Table of Contents
Normal requirements for hospital patients
Dependent on patient weight:
- Energy: 30kcal/kg/day
- Protein: 0.8-1g/kg/day
- Fluid: 30-35ml/kg/day
e.g. for an average 70kg patient over 24 hours: energy 2100kcal, 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)
- Nutritional status exam
- Bloods: haemoglobin, electrolytes (including Mg2+, PO43-, Ca2+), LFTs (including albumin), haematinics (B12, folate, ferritin)
- Meals should ideally contain 650-850kcal
- A food guide should be used to calculate energy and protein intake
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||36||20||11|
|Fortisip Compact (125ml milkshake) – similar contents in smaller volume||300||37||12||12|
|Fortisip Multi Fibre (200ml milkshake) – with 5g fibre to help bowel function||300||37||12||12|
|Fortijuice (200ml juice) – avoid in diabetes (contains sugar)||300||67||8||0|
|Nestlé Resource Energy (200ml milkshake)||300||42||11||10|
|Nestlé Build Up soup (49g sachet)||200||27||7||6.9|
|Nutricia PreOp (200ml clear drink) – 2 taken 2 hours pre-op for major elective operations||100||25||0||0|
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)
Enteric feeds may be required when oral intake is likely to be absent for >5-7 days and gut is functioning.
- 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
- Most feeds contain 1kcal/ml and are nutritionally complete (hence, 30ml/kg/day will match requirements, but start slower in patients at risk of re-feeding syndrome – see below)
- 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
- 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 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
Test your knowledge on refeeding syndrome
What is refeeding syndrome?
What are the risk factors?
How would you manage a malnourished patient at risk of refeeding syndrome?
How would you manage a patient with established refeeding syndrome?