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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)
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
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)
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
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
