, a central venous line
dedicated solely for TPN should be used.
Peripheral Parenteral Nutrition (PPN)
• Should be provided to patients who require only short-
­term therapy (<7-10 days) and can take at least part
of their nutritional requirements via the enteral route.
This therapy may provide for some protein sparing.
• Because the solutions are hypertonic, thrombo­
phlebitis of the site administration is inevitable.
Never use dextrose solutions of greater than 10%
concentration or 900 mOsm.
Central Venous Access
• Catheter may be inserted by any standard technique,
such as percutaneous subclavian puncture or open
cutdown. In any case, the tip should rest in the supe­
rior or inferior vena cava.
• Double and triple lumen catheters may be used if a
dedicated TPN line is unavailable. However, multi-
lumen catheters are more prone to contamination
and therefore, if multi-lumen catheters must be used,
a designated TPN port should be used. Intrusion of
a central venous catheter should be permitted only
under emergency conditions (e.g., CPR) and should
not be used for CVP monitoring, blood transfusion,
or IV injections.
Components of TPN Solutions
• Dextrose
• Protein (Amino Acids)
• Lipid Emulsion
• Electrolytes
• Vitamins, Minerals, and Trace Elements
TPN Monitoring
Proper monitoring of patients receiving parenteral nutri­
tion is essential to:
1. Detect and prevent complications.
2. Determine if proper and adequate nutritional ingre­
NUTRITIONAL AND METABOLIC SUPPORT
dients are being infused.
3. Document positive clinical benefits (important for
generation of evidence-based conclusions).
The recommended laboratory tests and monitoring
frequency are as follows:
1. Initial measurement of weight and height; daily
weights thereafter.
2. Temperature every 8 hours.
3. Strict intake and output recording.
4. Blood glucose 2 hours after each rate increase for
TPN and every 6 hours until patient is stable, then
urine glucose each nursing shift thereafter.
5. Baseline blood tests:
Electrolytes (including magnesium, calcium,
phosphate), glucose, CBC, platelet count, PT, total
proteins, albumin, BUN and creatinine, AST, ALT,
bilirubin and alkaline phosphatase, triglycerides
6. Tests performed daily until patient is stable (usually
the first four days):
Electrolytes, including magnesium, calcium, phos­
phate. Glucose 2 hours after each rate increase and
every 6 hours. BUN and creatinine.
When the patient is stable, these blood tests should
not be repeated more frequently than twice weekly,
unless otherwise clinically indicated.
7. Laboratory tests performed weekly or biweekly:
AST, ALT, bilirubin. Total protein, albumin, CBC
and platelets.
Various trace elements (where available) if patient is
receiving additional supplementation 24 hour urine
for total urine nitrogen (TUN)
Complications
Mechanical
Related to CVC Placement
• Pneumo-, hydrothorax
• Catheter embolism
• Arterial puncture
• Air embolism
• Central venous thrombosis
• SVC or IVC Syndrome
• Brachial plexus injury
• Myocardial perforation
• Cardiac tamponade
• Cardiac arrhythmias
• Catheter malposition
• Thoracic duct injury
Catheter Occlusion
Catheter Thrombosis
Partial or complete occlusion by fibrin accumulation
may be cleared by push administration of 1-2 mL
urokinase (5,000 units/mL)
Non-Thrombotic Occlusion
May be caused by poor solubility of calcium, phospho­
rus, and other divalent cations.
Infections
Central Catheters become infected at three sites: skin
entry site, the catheter hub, and the fibrin sheath coating
the outside of the catheter inside the vein.
305
NUTRITIONAL AND METABOLIC SUPPORT
Catheter Sepsis
This is the greatest concern in patients receiving
parenteral nutrition since an indwelling catheter is a
potential conduit for organism entry from skin conta­
mination, and a malnourished or debilitated patient may
be immunocompromised and, therefore, a good host
for infection. Strict aseptic technique in catheter care
is essential for minimizing infections.
Exit and Tunnel Site Infections
These infections usually occur in the absence of fever
or leukocytosis. They are identified by local tenderness,
purulent exudate and/or erythema at the catheter exit
site. Temporary catheters should be removed and the
exudate cultured. The usual organisms are S. aureus or S.
epidermidis. Appro­priate intravenous antibiotics should
be initiated pending culture results, and continued for
5-7 days even in the absence of positive cultures.
Care should be taken to exclude infection of the sub­
cutaneous tunnel that the catheter follows under the
skin. This infection cannot be treated without catheter
removal. It is indicated by a red streak and tenderness
of the skin overlying the tunnel tract.
Metabolic Complications
• Hyperglycemia
• Hypoglycemia
• Electrolyte imbalances
• Elevated BUN
• Hepatic aminotransferase elevation
• Cholecystitis
• Delayed gastric emptying
• Lipoprotein abnormalities
• Refeeding syndrome
• Overfeeding
• Intestinal morphology and functional changes
Enteral Nutrition
The old dictum, “if the gut works, use it,” remains a
most compelling guideline in nutritional support. Enteral
nutrition is preferable to parenteral whenever possible
because it is safer, more economical, more nutritionally
complete, and because it maintains gut structure and
integrity. All patients with func­tioning gastrointestinal
tracts who are unable to orally ingest adequate nutrients
to meet their nutritional require­ments can benefit from
supple­mental oral or tube feeding.
Long-term disuse of the gastrointestinal tract leads to a
decrease in villus height after two weeks and may lead
to intestinal atrophy over longer periods. Therefore,
when TPN has been used exclusively for more than 2
weeks, the return to oral or enteral (tube feeding) nutri­
tion should be gradual. Parenteral nutrition should be
continued until 50-75% of the patient’s needs can be
supported with oral or enteral feeding but should be
tapered to allow for the hypocaloric stimulation of ap­
petite. The amount of lipid emulsion should be reduced
first because it has more effect on appetite suppression
306
CPM 9th EDITION
and gastric emptying than dextrose and amino acids.
Indications
• Protein calorie malnutrition (inadequate oral intake
of nutrients for the 5 days prior or normal nutrition
status but with inadequate oral intake for the previous
7-10 days)
• CNS disorders: comatose state, CVA, Parkinson’s
disease
• Neoplasms, especially at least a 2-month prognosis;
eg. head and neck carcinoma; in these instances nut-ri­
tional supple­mentation becomes an ethical concern.
• Gastrointestinal disease: gastroparesis, mal­absorp­
tion, short bowel syndrome, chronic pancreatitis,
pos­sibly severe acute pancreatitis, pseudo-obstruct­
ion, scleroderma, low output distal enterocutaneous
fistulas.
• Psychiatric disorders: Severe depression, anorexia
nervosa.
Contraindications
• Adynamic ileus
• Complete intestinal or colonic obstruction
• Intractable vomiting
• Proximal high output enterocutaneous fistulas
• Active gastrointestinal bleeding, and shock
• Diarrhea with or without malabsorption may be a
contraindication and may possibly be manage­able by
an adjustment in enteral nutrition flow rate or formula
selection.
Enteral Feeding Access
Nasoenteric Feeding Tube
• Preferably a small bore, 10-12 Fr feeding tube should
be used to avoid esophageal reflux, ulcer, and stricture
formation, as well as for patient comfort.
• Risks associated with even small-bore tube placement
include pneumomediastinum, bron­cho­pleural fistula,
pneumothorax, and hydro­thorax.
• Placement should be either in the stomach or the
duodenum (or lower). The risk of aspiration is not
necessarily decreased with duodenal feeding. If
duodenal feeding is desired, there is no efficacy in
the adjunctive use of metoclopramide, except in the
pa­tient with diabetes.
• However, preliminary studies have suggested the
potential benefit of erythromycin in assuring duodenal
placement.
• Verify proper tube placement of the tube radio­
logically before initiating feeding. Aus­cultatory
confirmation is inaccurate for de­termining correct
tube placement.
Percutaneous (PEG) or Surgical Gastrostomy
For long-term enteral feeding, gastrostomy tube place­
ment offers quite a few advantages over naso­gastric
feeding with respect to patient nutrition, perfor­mance,
or survival.
• It eliminates replacement of the nasogastric tube every
CPM 9th EDITION
6 weeks.
• A PEG is less easily dislodged and is more comfort­
able for the patient.
• The absence of nasoesophageal erosion and sinusitis
is notable in contrast to a nasoenteric feeding tube.
• There is, however, no decrease in the aspiration
risk.
• Complications do include stomal leakage, tube
migration, gastric perforation, bleeding, and wound
infection.
Percutaneous (PEJ) or Surgical Jejunostomy
• If short-term feeding is anticipated, a nasojejunal tube
can be inserted with a wire guide and radiologic con­
firmation, or positioned during laparotomy performed
for other indications.
• If long-term feeding is anticipated, jejunostomy tubes
are better placed surgically, as those placed through a
PEG have been known to flip back into the duo­denum
or stomach.
Formula Selection
Considerations
a. Patient diagnosis, nutritional status, and related
concerns such as the presence of congestive heart
failure, renal or hepatic insufficiency, or hyper­­meta­
bolic state
b. Purpose of the formula
c. Patient’s digestive and absorptive ability
d. Formula osmolality
e. Cost
Categories of Formulas
Nutritionally Complete (Polymeric) Formulas
These formulas are composed of protein, carbo­hydrate,
and fat in high molecular weight form and, therefore,
of lower osmolality. These formulas require normal
digestive and lipolytic activity and are also less
expen­sive. Most of these formulas are lactose free
and provide 1 kcal/mL. Formulas with higher caloric
densi­ty (1.5-2.0 kcal/mL) are available for use in
patients who are fluid restricted. Lower sodium and
potassium containing formulas and higher protein
containing formulas are also available. Isotonic
formulas should never be diluted. Instead delivery
rate can be reduced.
Chemically Defined Formulas
These formulas have a low residue and use free amino
acids or peptides as a protein source. Oligosaccha­
rides or monosaccharides provide the carbohydrate
source and most contain medium as well as long
chain triglyce­rides. These formulas are hyperosmolar,
al­though some are only minimally hyperosmolar and
can be infused into the stomach undiluted. Dilution is
unnecessary for jejunal feeding. Chemically defined
formulas do not require proteolytic capacity, and some
do not require lipolytic activity. Theo­retically, intestinal
absorption of formulas containing di- and tripeptides
may be facilitated over those containing crystalline
amino acids. In addition, improved absorption does
not mean that increased nitrogen will be available for
protein synthe­sis or to improve nitrogen balance. All
chemi­cal­ly defined formulas are expensive and should
NUTRITIONAL AND METABOLIC SUPPORT
be limited to use in research applications and in patients
with mal­absorption, or pancreatitis. Routine use, even
in the hypo­albuminemic patient, is unwarranted. Rou­-
tine use of intact protein formulas may actually lead to
a lower incidence of diarrhea in postoperative patients
who have undergone upper gastrointestinal tract sur­
gery.
Specialty Formulas
Specialty formulas are available for use in patients with
a variety of clinical conditions including renal, respira­
tory, or hepatic insufficiency, diabetes, hypermetabolic
states, and immunocompromised states. There is limited
literature describing the use of many of these products
and limited data supporting their efficacy at this point
in time.
There is also limited literature regarding efficacy for the
use of fiber-containing formula even to prevent diarrhea
in the critically ill, though future research is expected to
demonstrate the utility of fiber-containing formulas.
Although evidence is not conclusive, there seems to
be some clinical efficacy in the use of a hepatic failure
formula (high-branched chain, low aromatic amino
acids) in chronic hepatic encephalopathy. Patients who
would otherwise be unable to ingest a sufficient level
of protein without precipitating a worsening of the en­
cephalopathy may benefit from supplementation with
this product.
Rate of Administration
Continuous
The volume and rate of formula infusion should be
individually determined for each patient based on
esti­mated caloric requirements by equations or indi­
rect calorimetry and estimated protein requirements,
confirmed with nitrogen balance studies. Isotonic
formulas never require dilution. Unless there has been
recent prior feeding, continuous drip infusion is pre­
ferred over intermittent feedings because initially, a
rapid rate of feeding (especially for jejunal feeding) may
produce cramping and diarrhea. If there is any question
about the patient’s digestive and/or absorptive capac­
ity, 24-hour continuous infusion is preferred. To avoid
uncontrolled changes in flow rate, an enteral feeding
pump is recommended.
Tube feedings into the stomach should be initiated at
isotonic strength at a rate of 40 mL/hr. If the patient
tolerates this regimen, the rate can then be increased
by 25 mL/hr every 8-12 hours as tolerated until the
prescribed goal is met. Jejunal feeding may require
initial rates as low as 10 mL/hr, especially in the im­
mediate postoperative patient. In this situation, gas­
troparesis may otherwise completely preclude the use
of nasogastric feeding. If nausea, vomiting, cramping,
or diarrhea occur, the rate of adminis­tration should be
decreased or, in gastric feedings, the concentration can
be decreased. Avoid altering both rate and concentration
simultaneously.
lntermittent Feedings
Intermittent feedings can be used if there has been no
history of diarrhea or malabsorption, and the gastro­
307
NUTRITIONAL AND METABOLIC SUPPORT
intestinal tract is intact.
Bolus Feeding
Bolus infusions can be administered 3-5 times daily.
They do not require a pump and simulate normal food
intake more effectively than continuous feeding, at least
in terms of gallbladder motility. Bolus feeding is most
useful with a gastrostomy tube and should never be
used in jejunal feeding. The formula should be adminis­
tered at a drip rate or via syringe injection not exceeding
240 mL/30 minutes. Use a 100-mL bolus initially and
increase the volume by 50 mL daily as tolerated. Orders
should be written to specify the number of feedings and
the volume to be administered over a specified period.
Diarrhea is more common with bolus feeding than with
continuous feeding, so consideration must be given to
the individual’s gastric storage and emptying capacity
before considering bolus feeding.
Cyclic, Intermittent Feeding
Continuous drip feeding can be compressed or “cycled”
into a 10-12 hour overnight feeding.
Fluid Requirements
No formula provides sufficient free water to meet a
patient’s daily fluid requirement. The recom­mended
daily water requirement in the absence of hepatic,
renal, or cardiac disease is 1 mL/kcal. Most 1 kcal/mL
formulas contain approximately 75% water. Therefore,
patients without fluid restriction should receive enough
additional free water to equal at least 25% of the total
formula volume (i.e., for 1500 mL of formula per 24
hours, an additional 375 mL of water is required). The
additional free water can be administered in two or
three divided doses. The water used to flush the tube
from feedings or medications should be included in this
total. Ordinary drinking water is fine; distilled water is
unnecessary.
Monitoring
Proper monitoring of patients receiving enteral nu­trition
is necessary to detect & prevent com­plications.
1. Before initiating feeding, it is advisable to confirm
placement of feeding tube by X-ray, since studies have
revealed the inaccuracy of auscultation or aspi­ra­tion.
If the feeding tube becomes dislodged, proper place­
ment should be confirmed by radio­graph.
2. Keep the patient’s head and shoulders (not solely
only the head of the bed) elevated at 30-45o at all
times during feeding and for 1 hour after feeding to
prevent aspiration of the formula.
3. Use a 30-35 mL syringe to check gastric residuals
every 4 hours. The residual should be <150 mL. If
not, the feeding should be held and the condi­tion
inves­tigated. If <150 mL, return contents to sto­mach.
Gastric residual may be increased due to delayed
gastric emptying caused by recent ad­mi­­­­­nis­­­tration of
hypertonic medications in liquid form. After check­
ing the gastric residual, the tube should be flushed
with 30 mL of water to avoid clogging. Checking
residuals is not use­ful for jeju­nal feeding.
4. Maintain accurate intake and output records and
308
CPM 9th EDITION
record the amount of prescribed feeding actually
received.
5. Record patient’s weight at least three times week­
ly.
6. Observe the patient for abdominal distention, pain,
diarrhea or dyspnea and treat accordingly.
Monitor the patient’s response to therapy at least:
Every 8 hours Vital signs
Twice weekly Electrolytes including magne­
sium, calcium,
phosphate, blood glucose,
BUN, creatinine
Biweekly Total protein, albumin, pre­-albu­min
(if available), CBC with diffe­rential
count, AST, ALT
Monitoring frequency may be decreased in stable, long
term enterally fed patients.
Complications of Enteral Feeding
• Mechanical (obstruction of the tube lumen)
• Esophageal complications
• Nasopharyngeal complications
• Tube misplacement
• Complications of PEG/PEJ
1. Wound infection
2. Leakage around tube
3. Bleeding from the puncture site
4. Premature removal by patient
5. Excessive granulation tissue (at the skin site
exit)
• Skin irritation
• Gastrointestinal complications
• Pulmonary aspiration
• Metabolic complications
Figure 5: Nutrition Risk Assessment
The Nutrition Risk Assessment recommended by
PhilSPEN represents an approach to the identification
of significant risk for nutrition-related complications
in hospitalized patients. This approach is based on a
combination of laboratory determinations; namely, body
mass index (BMI), total lymphocyte count (TLC), and
serum albumin- and a clinical assessment known as
Subjective Global Assessment (SGA). Using relatively
simple parameters that are easily affordable and a
simplified tick-box scoring system, the Nutrition Risk
Level is easily determined, and appropriate action can
be recommended accordingly.
Figure 6: Nutrient Monitoring Form
The Nutrient Monitoring Form reflects an important
aspect of nutrition support; namely, daily monitoring
of actual nutrient intake. Once the Nutrition Support
prescription is ordered, it is only by accomplishing
the nutrient monitoring form that an accurate measure
of the success of treatment is recorded. In general,
implementation of the nutrition care plan is considered
acceptable if at least 75% of the daily targets for calories
and protein is reached.
CPM 9th EDITION NUTRITIONAL AND METABOLIC SUPPORT

Figure 5. Nutrition Risk Assessment

SGA CRITERIA NORMAL/ MILD MODERATE SEVERE

Weight Loss None  < 10% of usual wt.  > 10% of usual wt. 
Food Intake No change  Suboptimal  Starvation 
(last 1-2 months)
Gastro symptoms None  Nausea, vomiting  Anorexia 
> 2 weeks Diarrhea, severe
Dysfunction < 3 wks
Functional capacity No change  Suboptimal work  Bedridden < 2 wks 
Bedridden 2 wks
Disease and relation to No or low stress  Moderate stress  Severe stress 
Nutritional requirements
0 +1 to +2 +3
Physical examination Subcutaneous fat  Subcutaneous fat  Subcutaneous fat 
and/or muscle loss and/or muscle loss and/or muscle loss
SGA Grade A 0 B 1 C 2 

BMI 18.5 – 25 0  25.1 – 30 1 < 18.5 or > 30 2 

Albumin (g/dL) >3.4 0  2.5 – 3.4 1 < 2.5 2 
TLC ≥ 1500 0  900 < 1500 1 <900 2 
0-1  LOW RISK (LEVEL 1)
TOTAL NUTRITION RISK LEVEL 2-3  MODERATE RISK (LEVEL 2)
SCORE 4+  HIGH RISK (LEVEL 3)

Figure 6. NUTRIENT MONITORING FORM

NUTRIENT TARGET
Total Calorie Requirement kcal Total Protein Requirement g

Nutrient Actual % of Actual % of Total Total

Date Source Calorie target Protein target Fluid Fluid
Intake Intake Intake Output
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL
Oral
Tube Feed
IV Dextrose
Parenteral
TOTAL

309
NUTRITIONAL AND METABOLIC SUPPORT CPM 9th EDITION

Recommended Therapeutics
(Drugs Mentioned in the Treatment Guideline)
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class.

Crystalloids Resource High Protein

B. Braun 5% Dextrose in Resource Standard
Lactated Ringer's Soln Suplena
B. Braun 5% Dextrose Supportan/ Supportan Drink
in Water Sustagen Premium
B. Braun 10% Dextrose Parenteral Electrolytes
in Water Addamel N
B. Braun Dextrose 5% B. Braun 8.4 % Sodium
in 0.33% NaCl Bicarbonate
B. Braun Dextrose 5% B. Braun 10% w/v Calcium
in 0.9% NaCl Gluconate
LVP D10W B. Braun NaCl 0.9% Soln
LVP D5LR B. Braun NaCl 0.9% Soln
LVP D5S3 for Inj
LVP D5S9 B. Braun Lactated Ringer's
LVP D5W Soln
Maintesol B. Braun Potassium Chloride
Osmofundin 20% Elin Potassium Chloride
Enteral Nutrition Formulas Elin Sodium Chloride
Alitraq 2.5 mEq Injection
Aminoleban Oral Hizon Calcium
Choice DM Gluconate
Ensure Hizon 0.9% Sodium Chloride
Ensure Plus LVP S9
Ensure with Fiber Parenteral Nutritional Products
Essential Aminoleban
Falkamin Aminoplasmal E
Fresubin Original Fibre/ Aminosteril Infant 6%
Fresubin Original Drink Aminosteril Infant 10%
Glucerna Intralipid
Glucerna SR Kabiven Central/Kabiven
Jevity Peripheral
Nepro Lipofundin MCT/LCT
Nutren Diabetes Moriamin S-2
Nutren Fibre Nephrosteril
Nutren Junior Nutriflex Lipid Peri
Nutren Optimum Nutripack
Pediasure Soluvit N
Peptamen Vamin 9 Glucose/Vamin 14/
Peptamen Junior Vamin 18
Polycose Vitalipid N
Promod Vitrimix
Prosure
Providextra
Pulmocare
Reconvan
Resource Diabetic

310