Table of Contents Background knowledgeNormal requirements for hospital patientsAssessing nutritional statusFoodsOral supplementsNutritional drinksAdditional micronutrients to considerEnteric feedsAdministration methodsMatching requirementsTypes of feedAdministration optionsGiving drugs via enteric tubesParenteral nutritionTest your knowledge on refeeding syndrome Background knowledge Normal requirements for hospital patients Dependent on patient weight: Energy: 25-35kcal/kg/day Protein: 0.8-1g/kg/day Fluid: 30-35ml/kg/day e.g. for an average 70kg patient over 24 hours: energy 1750-2450kcal, protein 56-70g, fluid 2.1-2.45L Assessing nutritional status Malnutrition Universal Screening Tool (MUST) score: 0 = low risk; 1 = medium risk (observe); 2 or more = high risk (treat). Scoring takes into account BMI, unplanned weight loss, and whether patient is acutely ill and has had/will have no nutritional intake for >5 days (Elia et al. 2003) BMI History Nutritional status exam Bloods: haemoglobin, electrolytes (including Mg2+, PO43-, Ca2+), LFTs (including albumin), haematinics (B12, folate, ferritin) Foods Meals should ideally contain 650-850kcal A food guide should be used to calculate energy and protein intake Oral supplements Nutritional drinks Quantity required is determined by calculating the difference between the patient’s daily calorie requirement and their intake. Energy (kcal)Carbohydrate (g)Protein (g)Fat (g)Fortisip Extra (200ml milkshake)320 362011Fortisip Compact (125ml milkshake) – similar contents in smaller volume300371212Fortisip Multi Fibre (200ml milkshake) – with 5g fibre to help bowel function300371212Fortijuice (200ml juice) – avoid in diabetes (contains sugar)3006780Nestlé Resource Energy (200ml milkshake)300 421110Nestlé Build Up soup (49g sachet)200 2776.9Nutricia PreOp (200ml clear drink) – 2 taken 2 hours pre-op for major elective operations1002500 Additional micronutrients to consider Vitamin supplements Sanatogen multivitamin tablets Oral Vitamin B Compound Strong + thiamine Pabrinex (IV equivalent of oral Vitamin B Compound Strong + thiamine) – consider using IV for first 3 days before changing to oral if patient has anorexia nervosa, chronic alcoholism or very high refeeding risk Electrolyte supplements (replace if low) Potassium Phosphate Magnesium Enteric feeds Enteric feeds may be required when oral intake is likely to be absent for >5-7 days and gut is functioning. Administration methods Fine-bore nasogastric (NG) tube – for short-term use Nasojejunal (NJ) tube – if problems with gastric reflux or delayed gastric emptying Percutaneous gastrostomy/jejunostomy tube – for longer-term feeding, i.e. >4-6 weeks, or if there is a mechanical swallowing obstruction May be inserted: Endoscopically: percutaneous endoscopic gastrostomy/ jejunostomy (PEG/J) – most Radiologically: radiologically inserted gastrostomy (RIG) – if patient cannot swallow Surgically – if having other surgery, tube may be placed at the same time Matching requirements Most feeds contain 1kcal/ml and are nutritionally complete (hence, 25-35ml/kg/day will usually match standard requirements)In patients at risk of refeeding syndrome, start much slower – see below In seriously ill/injured people, start at 50% of estimated requirements and build up over 24-48 hours Reduce feed if they are also eating (deduct their oral intake of calories) Exact feed choice is influenced by nutritional requirements, absorption/motility abnormalities, diarrhoeal loss, and presence of liver/renal impairment Types of feed Polymeric feeds (polypeptides), e.g. Nutrison, Nutrison Multifibre – most commonly used Pre-digested feeds (small peptides) – better absorbed, for maldigestive patients, patients with short gut or pancreatic insufficiency Disease-specific and pharmaco-nutrient feeds – for patients with liver/renal impairment Administration options Boluses (e.g. 200-400ml over 15-60 minutes at regular intervals) – more physiological but can cause dumping syndrome Intermittent infusion (breaks of 6 or more hours depending on requirements) – most commonly used Continuous infusion – used for very ill patients Giving drugs via enteric tubes Use solutions where possible Some tablets can be crushed and some capsules can be opened (check with pharmacist) Tablets which cannot be crushed: modified release tablets, enteric coated tablets Parenteral nutrition Parenteral nutrition may be required in intestinal failure (acute or chronic) and is given via central venous line. Parenteral nutrition (PN) – if also feeding patient by other methods Total parenteral nutrition (TPN) – only IV feeding Reference: NICE ‘CG32 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ 2017 Test your knowledge on refeeding syndrome What is refeeding syndrome? Oops! This section is restricted to members. What are the risk factors? Oops! This section is restricted to members. How would you manage a malnourished patient at risk of refeeding syndrome? Oops! This section is restricted to members. How would you manage a patient with established refeeding syndrome? Oops! This section is restricted to members.