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 2.1-2.45LÂ
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 | 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.
- 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, 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
- 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
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?
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What are the risk factors?
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How would you manage a malnourished patient at risk of refeeding syndrome?
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How would you manage a patient with established refeeding syndrome?
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