does this mean what i think it means ? interpreting ... · pdf file6/30/2015 1 does this mean...

6/30/2015

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Does this Mean what I

think it means ? -Interpreting Nutrition Related Labs

-Enteral Nutrition Challenges in Long Term Care

Lorraine Linford, RN BS CNSC Idaho Health Care Association 2015

Lab data:

Clinical RD’s perceptions of usefulness

and barriers n=969

Usefulness

• Assess nutrition status

(85%)

• Improve nutrition care

(73%)

• Understand

illness/disease state

(72%)

Barriers

• MD failing to routinely order

labs for NA (45%)

• Lab results not routinely

available (38%)

• MD unresponsive to

requests for specific labs

(20%)

Vickery et al, Journal of the American Dietetic Association, 1999

Volume 99, Issue 9, Page A124

CHALLENGES

IN LAB

INTERPRETATION

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Lab Display Shorthand

Blood Counts Chemistries • Why?

• What is happening clinically?

• Disease state

• Losses

• Repletion

• Medications

• Patient intervention (non-compliance)

• Potential errors

Critical Thinking Skills Potential Pitfalls

Easy to jump to conclusions before evaluating all

the data

Pt on TPN with these a.m. labs Na K Glucose BUN Crt

What could be causing the elevated K+ and glucose?

What is your intervention?

Today 139 5.3 368 14 0.25

135 3.8 132 16 0.21

136 3.9 124 16 0.20

Yesterday

Day before

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Potential Pitfalls

• Must make connections between seemingly disparate clinical findings, data abnormalities, and disease pathophysiology

• Micro-managing lab results

• Managing electrolytes by ‘gut feeling’—may result in over or under correction

• Ordering labs more often than necessary

• Ignoring ‘trends’

Tips When in doubt…

• It is better to recheck the lab than to treat an incorrect value

•Remember to be suspect of ALL lab results.

Order Labs

Accountable for

Results

Communicate

&

Collaborate

Clinical Interventions

Ordering & Ownership Cycle L Linford, Understanding Lab Values

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FLUID &

ELECTROLYTES The tricky ones…

Total Body Water Adapted from Jia Y, Disorders of Water and Electrolyte metabolism presentation

Body Fluid Distribution Adapted from Jia Y, Disorders of Water and Electrolyte metabolism presentation,

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Normal Routes of Exit

1. Feces

2. Urine

3. Sweat

Abnormal Routes of Exit

1. Fistula drainage

2. Open wounds/burns

3. Emesis

4. Gastric or intestinal suction

5. Paracentesis

6. Exudates

Losses—Fluids & Electrolytes Volume & Composition of

GI Secretions* Sources: Mosby’s Pocket Guide, Fluid & Electrolytes 2005, Grant

JP, Handbook of Total Parenteral Nutrition

Type of

Secretion

L/24

hours

Na+

(mEq/L)

K+

(mEq/L)

Cl-

(mEq/L)

HCO3-

(mEq/L)

Saliva 1 40 15 30 --

Gastric 1-2 40 7 100 --

Pancreas 1-2 130 7 60 100

Bile 1 130 7 80 30

Small

bowel

1-2 140 5 25 100

Diarrhea 1-4 60 30 45 45

*Values are approximate

What is Hypovolemia?

Loss of Na+ and H20 from extracellular space

Causes 1. Fluid Losses

• Bleeding • NG suction • Fistula • Vomiting & diarrhea • Excessive diuresis

2. Decreased intake 3. Third Space shift

Abdominal cavity—ascites • Pleural cavity • Pericardial sac

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What is Dehydration?

Water shifts out of cells into blood • Loss of fluids increases the concentration of solutes in the

blood (increased osmolality)

Loss of free water

Causes

Excessive prolonged fever

• Watery diarrhea

• Failure to respond to thirst

• Highly concentrated feedings, including TF

Hypovolemia Dehydration Lab

Changes ↑ BUN ↑ Na+

↑ BUN: Crt ratio ↑ serum osmolality

Treatment Replace lost fluids

with fluids of similar

concentration

Isotonic solution—

NS or LR

Provide free water to

expand both fluid

compartments

(primarily ICF)

Hypotonic solution—

D5W

Electrolyte Content of

Intravenous Fluid Solutions in mEq/L

Adapted from Rhoda K, Porter M, Developing a Plan of Care for Fluid and

Electrolyte Management, Support Line: June 2011

Source Na+ Cl K+ Lactate Dextrose mOsm

NS 154 154 0 0 0 280-300

D5W 0 0 0 0 50 250

D5,

0.45NS

77 77 0 0 50 400

D5,

0.9NS

154 154 0 0 50 560

LR 130 109 4 28 0 270

D5, LR 130 109 4 28 50 525

Cl=chloride, D5=5% dextrose solution, D5W=5% dextrose solution in

water, K+=potassium

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Causes

Fluid shifts into vasculature caused by remobilization of fluids

• Aggressive fluid resuscitation

• Administration of hypertonic fluids

• Use of colloid oncotic fluids such as albumin Treatment

• Correct underlying cause

• Limit sodium intake

• Fluid restriction

What is Hypervolemia?

Water retention with a decrease in body sodium concentration

Electrolytes

Four major electrolytes • Sodium (extracellular)

• Chloride (extracellular)

• Potassium (intracellular)

• Bicarbonate (extracellular)

Three lesser electrolytes • Calcium (extracellular)

• Magnesium (intracellular)

• Phosphate (intracellular)

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Sodium Level of Caution < 128 - > 150

Conditions that cause

Hyponatremia

• Excess body water (ascites, CHF)

• Excess oral fluid intake

• Diuretics (thiazides, Lasix, Aldactone)

• NSAID

• Severe burns

• Diarrhea

• Vomiting

• Addison's

• Nephritis

• Pyloric obstruction

• Malabsorption

• DKA

• NG suction with PO ice chips / H2O

• False low with hyperglycemia

• SIADH

Variables to evaluate with Hyponatremia

• Heart failure

• Ascites

• Diarrhea output

• Vomiting output

• Urine output

• TPN fluid restricted

• Gastric drainage

• PO intake


Hypernatremia

• Dehydration

• Steroids

• Diuretics (Edecrin, Lasix, loop diuretic)

• Aldosteronism

• Cushings disease

• Coma

• Diabetes insipidus

• Osmotic diuresis

• Tracheobronchitis

• Hypoglycemia

• Therapeutic Rx for TBI

Variables to evaluate with Hypernatremia

• Dehydration

• Closed head injury

• Other sources of Na++

• Urine output

• Fluid restricted

• Gastric drainage

• PO intake

Hypernatremia

Effect of Hyperglycemia on

Serum Na+

• Glucose is osmotically active and induces flow of water from the cells to the ECF

In Normal adults:

Na+ decreases approx 1.5 mEq/L for each

100 mg/dL of glucose

Henry’s Clinical Diagnosis and management by laboratory methods, WB Saunders Co, 2007

Clinical Example

Glucose 311

Na+ 129

Corrected Na+ 132

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Sodium Repletion Calculations

To estimate the amount of sodium required to achieve the desired change in plasma [Na+], the following equation can be used:

Na+ requirement =

TBW × (desired plasma [Na+]–current plasma [Na+])

where TBW (total body water) equals ∼0.60 × (current weight in kilograms) for men ∼0.50 × (current weight in kilograms) for women

Henry’s Clinical Diagnosis and management by laboratory methods, WB Saunders Co, 2007

Goals of sodium repletion:

• restore normal effective ECF volume

• alleviate symptoms

• normalize plasma sodium concentration safely

• restore ICF volume Suggested Repletion:

Na+ ▲ should not exceed 0.5 mEq/L per hour Tip: the slower the development of hyponatremia (over 3 days or more), the greater the brain adaptation and the greater the risks associated with rapid correction. Speed Limit:

0.5 mmol/L/hr

No more than 12 mmol/l in first 24 hours

Tips Sodium Repletion Hyponatremia & the brain

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Potassium Level of Caution < 3.0- > 5.3


Hypokalemia

• Diuretics (HCTZ, Zaroxylyn, Lasix)

• Pyloric obstruction

• Malabsorption

• Vomiting

• Aldosteronism

• Alcoholism

• Intestinal / billary fistula

• NG suction

• Met alkalosis

• Renal tubular acidosis

• Steroids

• Estrogen

• Low Mg++

• Refeeding syndrome

• Amphotericin

Variables to evaluate with Hypokalemia

• Acidosis

• Diarrhea output

• Vomiting output

• GI tube drainage

• Frequency of lab monitoring


Hyperkalemia

• Renal failure

• Burns

• Internal hemorrhage

• Uncontrolled diabetes

• Acidosis

• Renal insufficiency

• Blood transfusions

• Dehydration

• K+ sparing diuretics (Amiloride, Aldactone)

• Rhabdomyelosis

Variables to evaluate with Hyperkalemia

• Renal function tests • Other sources of K+- (medications/IV

fluids)

• Fluid status


• K+ sparing diuretics

• Alkalosis

Potassium Repletion in TPN Post –op ileus

On TPN for 2 days, 1500 ml per day

K+ in TPN yesterday—20 mEq/liter

Example of TPN Ordering Guidelines—Intermountain Medical Center

Na 135 K+ 3.2 BUN 14 Crt .49 PO4 3.8 Mg 1.7

Cl 98 CO2 32

K+ Value Action

< 3.0 Correct Mg+ if low

K+ as separate administration per MD order

Add as Cl, acetate (see acetate), or PO4

3.0 – 3.4 Increase by 50%

> 4.8 Decrease by 50%

> 5.5 Remove from TPN

Maximum dose 100 mEq/l

Telemetry if > 15 mEq/hr, must be in ICU if > 20 mEq/hr

If urine output < 500 ml/day or pt on dialysis, max K+ dose = 30mEq/L

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Magnesium Level of caution < 1.0 - > 6.0


Hypomagnesemia

• Malabsorption

• Fistula losses

• Prolonged NG suction

• Prolonged diarrhea

• Protein/calorie malnutrition

• Alcoholic cirrhosis

• Pancreatitis

• Hypoparathyroidism

• Aldosteronism

• Diabetic coma

• Renal diseases

• Malignant osteolytic disease

• Diuretics

• Porphyria with SIADH

• Re-feeding syndrome

Variables to evaluate

with Mg

• Fistula output / drain output

• Diarrhea output

• Leg cramps

• Risk for re-feeding


• Ca++ level

Magnesium Level of caution < 1.0 - > 6.0


Hypermagnesemia

• Renal failure

• DKA after treatment

• Hypothyroid

• Addison’s disease

• Dehydration

• Thiazide

• Ethacrynic acid

Variables to evaluate

with Mg

• Renal function tests

• Possible dehydration /

fluid status

• Frequency of lab

monitoring

Phosphate Level of caution < 1.6 - > 4.5


Hypophosphatemia

Diarrhea

Vomiting

NG suction

Intestinal/biliary fistula

Malabsorption

Decreased Mg++

Decreased K

Alcoholism

Refeeding syndrome

Excess IV antacid use

Variables to evaluate with PO4

Renal function tests

Ca++ level

Diarrhea output

Vomiting output

Risk for refeeding syndrome

Frequency of lab monitoring


Hyperphosphatemia

Dehydration

Renal insufficiency

Hypocalcemia

Tissue necrosis

Laxative/enema abuse

Variables to evaluate with PO4

Renal function tests

Fluid status

Ca++ level

Other PO4 sources

Frequency of lab monitoring

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Weight status

Check for drain output and GI losses

Renal function trends (ng or ng?)

Diuretics

Other IVF (type & rate) ipatient receiving

Lab data & electrolytes

Check organ function

Will metabolic tolerance impact dosing of nutrients and /or fluid?

Are individual labs trending upward or downward?

Consider electrolyte content of currently administered IVF

Which electrolytes are currently on repletion protocols?

Which electrolytes are currently removed from TPN recipe? Why?

Should it still be out of the TPN order?

Look at the chloride/acetate ratio in regard to current lab trends

Tips: Consistent data analysis—

follow a process that works

Hydration

Source: Checklist for Writing TPN orders, Nutrition Support Service at Intermountain

Medical Center, Salt Lake City, UT 2015

Case Study • Betty Dawson is newly admitted with dehydration and

malnutrition. Diagnosed with inflammatory bowel disease.

She reports a 16 pound weight loss in last 3 months.

73 years old 5 feet 6 inches 121 pounds (55 kg)

• Admission basic metabolic panel

sodium

potassium

magnesium

phosphorus

149 mEq/L

3.3 mEq/L

2.2 mg/dL

3 mg/dL

• D5W 0.45% NS for hydration

• I.V. potassium to correct her hypokalemia.

Case Study (cont) On hospital day 2:

• parenteral nutrition (TPN) delivers 30 to 35

kcal/kg or 1,675 to 1,925 kcal/day

• condition is stable.

On hospital day 3:

Physical assessment notes lethargy, shortness of

breath, and muscle weakness. All of her vital signs

are normal except her pulse, which has become

irregular.

• What are your concerns?

• What intervention would you make?

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How electrolyte values change in

Refeeding Syndrome

Step 1

Glucose (G) enters

bloodstream by enteral,

parenteral, oral, or IV

route

Yantis, How to Recognize and Respond to Refeeding, Nursing Critical

Care:May 2009 - Volume 4 - Issue 3 - p 14-20

How electrolyte values change in

Refeeding Syndrome

Step 2

Pancreas secretes

insulin in response to

increase in serum

glucose

Yantis, How to Recognize and Respond to Refeeding, Nursing Critical


Insulin promotes cellular

uptake of glucose,

potassium (K+),

magnesium (Mg++), and

phosphorus (PO4).

Low serum electrolyte

values for potassium,

magnesium, and

phosphorus

result.

How electrolyte values change

in Refeeding Syndrome Yantis, How to Recognize and Respond to Refeeding, Nursing Critical


Step 3

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• 15 kcals/kg

• No more than 20% above BEE

• 50% of total needs based on

REE × 1.3 – 1.5 • 1000 kcals/day

Start slow

Provide thiamine, vitamins

Replete K, Mg, PO4 as needed—check labs often

Proceed with Caution

Tips Refeeding

Various Methods for Initiating Nutrition Support in Malnourished Patients

Adapted from McCray S, Walker S, Parrish CR. Much ado about Refeeding.

Pract Gastroenterol. 2005;30(1):26-44.

Electrolyte imbalance

• hypokalemia

• hypophosphatemia

• hypomagnesemia

Neurologic

• weakness

• seizure

• paresthesia

• altered mental status

• paralysis

• tetany

Musculoskeletal

• weakness

• myalgia

Hematologic

• thrombocytopenia

• platelet dysfunction

• anemia

• infections

• bleeding

Respiratory

• hypoxia

Gastrointestinal

• anorexia

• abdominal pain

• constipation

• diarrhea

Watch for these refeeding

signs and symptoms

Cardiovascular

•dysrhythmias

• hypotension

Renal

• edema

•elevated blood urea nitrogen

• elevated creatinine

Metabolic

• metabolic alkalosis

• metabolic acidosis

Nutritional •vitamin deficiency, such as thiamine (B1)

• low albumin & prealbumin

Adapted from McCray S, Walker S, Parrish CR. Much ado about Refeeding.

Pract Gastroenterol. 2005;30(1):26-44.

PROTEIN MARKERS Albumin, Prealbumin, CRP

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Which pt is more

malnourished?

Case 1 • AP is a well-nourished 70-year-

old female with community acquired pneumonia

• intubated in the medical ICU,

• on tube feedings at goal.

• received three-quarters of her ordered tube feedings the past 3 days.

• AP’s albumin level is 2.1 g/dL. • MD orders weekly albumin and

prealbumin and re-assessment

Case 2 • SA is a 70-year-old female

nursing home resident

• altered mental status

• a urinary tract infection

• recent 10 lb weight loss.

• “dysphagia 2” diet.

• calorie count--only one meal/day of a 3-day calorie count is recorded

• RN reports that the patient is eating very little.

• SA’s albumin level is 4.2g/dL.

Acute Phase Reactants (APR) concentration changes in response to an inflammatory event:

acute Mi, infection, inflammation, tissue damage, malignancy

Negative APRs

(Protein concentration )

• Albumin

• Prealbumin

• Transferrin

Positive APRs

(Protein concentration )

• Alpha-1-antitrypsin

• Haptoglobin

• Ceruloplasmin

• Fibrinogen

• C-Reactive protein

• Wide variance in studies evaluating increased intake (protein and calorie) and effects on serum protein status

• The concentrations of these proteins are affected by acute phase response and inversely associated with CRP

• Decreased intake does not necessarily = decreased Alb, PAB, transferrin and RBP levels (examples of anorexia from Banh)

• increased intake does not necessarily = increased Alb, PAB, transferrin and RBP levels

Serum Proteins as

Nutritional Markers

Where is the Evidence?

Banh L, Serum Proteins as Markers of Nutrition: Pract Gastroenterol

2006;43:46-64.

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Professional Guidelines

Academy of Nutrition and Dietetics–

Nutrition Care Manual

‘there is no need to check serum proteins for the

purpose of nutritional assessment, although they

have been used as markers of the acute phase

protein response/development of sepsis’

A.S.P.E.N.

Clinical Guidelines Nutrition Screening,

Assessment, and Intervention in Adults 2014

‘experts have advised that albumin and prealbumin

not be used in isolation to assess nutrition status

because they are fundamentally markers of

inflammatory metabolism’

Values going ▲

• Feel confident and

validated in our

nutrition

recommendations

Values going

• Feel compelled to

change our nutrition

recommendations,

especially protein

amounts or

configuration

‘An increase in PAB or Alb level may be

the result of improvement in overall status,

and not necessarily due to

improved nutritional status’ L Banh

Albumin & Prealbumin Values

Survey of 12 Nutrition Support RDs, nurses, NP at Intermountain Medical Center (all CNSCs)

• Do not use pre-albumin or CRP in critically ill

• Inconsistent use in the recovering pt—more likely to order in large wounds, slow to recover, complex pts

• All reported they like to ‘see’ the value if ordered—curiosity and some validation

• Utilize serial ALB, PAB, and CRP trending in the outpatient TPN population (every 6 months)

CRP and Prealbumin

What do we REALLY do?

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Look at the patient—

did the CRP tell you more?

LIVER FUNCTION

TESTS Content adapted from Coates P, Liver Function Tests. Australian Family Physician Vol 40, No 3, March 2011

Basic Skills in Interpreting Laboratory Data 5th Ed., 2015

Categories of Liver Function Tests

PT/INR = Prothrombin Time and International Normalized Ratio

ALP=alkaline phophatase GGT= gamma-glutamyl transferase ALT=alanine transaminase AST= aspartate transaminase

Adapted from Basic Skills in Interpreting Lab Data, Lee 2015

PROCESS MOST CLOSELY RELATED TESTS

Protein

Synthesis

Albumin

Prealbumin

PT/INR (clotting proteins)

Excretory

Function

(cholestasis)

Bilirubin

ALP

GGT

Hepatocellular

Injury

AST

ALT

Detoxification Ammonia (NH3+)

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Classification of Liver Function Tests & Abnormalities

Adapted from Coates P, Australian Physician 2011

adapted from Coates P, Liver Function Tests. Australian Family Physician Vol 40, No 3, March 2011

• Is this typical of cholestasis? (interruption of bile flow)

• Is this consistent with hepatocellular damage?

• Isolated ↑ ALP? (typically bone disease, Vitamin D deficiency,

metastasis)

• ↑ ALP & ↑ GGT? (probable liver origin, ie cholestasis and

enzyme induction by alcohol/meds)

Be Aware: • Bilirubin increases in both cholestasis and

hepatoxic liver disease

What do the LFT results mean?

Ask these questions--

ALP=alkaline phosphatase GGT= gamma-glutamyl transferase

ALT=alanine transaminase AST= aspartatetransaminase

Not helpful in chronic liver

failure permeability of the blood-brain barrier to

ammonia

Should serum ammonia

levels be used to determine

hepatic encephalopathy?

Ammonia Normal Values: 3.2 - 4.5 g/dl

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(a clinical sign supporting

nutrition diagnosis)

• Used in Monitoring and

Evaluation

• Dietitians bring a unique

strength to analysis of the

‘whole picture’

Lab Data & Nutrition

Care Process

• Used in Nutrition Assessment

ENTERAL NUTRITION–

CHALLENGES IN LONG

TERM CARE

residents on tube

feedings

(+ 3.8 to 44.8%)

Enteral Nutrition in

Long Term Care

8.1% of all

nursing home

• Nasoenteral

• Gastrostomy

• Jejunostomy

Prevalence (2006 Minimum Data Set)

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Physiologic Aging

Changes & Nutrition

System Aging Changes

Mouth Dentition problems, decreased salivary production

Sensory visual, hearing, smell, taste

GI Tract Inflammation, abnormal bacterial growth, acid

output

Body

composition

fat, muscle, resting metabolic rate

Urinary tract Kidney in size, function

Enzymes Affects absorption

Enteral Feeding Challenges

• Mechanical

• Gastrointestinal

• Metabolic

Mechanical

• Leakage at ostomy site

• Tube dislodgment • Tape

• Suturing

• Bridle

• Securement device

• Pressure necrosis /erosion • Nasal

• Esophageal

• Sinusitis, otitis

• Clogged tube

Stabilize

the tube!

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Nasal Tube Dislodgement

• New trend—

Magnetic Bridles

• Nursing Action →

Must still secure

feeding tube to face

to prevent septal

necrosis

Mechanical

Nasal Bridles

Magnetic Bridles

• Is there a

problem here?

Mechanical Complications

Assess your tube Adapted from Dr. Steve McClave, Complications of Enteral Tube Feeding

Mechanical

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Abdominal Tubes

Excess Drainage

Deterioration of PEG site

• Excess drainage

• Breakdown at site

• Enlarging hole

Fungal Colonization

Buried Bumper

Photos from Dr. Steve McClave, Dr. John Fang


Tube Occlusion • Causes of

clogged tubes • Formula adherence to tube

• Medication ‘cement’ precipitates

• meds inadequately crushed

• meds mixed with the formula

• meds mixed together

• Small tube diameter

• fiber containing formulas

• medications

• Kinked or knotted tube

Mechanical

Adapted from Dr. Steve McClave,

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Declogging Feeding Tubes

1. Irrigate

• Warm water

• ‘Push-Pull’ plunger

2. Insert small diameter catheter to the clog

3. Enzymes Clog Zapper

repeat x 1

4. Clamp and wait

5. Irrigate

Pancrealipase

1 capsule with 325 mg Na+ Bicarb

Mechanical

•Bionix

Feeding Tube

Declogger

Declogging Strategies

Commercially Available

• BARD PEG Brush • TubeClear

• Requires machine

• Single patient use stylet

Mechanical

(works 100% of the time)

• Large bore tubes if possible

• Medications—do it right!

• Dilute

• Crush well and dissolve

• Use elixirs if approp

• Don’t add to formula

• Don’t mix together

• Flush well before & after

• Consult with pharmacy

• Limit residual checks • Flush, flush, flush

Tube Occlusion

Prevention

PREVENTION

Mechanical

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Feeding Bag Set connectors

• Phase 2

Enteral syringes

• Phase 3

Feeding tube end design

Stay Connected Initiative

‘ENFit’

• Phase 1

Mechanical

Timeline for New ENFit Connectors

• International Standard created

• Nutrition Container End Connectors

Introduce Stay Connected Initiative

Administration set change with ENFit transition piece

(Patient Access End Transition Set)

Enteral specific syringes

(Patient Access End Syringe)

New enteral feeding tubes with

ENFit connector available

2017 Transition to ENFit connectors complete


2017

Gastrointestinal Complications

• High gastric residual

• Aspiration

• Diarrhea

• Constipation

• Distention, bloating, cramping, gas

Parish 2006; Gavi 2015

Gastrointestinal

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• Clinically significant aspiration 5% gastric-

fed pts

• Many aspiration events are

“silent” -- oropharyngeal

secretions

• Symptoms: dyspnea, tachycardia, wheezing,

rales, anxiety, agitation, cyanosis

• May lead to aspiration pneumonia

Aspiration

• Reported incidence 0.8% to 95%.

Gastrointestinal

Residual Volumes

Gastrointestinal

Adult with PEG recently started on standard TF Gastric

residual (GRV) = 380 mL

Which one is the appropriate action?

Administer promotility agent, check GRV in 4 hrs

Continue TF and check GRV in 4 hrs

Hold TF and reassess pt in 4 hrs

1. Evaluate for risk of aspiration.

2. Assure FT in proper position.

3. Head of the bed 30º-45º at all times

4. When possible, use a large-bore sump tube for the first 1-2 days of enteral feeding. Evaluate GRV using 60 mL syringe.

5. Check GRV every 4 hours during the first 48 hours for gastrically fed patients. After goal rate is achieved and/ or the sump tube is replaced with smallbore feeding tube, decrease gastric residual monitoring to every 6-8 hours in noncritically ill patients.

6. If the GRV is > 250 mL after a second gastric residual check, consider promotility agent

7. GRV >500 mL -- hold EN and reassess patient & tolerance

8. Consider feeding tube below the ligament of Treitz when GRVs are

consistently measured at > 500 mL.

ASPEN Practice

Recommendations (adult)

Gastric Residual Volumes

ASPEN Enteral Nutrition Practice Recommendations.

JPEN Vol. 33, No. 2, 2009

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Diarrhea

Myth—TEN causes Diarrhea

• Occurs in 2 to 63% of enterally-fed pts

depending on how defined

• Definition: >500 ml every 8 hours or more

than 3 stools a day for at least two

consecutive days.

Relates more to stool consistency than

frequency

Gastrointestinal

Diarrhea

• Maintain hydration & electrolyte balance

• Replace losses

• Identify cause

Medication

Sorbitol elixirs

Mg++ antacids

H2 blockers

Lactulose/laxatives

K+

PO4++

Disease

Malabsorption

SBS

Decreased bile salts

Decreased pancreatic Fx

Fecal impaction

Formula

Rate

Fiber

Infectious

C. Diff

Salmonella

Shigella

Parasites

Gastrointestinal

Photos from Dr. Steve McClave, Dr. John Fang

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• Add soluble fiber (such as banana flakes or

Benefiber) or insoluble fiber such as psillium

• Consider an enteral formula with added fiber

• Use an antidiarrheal agent (loperamide,

diphenoxylate, paregoric, octreotide)

• Change the formula

Treatment of Diarrhea

in General

After Infectious Source ruled out:

Gastrointestinal

Metabolic Challenges

• Critically ill approach

• Basal bolus regimens for enteral -long acting

-short acting periodic doses

( based on grams of CHO and hours of infusion)

-correction coverage

• Individualize to pt

• BMI > 30

• BMI > 40

• Wounds

Blood Glucose Management Obesity & Nutrient Needs

MONITORING

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• Labs • Weight trend • Input/output

• Compare needs to calories/nutrients delivered • Compare needs to free water in formula/flushes

delivered • Formula

• Tolerance • Standard formula vs specialized

• Wound healing • Access device site • Stool frequency/consistency • Abdominal examination • Nutrition focused physical re-assessments

Monitoring of Patients on EN

Laboratory References • Banh L, Serum Proteins as Markers of Nutrition: What are we Treating?

Pract Gastroenterol 2006;43:46-64. • Coates P, Liver Function Tests. Australian Family Physician, March 2011;

Vol 40, No 3: 113-115 • Davis J, Sowa D, et al, The Use of Prealbumin and C-Reactive Protein for

Monitoring Nutrition Support in Adult Patients Receiving Enteral Nutrition in an Urban Medical Center. JPEN 2011; Vol 62 No, 2; 197-204

• Lee, M, Basic Skills in Interpreting Laboratory Data, 5th Ed., 2013 American Society of Health-System Pharmacist

• McCray S, Walker S, Parrish CR. Much ado about refeeding. Pract Gastroenterol. 2005;30(1):26-44.

• Mosby’s Pocket Guide, Fluid & Electrolytes 2005,

• Rhoda K, Porter M, Developing a Plan of Care for Fluid and Electrolyte Management. Support Line June 2011; Vol 33 No 3 :7-12

• Vickery CE, Cotugna N; Journal of the American Dietetic Association, 1999 Volume 99, Issue 9, Page A124

• Whitmire S, Nutrition-Focused Evaluation and Management of Dysnatremias. Nutr Clin Pract April 2008 vol. 23 no. 2; 108-121

• Yaris M, Velander R, How to recognize and respond to refeeding. Nursing 2009 Critical Care. 2009; 4(3): 14-20.

Enteral References • Boullata J, Brantley S, et al. ASPEN Enteral Nutrition Practice

Recommendations. Journal of Enteral and Parenteral Nutrition Vol. 33, No. 2, March/April 2009

• Dorner B, Posthauer M, et al, Enteral Nutrition for Older Adults in Nursing Facilities; Nutr Clin Pract April 2011 vol. 26 no. 1; 261-272

• Durfee S, Adams S, et al., ASPEN Standards for Nutrition Support: Home and Alternate Site Care; Nutr Clin Pract Aug 2014 vol. 29 no. 4; 542- 555

• Fisher C, Blalock B, Clogged Feeding Tubes: A Clinician’s Thorn. Pract Gastroenterol . March 2014; 16-22

• Gavi S, Hensley J, Management of Feeding Tube Complications in the Long-Term Care Resident. Annals of Long Term Care, April 2008 Vol 16, Issue 4

• Parrish C, McCray S, Enteral Feeding: Dispelling Myths. Pract Gastroenterol . Sept 2003; 33-50

• Rhodes, R, When Evidence Clashes with Emotion: Feeding Tubes in Advanced Dementia. Annals of Long Term Care, September 2014, Vol 22, Issue 9

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