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					       Intensive Care Unit, Royal Liverpool University Hospital: GUIDELINES FOR NUTRITIONAL SUPPORT.



                 GUIDELINES FOR NUTRITIONAL SUPPORT.
        The nutritional status and intake of all ITU patients are integral parts of
         their assessment and management and must be reviewed on a daily basis.

        Evidence supports using the enteral route except where there is a specific
         contraindication (e.g. following certain surgical procedures) or where
         enteral feeding has recently failed. Even in these circumstances some
         enteral intake may still be possible and may protect against villous atrophy
         and bacterial translocation.

        Maintenance of normo-glycaemia is essential (see the Unit’s Glycaemic
         Control guideline).

        See also the Unit’s guideline on the Management and Prevention of
         Constipation.

        Chemical Pathology, Dietician (ext. 2121 or bleep 134) and Nutrition Team
         staff are readily available to advise and assist.

        ITU medical staff are responsible for prescribing nutrition.

        ITU Nursing staff are responsible for administration of prescribed nutrition
         to the patient and for requesting routine tests:


                                 MONITORING and BLOOD TESTS:

        In addition to the routine daily "ICU profile" the following tests ("Nutrition
         bloods") must be requested on all patients every Monday:

Zinc (Zn), Copper (Cu), Selenium (Se), triglycerides, pre-albumin, C-reactive
protein (CRP), folate, B12.

        An additional request, on Thursdays, for CRP must also be sent.


                                    RE-FEEDING SYNDROME
The initiation of feeding in some patients may precipitate this syndrome that
includes acute life-threatening falls in potassium (K+), magnesium (Mg2+), trace
elements, phosphate (P) and thiamine. ITU patients, especially those already
malnourished, alcoholics, diabetics etc are at particular risk. Therefore:

        Additional B vitamins (as Pabrinex®) should be given to these patients
         (NICE guidance suggests for 10 days).

        Patients with low Zn, Cu and Se should get Additrace® for 1 week (then

         _______________________________________________________________________________
                                     Directorate of Intensive Care.

                                              http://www.rluhicu.org

                 Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.
                                                                                                       Page 1 of 5
        Intensive Care Unit, Royal Liverpool University Hospital: GUIDELINES FOR NUTRITIONAL SUPPORT.


          check levels). This can be given in 5% glucose or 0.9% saline 100 to 500
          mL and infused over 2–24 hours. It must not be given in a period shorter
          than 2 hours. There is also some evidence that deranged trace elements
          may contribute to the development of critical illness polyneuropathy.

         Patients with low Zn only, who are enterally fed, should get Solvazinc®
          via NG for 3 days (then check levels).


                                         ENTERAL FEEDING.
The preferred route of feeding for all patients. At least a small volume of enteral
intake (e.g. 10 mL/hr of feed) should be considered in all patients.

                                                  METHODS:

*   Normal diet (rarely possible in our patients but should be considered.)
*   Naso-gastric (or oro-gastric) tube.
*   Naso-jejunal tube (self-propelling or endoscopically placed)
*   Fine-bore feeding tube.
*   Feeding gastrostomy (e.g. via a PEG) or jejunostomy (e.g. via a PEJ).

Naso-gastric feeding is our usual first choice unless a patient has normal
swallowing and can be adequately fed orally.

                       PLACEMENT AND USE OF NASO-GASTRIC TUBES:

There is guidance published both within the Trust and by the National Patient
Safety Agency. They have been modified for use in Unit as follows

         Withdraw an aspirate when the tube is placed and check, with pH paper,
          that the pH is less than 5.5

         The tube will be marked. Nursing staff must check the positioning of the
          tube at the nose daily with reference to the markings and length.

         Many of our patients may have an aspirate of pH > 5.5 and, where any
          doubt exists, a CXR must be performed. ITU medical staff must review the
          film and make a record in the case notes.

         The position of fine-bore NG tubes must be checked with a CXR. ITU
          medical staff must review the film and make a record in the case notes.


Where NG feeding has failed due to impaired gastric motility but with relatively
normal small bowel motility (in practice a quite common situation) try
domperidone 10 mg oral TDS or metoclopramide 10 mg IV TDS. If this is
unsuccessful, add erythromycin 125 mg TDS IV).

          _______________________________________________________________________________
                                      Directorate of Intensive Care.

                                               http://www.rluhicu.org

                  Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.
                                                                                                        Page 2 of 5
    Intensive Care Unit, Royal Liverpool University Hospital: GUIDELINES FOR NUTRITIONAL SUPPORT.




If these measures are still unhelpful then a fine-bore feeding tube should be
passed. If this fails then a more invasive approach such as feeding jejunostomy
(e.g. PEJ) may be warranted.

                                           FORMULATION:

Our most commonly used feed is Jevity®.

 These feeds can also be used through a feeding jejunostomy (although other
feeds are sometimes recommended.)

Most feeds contain 1–1.5 kcal/mL (4.2-6.3 kJ/mL) and 3 g nitrogen (20 g
protein) per 500 mL.

We will occasionally use Nepro® when fluid restriction is essential, and in some
patients with hepatic dysfunction.

                                           PRESCRIBING:

The chosen formulation should be given over 24 hours i.e. without a break.
Patients should be "built-up" from a rate of 10 mL/hr of feed as tolerated and as
quickly as possible. Do not exceed a rate, for these feeds, of 75 mL/hr until
formal review by dieticians.

                                             PROBLEMS:

      * Inadequate intake (see above).
      * Diarrhoea:
                      send stool for Clostridium difficile toxin (CDT)
                      live yoghurt n/g 30 mL 4 to 6 hourly
                      If CDT-negative: loperamide, codeine phos, Lomotil®
                      Do not reduce feed rate
                      Do not dilute feed
                      Consider using a pre-biotic e.g. guar gum (Resource®
                       Benefiber®)



                    TOTAL PARENTERAL NUTRITION (TPN).
                                           INDICATIONS:

 All patients whose enteral intake is inadequate to meet their nutritional
requirements.
                                       ROUTE:

TPN should be administered preferably through a dedicated port of a multi-
lumen central line or a dedicated single lumen central line. Some preparations
      _______________________________________________________________________________
                                  Directorate of Intensive Care.

                                           http://www.rluhicu.org

              Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.
                                                                                                    Page 3 of 5
    Intensive Care Unit, Royal Liverpool University Hospital: GUIDELINES FOR NUTRITIONAL SUPPORT.


are suitable for administration through long (not central) peripheral lines,
MidLines or PICC lines

                                           FORMULATION:

TPN as an "ALL-IN-ONE-BAG" regimen is provided by Pharmacy, (and stored on
ITU) as an “ITU Standard Bag with electrolytes” or as an “ITU Standard
Bag without electrolytes.”

These provide:
 2 litres of fluid
 11 g nitrogen (as Glamin®)
 5.73 MJ (1,370 kcal) total energy

To each bag should be added:

* 1 vial (10 mL) of Vitlipid®.
* 1 vial of Solvito®.
* 1 vial of Additrace®.

                     No other additions may be made to these bags.

Particular note should be made of the presence of any of the following that may
indicate the need for a more tailored recipe: renal failure, liver failure or propofol
infusion.

For some patients a specially prepared recipe is provided by Pharmacy, usually
after consultation with a Consultant in Clinical Chemistry and the ICU Medical
staff (usually Consultant or Fellow).

Bags are designed to last 24 h and must be discarded when 24 h have elapsed.
It is essential that the volume of TPN and the planned duration of infusion be
checked for every patient, every day, so that the appropriate rate of infusion is
prescribed and maintained:

                       i.e.       volume (mL) / 24 h = rate (mL/hr)

The appropriate rate of infusion must not be altered without discussing with
Fellow or Consultant.


                              DISCHARGING A PATIENT FROM ITU:

When a patient receiving TPN leaves the ITU please ensure that their TPN bags
in the 'fridge go with them. Pharmacy must be notified if any bags in the 'fridge
are no longer needed.
Whenever possible, give adequate notice so that appropriate IV access to be
provided on the ward.

      _______________________________________________________________________________
                                  Directorate of Intensive Care.

                                           http://www.rluhicu.org

              Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.
                                                                                                    Page 4 of 5
       Intensive Care Unit, Royal Liverpool University Hospital: GUIDELINES FOR NUTRITIONAL SUPPORT.




                                                PROBLEMS:

 In addition to line related problems, any of the following may occur in patients
receiving TPN:
                    altered fluid balance
                    metabolic acidosis
                    re-feeding syndrome (see above)
                    hypophosphataemia
                    hypo- and hyper-glycaemia
                    hypo- (or hyper-) kalaemia
                    deranged LFTs
                    elevated triglycerides
                    acalculous cholecystitis
                    gut atrophy, lactose intolerance


References:

        Nutrition support in adults. Oral nutrition support, enteral tube feeding and parenteral
         nutrition. NICE. February 2006.

        Confirming the correct position of nasogastric feeding tubes in critically ill. National
         Patient Safety Agency.
        Testing nasogastric tube position: Audit of three adult intensive care units. National
         Patient Safety Agency. Sept 2005




                                                   R.Wenstone (Last revision and update: April 2006)

                                                                       With particular acknowledgements to:
                                                                            Alan Shenkin (Dept. Clin. Chem)
                                                                           and Peter Turner (Dept. Dietetics)




         _______________________________________________________________________________
                                     Directorate of Intensive Care.

                                              http://www.rluhicu.org

                 Tel. Direct line: 0151 706 2400, Secretariat: 0151 706 3191, Fax: 0151 706 5646.
                                                                                                       Page 5 of 5

				
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