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Ростовский Государственный Медицинский Университет

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Медицина общая

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20–24 20–25

25–29 15–20

≥30 <15

Note:Thesevaluesarerecommendedforcriticallyillpatientsandallobesepatients;add20%oftotalcaloriesinestimating energyrequirementsinnon–criticallyillpatients.

Idealbodyweightcanbeestimatedbasedonheight

Formen:106+6lbforeachinchover5ft

Forwomen,100+5lbforeachinchover5ft

Protein

Proteinintakeof0.8g/kg/dmeetstherequirementsof97%oftheadultpopulation. Protein requirements are affected by several factors, including the amount of nonprotein calories provided,overallenergyrequirements,proteinquality,baselinenutritionalstatus,andthepresenceof inflammationandmetabolicstressors(Table2-2).

TABLE2-2

RECOMMENDEDDAILYPROTEININTAKE

ClinicalCondition ProteinRequirements(g/kgIBW/d)

Normal 0.8

Metabolicstress(illness/injury) 1.0–1.5

Acuterenalfailure(undialyzed) 0.8–1.0

Hemodialysis 1.2–1.4

Peritonealdialysis 1.3–1.5

IBW,idealbodyweight.

Additionalproteinintakemaybeneededtocompensateforexcessproteinlossinspecificpatientpopulationssuchasthosewith burninjury,openwounds,andprotein-losingenteropathyornephropathy.Lowerproteinintakemaybenecessaryinpatientswith chronicrenalinsufficiencywhoarenottreatedbydialysisandcertainpatientswithhepaticencephalopathy.

Inadequateamountsofanyessentialaminoacidresultsininefficientutilization. Illnessincreasestheeffluxofaminoacidsfromskeletalmuscle;however,increasingproteinintaketo >1.2g/kg/dofprehospitalizationbodyweightincriticallyillpatientsmaynotreducethelossoflean bodymass.

EssentialFattyAcids

Humanslackthedesaturaseenzymeneededtoproducetheω-3andω-6fattyacids.Therefore,linoleic acidshouldconstituteatleast2%andlinolenicacidatleast0.5%ofthedailycaloricintaketoprevent deficiency. Theplasmapatternofincreasedtriene-to-tetraeneratio(>0.4)canbeusedtodetectessentialfattyacid deficiency.

https://t.me/med1917

Carbohydrate

Certaintissues,suchasbonemarrow,erythrocytes,leukocytes,renalmedulla,eyetissues,andperipheral nerves,cannotmetabolizefattyacidsandrequireglucose( 40g/d)asafuel.Endogenousproteinand glycerolfromlipidstorescanundergogluconeogenesistosupplyglucose-requiringorgans.

MajorMinerals

Majormineralssuchassodium,potassium,andchlorideareimportantforionicequilibrium,water balance,andnormalcellfunction.

Micronutrients(TraceElementsandVitamins)

Traceelementsandvitaminsareessentialconstituentsofenzymecomplexes.Therecommendeddietary intakefortraceelements,fat-solublevitamins,andwater-solublevitaminsissetattwostandard deviationsabovetheestimatedmeanastomeettheneedsof97%ofthehealthypopulation. SeeTable2-3forspecificsregardingtheassessmentofmicronutrientnutritionalstatesaswellassigns andsymptomsofmicronutrientdeficiencyandtoxicity.

TABLE2-3

TRACEMINERALS,FAT-SOLUBLEVITAMINS,ANDWATER-SOLUBLEVITAMINS: RECOMMENDEDDAILYINTAKE,DEFICIENCY,AT-RISKPOPULATIONS,TOXICITY,AND STATUSEVALUATION

Nutrient Recommended

DailyEnteral Intake32/Parenteral

Intake

SignsandSymptoms ofDeficiency

34-45

PopulationsatRisk forDeficiency

Signsand Symptomsof Toxicity

Chromium(Cr3+) 30–35μg/10–15μg Glucoseintolerance,

peripheralneuropathy

None

a,34

PO:gastritis IV:skinirritation Cr6+:(steel,welding) lungcarcinogenif inhaled

Copper(Cu2+) 900μg/300–500μg Hypochromic

normocyticor macrocyticanemia (rarelymicrocytic), neutropenia, thrombocytopenia, diarrhea, osteoporosis/pathologic fracturesa Intrinsic:Menkes disease

Chronicdiarrhea,highzinc/low-protein diets

47,48

PO:gastritis, nausea,vomiting, coma, movement/neurologic abnormalities, hepaticnecrosis Intrinsic:Wilson disease

Iodine(I−) 150μg/70–140μg

(notroutinely

Thyroidhyperplasia (goiter)+functional

Thosewithoutaccess tofortifiedsalt,grain,

Deficiency:causes hypothyroidism

https://t.me/med1917

added) hypothyroidism

Intrinsicinutero: cretinism,poorCNS development, hypothyroidism

milk,orcookingoil

Excess:acutely causes hypothyroidism; chronicexcess: hyperthyroidism

Iron(Fe

2+,3+

) 8mg/1.0–1.5μg

(notroutinely added)

Fatigue,hypochromic microcyticanemia, glossitis,koilonychia

Reproductive-age females,pregnant females,chronic anemias, hemoglobinopathies, post–gastric bypass/duodenectomy, alcoholics

POorIV: hemosiderosis, followedby depositioninliver, pancreas,heart,and glands Intrinsic:hereditary hemochromatosis

Manganese (Mn2+)

2.3mg/60–100μg Hypercholesterolemia, dermatitis,dementia, weightloss

Chronicliverdisease, iron-deficient populations

PO:none Inhalation: hallucination, Parkinsonian-type symptoms

Selenium 55μg/20–60μg Myalgias,

cardiomyopathya Intrinsic:Keshan disease(Chinese children),Kashin–Beck disease, myxedematous endemiccretinism

Endemicareasoflow soilcontentinclude certainpartsofChina and|NewZealand

PO:nausea, diarrhea,AMS, irritability,fatigue, peripheral neuropathy,hair loss,whitesplotchy nails,halitosis (garlic-likeodor)

Zinc(Zn2+) 11mg/2.5–5.0mg Poorwoundhealing,

diarrhea(highfistula risk),dysgeusia, teratogenicity, hypogonadism, infertility,acrofacialand oralskinlesions (glossitis,alopecia), behavioralchanges Intrinsic:acrodermatitis enteropathica

Chronicdiarrhea, cereal-baseddiets, alcoholics,chronicliver disease,sicklecell, HIV,pancreatic insufficiency/any intestinal malabsorptivestates, fistulas/ostomies, nephroticsyndrome, diabetes,post–gastric bypass/duodenectomy, anorexia,pregnancy48 Intrinsic: acrodermatitis enteropathica

PO:nausea, vomiting,gastritis, diarrhea,lowHDL, gastricerosions CompetitionwithGI absorptioncan precipitateCu

deficiency

Inhaled:hyperpnea, weakness, diaphoresis

VitaminA

Retinol

900μg/3300IU Conjunctivalxerosis,

keratomalacia,follicular

Anymalabsorptive stateinvolvingproximal

Acute:teratogenic, skinexfoliation,

https://t.me/med1917

hyperkeratosis,night blindness,Bitotspots, corneal+retinal dysfunction

smallbowel, vegetarians,chronic liverdisease

intracranial hypertension, hepatocellular necrosis Chronic:alopecia, ataxia,cheilitis, dermatitis, conjunctivitis, pseudotumor cerebri, hyperlipidemia, hyperostosis

VitaminD

Ergocalciferol

5–15μg/200IU Rickets/osteomalacia Anymalabsorptive

stateinvolvingproximal smallbowel,chronic liverdisease Ofnote:thosewith higherskinmelanin content(i.e.,darker skin)havelowbaseline 25-OHvitaminD levels;itisunclear whetherthismerits theirinclusionasan “at-risk”population

Hypercalcemia, hyperphosphatemia, whichcanleadto CaPO

systemiccalcification +/−AMS+/−AKI

VitaminE (α,γ)-Tocopherol

15mg/10IU Hemolyticanemia,

posteriorcolumn degeneration, ophthalmoplegia, peripheralneuropathy Seeninsevere malabsorption, abetalipoproteinemia

Anymalabsorptive stateinvolvingproximal smallbowel,chronic liverdisease

Possibleincreased riskinhemorrhagic CVA,functional inhibitionofvitamin K–mediated procoagulants

VitaminK

Phylloquinone

120μg/150IU Hemorrhagicdiseaseof

newborn,coagulopathy

Anymalabsorptive stateinvolvingproximal smallbowel,chronic liverdisease

Inutero:hemolytic anemia, hyperbilirubinemia, kernicterus IV:flushing, dyspnea, hypotension (possiblyrelatedto dispersalagent)

VitaminB1 1.2mg/6mg Irritability,fatigue, Alcoholics,severely IV:lethargyand

https://t.me/med1917

Thiamine headache

Wernicke encephalopathy, Korsakoffpsychosis, “wet”beriberi,“dry” beriberi

malnourished ataxia

VitaminB2

Riboflavin

1.3mg/3.6mg Cheilosis,angular stomatitis,glossitis, seborrheicdermatitis, normocytic normochromicanemia

Alcoholics,severely malnourished

None

VitaminB3

Niacin

16mg/40mg Pellagradysesthesias,

glossitis,stomatitis, vaginitis,vertigo Intrinsic:Hartnup disease

Alcoholics,malignant carcinoidsyndrome, severelymalnourished

Flushing, hyperglycemia, hyperuricemia, hepatocellularinjury

VitaminB5

Pantothenicacid

5mg/15mg Fatigue,abdominal

pain,vomiting, insomnia,paresthesias

Alcoholics

PO:diarrhea

VitaminB6

Pyridoxine

1.3–1.7mg/6mg Cheilosis,stomatitis, glossitis,irritability, depression,confusion, normochromic normocyticanemia

Alcoholics,diabetics, celiacsprue,chronic isoniazidor penicillamineuse

Peripheral neuropathy, photosensitivity

VitaminB7

Biotin

30μg/60μg Mentalstatuschanges,

myalgias, hyperesthesias, anorexia

c,55

(excessive eggwhiteconsumption resultsinavidinmediatedbiotin inactivation)

Alcoholics None

VitaminB9

Folicacid

400μg/600μg Bonemarrow

suppression, macrocytic megaloblasticanemia, glossitis,diarrhea Canbeprecipitatedby sulfasalazine+ phenytoin

Alcoholics,celiacor tropicalsprue,chronic sulfasalazineuse

PO:maylower seizurethresholdin thosetaking anticonvulsants

VitaminB12

Cobalamin

2.4μg/5μg Bonemarrow suppression, macrocytic

Vegetarians,atrophic gastritis,pernicious anemia,celiacsprue,

None

https://t.me/med1917

megaloblasticanemia, glossitis,diarrhea, posterolateralcolumn demyelination,AMS, depression,psychosis

Crohndisease, patients postgastrectomyor ilealresection

VitaminC

Ascorbicacid

90mg/200mg Scurvy,ossification

abnormalities Tobaccolowersplasma andWBCvitaminC42 Suddencessationof high-dosevitaminCcan precipitatescurvy

Fruit-deficientdiet, smokers,42 ESRD

Nausea,diarrhea, increasedoxalate synthesis(theoretical nephrolithiasisrisk)

AKI,acutekidneyinjury;AMS,alteredmentalstatus;CNS,centralnervoussystem;CVA,cerebrovascularaccident;ESRD,endstagerenaldisease;IOM,InstituteofMedicine;GI,gastrointestinal;HDL,high-densitylipoprotein(cholesterol);RBC,redblood cell;TIBC,totalironbondingcapacity;TPN,totalparenteralnutrition;TSH,thyroid-stimulatinghormone;WBC,whitebloodcell.

Subscript:b,blood;c,calculated;p,plasma;s,serum;u,urine.

Onlyreportedinpatientsonlong-termTPN.

Neverdemonstratedinhumans.

Onlyabletoinduceunderexperimentalconditionsand/oronlybeenabletoinduceinanimals.

SPECIALCONSIDERATIONS

Both theamount andlocationofprior gutresectioninfluencenutrientneeds. Patientswithareduced lengthoffunctionalsmallbowelmayrequireadditionalvitaminsandmineralsiftheyarenotreceiving parenteralnutrition.Table2-4providesguidelinesforsupplementationinthesepatients.

TABLE2-4

GUIDELINESFORVITAMINANDMINERALSUPPLEMENTATIONINPATIENTSWITH SEVEREMALABSORPTION

Supplement Dose Route

Prenatalmultivitaminwith minerals

1tabletdaily PO

VitaminD

50,000units2–3timesperweek PO

Calcium

500mgelementalcalciumtid–qid PO

VitaminB

1mgdaily PO

– 100–500μgq1–2mo SC

VitaminA

10,000–50,000unitsdaily PO

VitaminK

5mg/d PO

– 5–10mg/wk SC

VitaminE

30units/d PO

https://t.me/med1917

Magnesiumgluconate

108–169mgelementalmagnesiumqid PO

Magnesiumsulfate

290mgelementalmagnesium1–3timesperweek IM/IV

Zincgluconateorzinc sulfate

25mgelementalzincdailyplus100mgelementalzincper literintestinaloutput

Ferroussulfate

60mgelementalirontid PO

Irondextran

Dailydosebasedonformulaortable IV

Recommendedroutinelyforallpatients.

Recommendedforpatientswithdocumentednutrientdeficiencyormalabsorption.

Ilealinflammation,resection,inflammatoryboweldisease(IBD),andbypass(ileojejunalbypass)can cause B12 deficiency and bile salt loss. Diarrhea in this setting may be improved with oral

cholestyramine. Proximal gut resection (stomach or duodenum) via partial gastrectomy, Billroth I and II, duodenal switch/biliopancreaticdiversion,Roux-en-Ygastricbypass,pancreaticoduodenectomy(Whipple),and sleeve gastrectomy may impair absorption of divalent cations such as iron, calcium, and copper. Copper deficiency is extremely commoninpost–gastric bypass patients whodo notreceive routine supplementation.

Patientswithexcessivegastrointestinal(GI)tractlossesrequireadditionalfluidsandelectrolytes.An assessmentoffluidlossesduetodiarrhea,ostomyoutput,andfistulavolumeshouldbemadetohelp determinefluidrequirements.Intestinalminerallossesmaybecalculatedbymultiplyingthevolumeof fluidlossbythefluidelectrolyteconcentration(Table2-5).

TABLE2-5

ELECTROLYTECONCENTRATIONSINGASTROINTESTINALFLUIDS

Location Na(mEq/L) K(mEq/L) Cl(mEq/L) HCO3(mEq/L)

Stomach 65 10 100 –

Bile 150 4 100 35

Pancreas 150 7 80 75

Duodenum 90 15 90 15

Mid–smallbowel 140 6 100 20

Terminalileum 140 8 60 70

Rectum 40 90 15 30

Hyperammonemic encephalopathy is an uncommon but serious complication of Roux-en-Y gastric bypass with an estimated mortality rate of 50%.4 Laboratory hallmarks include elevated ammonia, elevated plasma glutamate, hypoalbuminemia, nutritional and essential amino acid deficiencies, and low zinc.5 It does not appear to resolve with replacement of trace elements. Some reports suggest improvementwithtotalparentalnutritionafterseveralmonths;however,dataremainlimited.

https://t.me/med1917

AssessmentofNutritionalStatus

GeneralPrinciples

Patientsshouldbeassessedforprotein–energymalnutritionaswellasspecificnutrientdeficiencies. Athoroughhistoryandphysicalexaminationcombinedwithappropriatelaboratorystudiesisthebest approachtoevaluatenutritionalstatus.

Diagnosis

History

Assessforchangesindietpattern(size,number,andcontentofmeals)andifpresent,thereason(s)for alteredfoodintake. Unintentionalweightlossof>10%bodyweightintheprior6monthsisassociatedwithapoorclinical outcome.Thismaynotbeduedirectlytomalnutritionbutrathertotheunderlyingillness.

7,8

Lookforevidenceofmalabsorption(diarrhea,weightloss). Forsymptomsofspecificnutrientdeficiencies,seeTable2-3. Considerfactorsthatmayincreasemetabolicstress(e.g.,infection,inflammatorydisease,malignancy). Assessthepatient’sfunctionalstatus(e.g.,bedridden,suboptimallyactive).

PhysicalExamination

By World Health Organization (WHO) criteria, patients can be classified by BMI as underweight (<18.5kg/m2),normalweight(18.5–24.9kg/m2),overweight(25.0–29.9kg/m2),classIobesity(30.0–

34.9kg/m2),classIIobesity(35.0–39.9kg/m2),orclassIIIobesity(≥40.0kg/m2).

Patientswhoareextremelyunderweight(BMI<15kg/m2) or thosewithrapid, severeweight loss (evenwithsupranormalBMI)haveahighriskofdeathandshouldbeconsideredforadmissiontothe hospitalfornutritionalsupport. Lookfortissuedepletion(lossofbodyfatandskeletalmuscleatrophy). Assessmusclefunction(strengthtestingofindividualmusclegroups). Fluid status: Evaluate patients for dehydration (e.g., hypotension, tachycardia, mucosal xerosis) or excessbodyfluid(edemaorascites). Evaluatepatientsforsourcesofproteinornutrientlosses: largewounds, burns,nephroticsyndrome, surgicaldrains,etc.Quantifythevolumeofdrainageandtheconcentrationoffatandproteincontentin thefluidlosses.

DiagnosticTesting

Perform laboratorystudies to determine specificnutrientdeficiencies onlywhen clinicallyindicated becausetheplasmaconcentrationofmanynutrientsmaynotaccuratelyreflectbodystores(Table2-3). Plasmaalbuminandprealbuminconcentrationsshouldnotbeusedtoassesspatientsformalnutritionor tomonitorthe adequacyofnutritionsupport.Althoughlevels oftheseplasmaproteinscorrelatewith clinical outcome, inflammation and injury can alter their synthesis and degradation, limiting their

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usefulnessfornutritionalassessment.

9-12

EnteralNutrition

GeneralPrinciples

Wheneverpossible,oral/enteralfeedingispreferredtoparenteralfeedingbecauseitlimitsmucosal atrophy,maintainsIgAsecretion,andpreventscholelithiasis.Additionally,oral/enteralfeedsareless expensivethanparenteralnutritionandhavealowerlikelihoodofinfectiouscomplications.

TypesofFeedings

Hospitaldietsincludearegulardietandthosemodifiedineithernutrientcontent(amountoffiber,fat, protein,orsodium)orconsistency(liquid,puréed,soft).Therearewaysthatfoodintakecanoftenbe increased:

Aidatmealtime. Allowrelativesandfriendstosupplyfood. Limitmissedmealsformedicaltestsandprocedures. Avoidunpalatable diets.Milk-based formulas (e.g.,Carnation Instant Breakfast™)containmilkas a sourceofproteinandfatandaremorepalatablethanmanyotherformuladiets. Useofcaloricallydensesupplements(e.g.,Ensure™,Boost™).

DefinedLiquidFormulas(Table2-6)

TABLE2-6

ENTERALFEEDINGFORMULAS:COMPARINGCOMPOSITION

Formula kcal/mL %

Protein%Lipid%Carbohydrate

(mEq/L)

(mg/L)

Purpose/Niche

Osmolite 1.0 16.7 29 54.3 40.2 760 Standardpolymeric

Jevity 1.5 17 29 53.6 40.2 1200 Standardpolymeric

TwoCalHN 2 16.7 40.1 43.2 62.6 1050 Volumerestricted

Neprowith CarbSteady

1.8 18 48 34 27.2 700 ESRD

Glucerna 1.5 22 45 33 64.6 1000 Glucose

intolerance/diabetes

Promote 1.0 25 23 52 50.8 1200 Highprotein

VitalAF 1.2 25 39 36 43.2 844 Shortgut,exocrine

pancreatic insufficiency

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VivonexRTF 1.0 20 10 70 31 668 Fatmalabsorption

Pivot1.5 1.5 25 30 45 51.3 1000 SIRS,ARDS,

sepsis

ARDS,acuterespiratorydistresssyndrome;ESRD,end-stagerenaldisease;SIRS,systemicinflammatoryresponsesyndrome. AdaptedfromBarnes-JewishHospitalEnteralNutritionFormulary(2019).

Polymeric formulas (e.g., Osmolite™, Jevity™) are appropriate for most patients. They contain nitrogen in the form of whole proteins and include blenderized food, milk-based, and lactose-free formulas. Other formulas are available with modified content including high-nitrogen, high-calorie, fiber-enriched,andlow-potassium/phosphorus/magnesium. Semielemental oligomeric formulas (e.g., Peptamen™) contain hydrolyzed protein in the form of smallpeptidesandfreeaminoacids.Althoughtheseformulasmayhavebenefitinthosewithexocrine pancreaticinsufficiencyorshortgut,pancreaticenzymereplacementisalessexpensiveandanequally effectiveinterventioninmostpatients. Elementalmonomericformulas (e.g., Vivonex™, Glutasorb™) containnitrogenin the form offree amino acids and small amounts of fat (<5% of total calories) and are hyperosmolar (550–650 mOsm/kg).Theseformulasarenot palatableandthereforerequireeithertubefeedingormixing with other foods or flavorings for oral ingestion.Furthermore, theseformulas havenot beenshownto be clinicallysuperiortooligomericorpolymericformulasinpatientswithadequatepancreaticdigestive functionandaremuchmoreexpensivethanpolymericformulas. Oral rehydration solutions stimulate sodium and water absorption via the sodium–glucose cotransporterpresentinthebrushborderofintestinalepithelium.Oralrehydrationtherapy(using90– 120mEq/Lsolutionstoavoidintestinalsodiumsecretionandnegativesodiumandwaterbalance)can be especially useful in patients with short bowel syndrome.13 The characteristics of several oral rehydrationsolutionsarelistedinTable2-6.

TubeFeeding

TubefeedingisusefulinpatientswhohaveafunctionalGItractbutcannotingestadequatenutrients. The type of feeding tube selected (nasogastric, nasoduodenal, nasojejunal, gastrostomy, jejunostomy, pharyngostomy, and esophagostomy tubes) depends on physician experience, clinical prognosis, gut patencyandmotility,riskofaspiratinggastriccontents,patientpreference,andanticipateddurationof feeding. Short-term(<6weeks)tubefeedingcanbeachievedusingasoft,small-borenasogastricornasoenteric feedingtube.Althoughnasogastricfeedingisusuallythemostappropriateroute,orogastricfeedingmay be needed in those who are intubated or those with nasal injury or deformity. Nasoduodenal and nasojejunalfeedingtubescanbeplacedatthebedside;however, 2%oftubescanbemisplacedand the use of electromagnetic, carbon dioxide sensing (capnography), or direct camera visualization devicesisrecommended.Confirmationofplacement,usuallybyusingradiography,ismandatoryprior touse.Auscultationshouldnotbeusedtoconfirmplacement. Long-term (>6 weeks) tube feeding usually requires a gastrostomy or jejunostomy tube that can be placed percutaneously by endoscopic or radiographic assistance. Alternatively, they can be placed surgically,dependingontheclinicalsituationandlocalexpertise.

FeedingSchedules

Patientswhohavefeedingtubesinthestomachcanoftentolerateintermittentbolusorgravityfeedings,in

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