Name: _Ziying Tan_____

Section: __A02______

Winter 2015

Major Case Study: Enteral and Parenteral Nutrition

Due 2/13/15
60 points
Mr. R, a 35 yo drug user, is hospitalized after a motor vehicle accident (MVA). He is currently
suffering from a severe concussion and lapses of consciousness, a broken jaw, multiple broken
bones, and possible internal injuries. He had not eaten anything for several days PTA because he
was overdosing on drugs. Enteral feeding has been recommended in order to improve his
nutritional status and given his decreased level of alertness. The patient will be bedridden until
his mental status improves. A nasogastric feeding tube has been inserted and the physician has
asked for your recommendation regarding the type of formula and amounts of kcal/protein
needed for this patient.
Ht: 511

Current wt: 156 #

UBW: 167 #

Serum albumin: 3.0 mg/dL

1. Write 1 PES statement for this patient. (2 pts)

Inadequate oral intake (NI-2.1) related to unable to self-feed as evidenced by motor vehicle
accident leading to unconsciousness, a broken jaw and multiple broken bones.
2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts)
Nasogastric feeding route is not appropriate for this patient, because it is not recommended for a
patient who is unconscious now and has a high risk of aspiration. It is also easy to cause reflux
because the patient will be bedridden for a period of time until his mental status improves. In this
situation, it is advantageous to tube feed directly to the small intestines such as nasoduodenal or
nasojejunal, because the patient is unconscious, and has a high aspiration risk.
3. 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, ml fluid/d.
(6 pts)
Using Mifflin: Men: RMR= (9.99 x weight) + (6.25 x height) (4.92 x age) +5
= (9.99 x 70.76kg) + (6.25 x 180.34cm) (4.92 x 35) +5
=1666.82 kcals (PR p.3)
Activity factor: 1.2: confined to bed (PR p.9)
Injury factor: 1.2-1.4: Skeletal trauma (NTP p.60)
Total Kcal requirements = RMR x activity factor x injury factor (PR p.9)
= 1666.82 kcals x 1.2 x 1.2~1.4
=2400~2800kcals
Protein requirement: 1.2 to 1.5g of protein/kg (PR p.10)
70.76kg x 1.2=84.9g/d85g/d
70.76kg x 1.5= 106g/d
Fluid requirement: 1ml/kcal
2400~2800kcals x 1ml/kcal= 2400~2800ml

Based on his current status, I would like to recommend his intake of 2400-2800kcals. I used
Mifflin-St.Jeor equation because it is one of the standard equations to estimate ones kcal needs.
I used 1.2 for activity factor because Mr.R will be bedridden until his mental status improves,
and I used 1.2~1.4 for injury factor because he has skeletal trauma including a broken jaw and
multiple broken bones.
For protein, I would recommend Mr.R to take 85g/d to 106g/d. I use 1.2 to 1.5gm/kg/day to
calculate the protein requirement, because by looking his lab value (serum albumin is in mild
depletion), he had not eating before PTA, and he has multiple trauma, therefore his needs higher
protein intake in order to meet nutrient needs.
For fluid, I use 1ml/kcal method, because he needs to have adequate fluid (2400~2800mL).
4. Based on the needs of this patient, describe three desirable characteristics for the type of
formula you would recommend. Give one example of an appropriate enteral formula meeting
these characteristics. Use Appendix C2 in NTP text or the formulary provided on the UCD
SmartSite. (4 pts)
Based on the needs of Mr. R, I would recommend Osmolite 1 CAL (Abbott). Firstly, since the
patient had not eaten anything due drug abuse before admission, I would say isotonic is helpful
to balance with body fluid, and isotonic formula goes straight to the small intestines, which is
better for Mr.R to absorb nutrients because he is unconscious now. Secondly, GI function is also
a consideration when selecting a formula, because I need to consider if the patient has the ability
to digest and absorb nutrient or not. Mr.R was not diagnosed with any GI dysfunction. Also, he
is in high need of protein due to skeletal trauma, so whole protein is recommended for Mr.R.
Thirdly, I would also recommend him low residue formula because of the possible internal
injuries. I do not want to take risks because possible internal injuries might cause inadequate
blood supply to the intestine, leading bowel ischemia. He is also unconscious now, so low
residue can be a good start to see if he can tolerate it or not. Therefore, by this point, I would
recommend Osmolite 1 CAL (Abbott) that meets these three characteristics, which are low
residue, isotonic, and whole protein.
5. a) Based on the enteral formula you selected in question 3 above, what daily total volume of
formula would meet Mr. Rs estimated kcal and protein needs? Show calculations. (3 pts)
Estimated energy requirement from #3: 2400~2800kcal
Using standard formula of Osmolite 1CAL (Abbott): 1.06kcal/mL
2400kcal/1.06kcal/ml=2264.2mL
2264.2mL/24hr=94.34mL/hr, which should be rounded up to 95mL/hr
Total volume of formula: 95mL/hr x 24hr = 2280mL
Energy from this formula: 2280mL x 1.06kcal/mL=2416.8kcal
Protein from this formula: 22.8L x 44g/L=100.32g
b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr
infusion? Show calculations. (1 pt)
Using standard formula of Osmolite 1CAL (Abbott): 1.06 kcal/ml
2400kcal x (mL/1.06kcal) =2264.2mL
2264.2mL/ 24 hours= 94.34 mL/hr which should be rounded up to 95 mL/hr.
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. (4 pts)

Using standard formula of Osmolite 1CAL (Abbott): 84% of water

Free water: 2280mL formula x 0.84= 1915.2mL
Fluid requirement is 2400~2800ml
Water flushes: 2400mL-1915.2mL=484.8mL
484.8mL/4=121.2, which should be rounded to 120mL of water by every 6 hours
in a day
6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts)
BUN (Blood urine nitrogen): it estimates nitrogen balance, which is an indicator of adequacy of
whole body protein delivery. By checking BUN, I can know if the patient is taking
adequate protein intake or not.
Blood glucose: to check if the patient has hyperglycemia or not. This is because the patient
have metabolic stress due the multiple injuries. Stress response may result in increased of
insulin resistant, which leading hyperglycemia.
Electrolyte: to check if the patient has refeeding syndrome or not. It may happen because this
patient had not eaten anything before admission. And it can lead to metabolic and
neuromuscular problems if he has refeeding syndrome.
7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts)
-Urine specific gravity: I want to know Mr.Rs hydration status, for example, if he is
getting enough fluid in her diet. Dehydration may result in increased in specific gravity, because
it increases the concentration of solutes in the urine. Excessive fluid intake may result in
decreased in specific gravity, because it decreases the concentration of solutes in urine.
Reference: http://en.wikipedia.org/wiki/Urine_specific_gravity
The patient, Mr. R, is now 5 days s/p his MVA. He did not tolerate the enteral feedings well
(diarrhea and pain) and now has been diagnosed with acute pancreatitis. The MD has ordered a
nutrition consult for evaluation of parenteral nutrition (PN) support. For the purposes of
answering questions 7-12, assume that your current estimated kcal and protein needs for Mr. R
are: 2600 kcal/day and 110 g protein/day.
8. Write a PES statement. (2 pts)
Inadequate enteral nutrition infusion (NI-2.3) related to intolerance to feeds as evidence by
diarrhea and pain.
9. Which type of PN support do you recommend central or peripheral? Justify your answer. (2
pts)
Central parental nutrition support is recommended to Mr.R. It is mainly because the patient has
an increase of caloric needs due to the elevated metabolic stress from his injury, nothing by
mouth status for several days even PTA, and a newly diagnosis of acute pancreatitis. Central
peripheral nutrition can do short term or long term venous access depending on the patients
status. Periheral PN is recommended when the caloric needs are low, which is restricted to 800900mOsm/kg, and that is not enough to meet Mr.Rs energy needs.

10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of Mr.
Rs total kcal needs. Show calculations. (2 pts)
Starting with 20% goal:
2600kcal/day x 20% (0.2)= 520kcal / 11kcal /gm= 47.3-> 47gm fat
520kcal / 1.1kcal/gm =472mL of a 10% lipid emulsion.
The lipid packages come in 100mL, 250mL, and 500mL, therefore in this case, I would choose
500mL(closest to 472mL) of 10% lipid emulsion=50gm fat, which can provide around 20% of
Mr.Rs total kcal needs.
11. 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. (2 pts)
2L=2000mL
110g protein/day / 2000mL x 100 =5.5 % of final amino acid concentration
b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals from
CHO and as grams of dextrose. Show calculations. (3 pts)
Given: dextrose monohydrate: 3.4kcal/gm
110g protein x 4kcal/g =440 kcal; 50g lipid x 11 kcal/gm=550 kcal
440kcal + 550kcal=990 kcal from protein and lipid
2600kcal 990kcal= 1610kcal from dextrose
Kcals from CHO: 1610kcal
Grams of dextrose: 1610kcal dextrose / 3.4kcal/g dextrose =473.5 474g dextrose
c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts)
474g / 2000mL x 100= 23.7% dextrose concentration of the 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. (2 pts)
Given: 474g dextrose from #11b
500 g dextrose/ 1000mL= 474g dextrose / x mL D50W
500x=474000
x=948mL of this stock D50W (0.948L)
e) Compare the grams of dextrose to be provided in this solution with the maximum glucose
infusion rate for Mr. R 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? (2 pts)
Maximum glucose infusion is 5 mg/kg BW/min
474 g dextrose/d / 70.76kg BW = 6.7g dextrose / kg BW/d x 1000mg/1gm=6699mg/kg BW/d x
1 d/1440min=4.652mg/kg BW/ min

Therefore, I would not make any changes to the PN solution based on 4.652 mg/kg BW/ min is
less than 5 mg/kg BW/min (within normal range)
12. List three lab values that you would monitor for this patient and the reasons why. (6 pts)
Blood glucose: since the patient now is having elevated metabolic stress, it is more likely for the
patient to have insulin resistant, which may result in hyperglycemia. Also, if the patient
cannot tolerate the glucose content in the solution, it may result in abnormal result in
blood glucose.
Electrolytes: abnormal changes in electrolytes are common in TPN, which may due to diarrhea,
renal dysfunction, refeeding syndrome, etc. It is very important to monitor when start
TPN, and correct the solution content immediately if notice any abnormal changes in
electrolytes.
Liver enzymes: the liver function decreases from long term TPN, and it is hard for the liver to
process all the fat. It tells whether the liver is functioning well for the patient.
13. Mr. R develops hyperglycemia while on PN support. Describe two actions you would
recommend to help lower blood glucose and achieve metabolic control of the patient. (2 pts)
If Mr.R develops hyperglycemia while on PN support, I would decrease his intake of
carbohydrate by decreasing the dextrose content. Another way to help lower blood glucose, I
would recommend to provide insulin treatment for the patient. Insulin treatment helps the blood
glucose get down to the normal level by monitoring the glucose level strictly with insulin
injections.
14. What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a
severely malnourished patient who is started on PN? (4 pts)
Refeeding syndrome is dangerous fluctuations in fluid and electrolytes that lead to
metabolic and neuromuscular problems. It occurs because the body is adapted to starvation for a
period of time, and when the body receives food suddenly, it causes hormonal and metabolic
changes such as electrolyte abnormalities. There are some characteristics that describe the
refeeding syndrome: low phosphorous, low potassium, low magnesium, high CO2, generalized
fatigue, muscle weakness, cardiac dysfunction, and death.
It is important to monitor for refeeding syndrome in a severely malnourished patient who
is started on PN because refeeding syndrome is likely to occur in severely malnourished patients
during first days/first week of nutritional repletion. Rapid CHO infusion stimulates insulin and
reduces Na and water excretion, which is a risk of fluid overload complications. Also, tissue
repair requires K, P, Mg, etc, which shift to intracellular space (electrolyte abnormalities). High
levels of CHO cause glucose and electrolytes to shift into the cells, which is dangerous for the
patient.
(NUT116B lecture slides)