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Ростовский Государственный Медицинский Университет

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Медицина общая

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Книга_2804_Библиотеки_им_академика_М_И_Перельмана

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whichthetotalamountofdailyformulaisdividedintofourtosixequalportions.

Bolusfeedingsaregivenbysyringeasrapidlyastolerated. Gravityfeedingsareinfusedover30–60minutes.

Thepatient’supperbodyshouldbeelevatedby30–45degreesduringfeedingandforatleast2hours afterward.Tubesshouldbe flushedwithwateraftereachfeeding.Intermittentfeedingsare useful for patientswhocannotbe positionedwith continuoushead-of-the-bedelevationor whorequire greater freedom from feeding. Patientswhoexperiencenausea andearly satietywithbolusgravityfeedings mayrequirecontinuousinfusionataslowerrate. Continuousfeedingcanoftenbestartedat20–30mL/handadvancedby10mL/hevery6hoursuntil thefeedinggoalisreached.Patientswhohavegastroparesisoftentolerategastrictubefeedingswhen theyarestartedataslowrate(e.g.,10mL/h)andadvancedbysmallincrements(e.g.,10mL/hevery 8–12 hours). Patientswithsevere gastroparesis may require passageof the feeding tube tippast the ligamentofTreitz.Continuousfeedingshouldalwaysbeusedwhenfeedingdirectlyintotheduodenum orjejunumtoavoiddistention,abdominalpain,anddumpingsyndrome. Jejunal feeding may be possible in closely monitored patients with mild to moderate acute pancreatitis.14 RCTs comparing jejunal and gastric feeding in severe acute pancreatitis showed no differences in tolerance, complicationrates, and mortality rates. Early initiation of enteral nutrition within24–72hoursofadmissionisassociatedwithdecreasedmortality,organfailure,andinfectious complicationscomparedwithdelayedenteralnutrition.

ContraindicationstoEnteralFeeding

Theintestinaltractcannotbeusedeffectivelyinsomepatientsbecauseofthefollowing:

Persistentnauseaorvomiting Postprandialabdominalpainordiarrhea Mechanicalobstructionorseverehypomotility Malabsorption Presenceofhigh-outputfistula

Complications

Mechanicalcomplications

Nasogastric feeding tube misplacement, including intubation of the tracheobronchial tree, occurs moreofteninunconsciouspatients.Intracranialplacementcanoccurinpatientswithskullfractures. Erosive tissue damage can lead to nasopharyngeal erosions, pharyngitis, sinusitis, otitis media, pneumothorax,andGItractperforation. Tube occlusion is often caused by inspissated feedings or pulverized medications given through small-diameter (<#10 French) tubes. Frequent flushing of the tube with 30–60 mL of water and avoiding administration of pill fragments or viscous medications help to prevent occlusion. The techniquesusedtounclogtubesincludetheuseofa small-volume syringe (10 mL)toflushwarm waterorpancreaticenzymes(Viokase™dissolvedinwater)throughthetube.

Hyperglycemia

ADA/AACE guidelines recommend a blood glucose target between 140 and180 mg/dL for most hospitalizedpatients.Inpatientswithseverecomorbiditiesandterminalillness,lessstringenttargets areappropriate.

16,17

The majority of non–critically ill inpatients will require basal insulin while receiving enteral nutritiontoachieveandmaintainreasonableglucosecontrol.

Long-duration insulin (e.g.,detemir, glargine) canbe used for basal coverage, while short-acting

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(e.g.,lispro™)canbeusedtocoverprandialandcorrectionalneeds. Patientsreceivingbolusfeedsshouldbe givenshort-actinginsulinatthetimeofeachfeedwithan approximatedoseof1unitofshort-actinginsulinper10–15gcarbohydrate,plusacorrectionaldose ifneeded. Patients receiving continuous (24 hours per day) feeding should receive basal and bolus insulin whenclinicallystable. Forpatientsreceivingnocturnaltubefeeding,intermediate-durationinsulin(e.g.,NPH)administered withinitiationoffeedingisareasonableapproach;however,careshouldbetakentoavoidnocturnal hypoglycemia. If tube feeds are interrupted and insulin has been given, an infusion of dextrose-containing fluid shouldbestartedataratetomatchtheinfusionrateofthescheduledtubefeedsuntiltheinsulinhas wornoff.

Pulmonarycomplications

Theetiologyofpulmonaryaspirationisoftendifficulttodiscernintube-fedpatientsasitcanoccur bothfromrefluxedtubefeedingsororopharyngealsecretionsunrelatedtofeedings.Recentevidence suggests that oral secretions play a far greater role in the development of ventilator-associated pneumoniathanaspirationoftubefeedings.

Gastricresidualsarepoorlypredictiveofaspirationrisk.

Preventionofreflux:Decrease gastricacid secretionwithH2blockersor protonpumpinhibitors, elevate head of bed during feeds, andavoid gastric feeding in high-riskpatients (e.g.,thosewith gastroparesis,frequentvomiting,gastricoutletobstruction).

GIcomplications

Nausea,vomiting,andabdominalpainarecommon. Diarrhea isoften associatedwithantibiotictherapyandtheuseof liquidmedicationsthat contain nonabsorbable carbohydrates, suchas sorbitol. If diarrhea from tube feeding persists afterproper evaluation of possible causes, a trial of antidiarrheal agents or fiber is warranted. Diarrhea is common in patients who receive tube feeding and occurs in up to 50% of critically ill patients. Supplementationwithfiberorswitchingtoafiber-enrichedfeedhasnotyieldedconsistentresults.A changetoanelementalfeedingformulaisrarelyneededandlikelywillnotresolvetheissueunless significantimpairmentinabsorptioniswell-documented.

Diarrheainpatientswith short gut,whodonothaveother causessuch asClostridioides difficile infection, may be minimized using small, frequent meals that do not contain concentrated sweets (e.g., soda). Intestinal transit time should be maximized to optimize nutrient absorption using a tincture ofopium, loperamide, or diphenoxylate. Low-dose clonidine(0.025–0.05 mg orallybid) maybe used to reduce diarrhea inhemodynamically stable patients withshortbowel syndrome.

Intestinal ischemia/necrosis has beenreported in patients receiving tube feeds. These cases have occurredpredominantlyincriticallyillpatientsreceiving vasopressorsforblood pressuresupport in conjunction with enteral feeding. There are no reliable clinical signs for diagnosis, and the mortality rate is high. Caution should be used when enterally feeding critically ill patients

requiringvasopressors.

ParenteralNutrition

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GeneralPrinciples

Parenteralnutritionshouldbeconsideredifenergyintakecannot,oritisanticipatedthatitcannot,bemet byenteralnutrition(<50%ofdailyrequirements)formorethan7–10days.Thisguidelineoriginatesfrom twointensivecareunit(ICU)-focusedmeta-analysescitingincreasedcomplicationsandincreasedoverall mortalityinICUpatientsreceivingearlyparenteralnutrition(i.e.,within7daysofadmission),compared withthosereceivingnonutritionsupport.

23,24

Recentstudieshavefoundthatcriticallyillpatientswhoare

unabletomeetcaloricgoalsbyenteralnutritionaloneforthefirst8daysofhospitalizationhavelonger durationsofstayandgreatermortalityratesthanthoseinwhomtotalparenteralnutrition(TPN)is withheldforthefirst8daysafteradmission.

CentralParenteralNutrition

Theinfusionofhyperosmolar(usually>1500mOsm/L) nutrientsolutionsrequiresalarge-bore,highflowvesseltominimizevesselirritationanddamage. Percutaneous subclavianveincatheterization andperipherallyinsertedcentral venous catheterization (PICC) are the most common techniques for central parenteral nutrition (CPN) access. Theinternal jugular, saphenous, andfemoral veins are also used, although they are less desirable due topatient discomfortanddifficultyinmaintainingsterility.Tunneledcathetersarepreferredinpatientslikelyto receive>8weeksofTPNinordertodecreasetheriskofmechanicalfailure. PICCsareincreasingly usedtoprovideCPNinpatientswith adequateantecubitalveinaccess. They shouldnotbeusedinpatientsrequiringCPNforanextendedtime(>6months).

CPNMacronutrientSolutions

Crystallineaminoacidsolutionsconsistingof40%–50%essentialand50%–60%nonessentialamino acids (usuallywithlittleornoglutamine,glutamate,aspartate,asparagine,tyrosine,andcysteine)are usedtoprovideproteinneeds(Table2-2).Infusedaminoacidsareoxidizedandshouldbeincludedin theestimateofenergyprovidedaspartoftheparenteralformulation. Some amino acid solutionshavebeenmodified forspecific disease statessuch as thoseenrichedin branched-chain amino acids for use in patients with hepatic encephalopathy and those that contain mostlyessentialaminoacidsforuseinpatientswithrenalinsufficiency. Glucose(dextrose)inIVsolutionsishydrated;eachgramofdextrosemonohydrateprovides3.4kcal. Althoughthereisnoabsoluterequirementforglucoseinmostpatients,providing>150gofglucoseper daymaximizesproteinbalance. Lipid emulsions are available as a 10% (1.1 kcal/mL) or 20% (2.0 kcal/mL) solution and provide energyaswellasserveasasourceofessentialfattyacids.Lipidemulsionsareaseffectiveasglucose in conserving body nitrogen economy once absolute tissue requirements for glucose are met. The optimal percentage of calories that should be infused as fat is not known, but 20%–30% of total calories are reasonable for most patients. The infusion rate should not exceed 1.0 kcal/kg/h (0.11 g/kg/h)asmostcomplicationsreportedhaveoccurredwhenprovidingmorethanthisamount.25Arate of0.03–0.05 g/kg/h is adequatefor mostpatientsreceiving continuousCPN.Lipidemulsions should not be used in patients with triglyceride concentrations >400 mg/dL. Moreover, patients at riskfor hypertriglyceridemiashouldhaveserumtriglycerideconcentrationscheckedatleastonceduringlipid emulsion infusiontoensure adequate clearance. Underfeeding obese patients by the amount oflipid calories that would normally be given (e.g., 20%–30% of calories) facilitates mobilization of endogenous fat stores for fuel and may improve insulin sensitivity. IV lipids should still be

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administeredtwiceweeklytothesepatientstoprovideessentialfattyacids.Arecentmeta-analysisof 49 RCTs demonstrated thatuseofω-3 fatty-acid-enrichedparenteral nutrition comparedtostandard parenteralnutritionleadstoreductionininfection,sepsis,andICUandhospitalstaylength.

PeripheralParenteralNutrition

Peripheralparenteralnutritionisoflimitedutilityduetohighriskofthrombophlebitis. Appropriatemanagementofperipheralparenteralnutritioncanincreasethelifeofasingleinfusionsite to>10days.Thefollowingguidelinesarerecommended:

Provideatleast50%oftotalenergyasalipidemulsionpiggybackedwiththedextrose–aminoacid solution. Add500–1000unitsofheparinand5mgofhydrocortisoneperliter(todecreasephlebitis). Place a fine-bore 22- or23-gaugepolyvinylpyrrolidone-coatedpolyurethanecatheterinas largea veinaspossibleintheproximalforearmusingsteriletechnique. Place a 5-mg glycerol trinitrateointmentpatch(or 0.25 inof 2% nitroglycerin ointment) over the infusionsite. Infusethesolutionwithavolumetricpump. Keepthetotalinfusedvolume<3500mL/d. Filterthesolutionwithaninline1.2-mfilter.

Long-TermHomeParenteralNutrition

Long-term home parenteral nutrition is usually given through a tunneled catheter or an implantable subcutaneousportinsertedinthesubclavianvein. Nutrientformulationscanbeinfusedovernighttopermitdaytimeactivitiesinpatientswhoareableto toleratethe fluid load.IVlipids may notbe necessaryinpatientswhoare abletoingestandabsorb adequateamountsoffat. Appropriate patient selection for home TPN is crucial due to high complication rates ( 50% at 6 months).Riskfactorsforcomplicationsincludetheuseofanontunneledormultilumencatheter,useof the catheter for blood draws, infusion of nonparenteral medications, use of lipid infusions, anticoagulation,olderage,andopenwounds.

Complications

MechanicalComplications

Complications at time of line placement include pneumothorax, air embolism, arterial puncture, hemothorax,andbrachialplexusinjury. Thrombosis and pulmonary embolism: Radiologically evident subclavian vein thrombosis occurs commonly;however,clinicalmanifestations(upperextremityedema,superiorvenacavasyndrome)are rare. Fatal microvascular pulmonary emboli can be caused by nonvisible precipitate in parenteral nutritionsolutions.Inlinefiltersshouldbeusedwithallsolutionstominimizetheriskofemboli.

MetabolicComplications

Fluidoverload. Hypertriglyceridemia. Hypercalcemia. Specific nutrient deficiencies. Consider providing supplemental thiamine (100 mg for 3–5 days)

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duringinitiationofCPNinpatientsatriskofthiaminedeficiency(e.g.,alcoholism). Hypoglycemia. Hyperglycemia.Inmostpatients,abloodglucoseconcentrationof140–180mg/dLshouldbetargeted duringTPNinfusion.Managementofpatientswithhyperglycemiaortype2diabetescanbeperformed inseveralways:

Ifbloodglucoseis>200mg/dL,considerimprovingbloodglucosecontrolbeforestartingCPN. IfCPNisstarted,(1)limitdextroseto<200g/d,(2)add0.1unitofregularinsulinforeachgramof dextroseinCPNsolution(e.g.,15unitsfor150g),(3)discontinueothersourcesofIVdextrose,and (4)orderroutine,regularinsulinwithbloodglucosemonitoringbyfingerstickevery4–6 hoursor IVregularinsulininfusionwithbloodglucosemonitoringbyfingerstickevery1–2hours. Inoutpatientswhouseinsulin,anestimateofthereductioninbloodsugarthatwillbecausedbythe administrationof1unitofinsulinmaybecalculatedbydividing1500bythetotaldailyinsulindose (e.g.,forapatientreceiving50unitsofinsulinasanoutpatient,1unitofinsulinmaybepredictedto reduceplasmaglucoseconcentrationby1500/50=30mg/dL). Ifbloodglucoseremains>200mg/dLandthepatienthasbeenrequiringSCinsulin,add50%ofthe supplemental short-acting insulin given in the last 24 hours to the next day’s CPN solution and doubletheamountofSCinsulinsliding-scaledoseforbloodglucosevalues>200mg/dL. Theinsulin-to-dextroseratiointheCPNformulationshouldbemaintainedwhiletheCPNdextrose contentischanged.

InfectiousComplications

Catheter-related sepsis is the mostcommon life-threatening complication inpatients receivingCPN. The responsible microorganisms are most often skin flora: Staphylococcus epidermidis and

Staphylococcusaureus.

In immunocompromised patients and those receiving CPN for >2 weeks, Enterococcus, Candida species, Escherichia coli, Pseudomonas, Klebsiella, Enterobacter, Acinetobacter, Proteus, and Xanthomonasshouldbeconsidered. Theprinciplesofevaluationandmanagementofsuspectedcatheter-relatedinfectionareoutlinedin

Chapter14,TreatmentofInfectiousDiseases.

Use ofsteriletechniqueduring connectionofTPN,avoiding access ofthe TPNlumen ofthecentral catheterforotherpurposes,andensuringthatTPNisneverdisconnectedandrestartedcanreducethe riskofinfection.Microorganismscanformbiofilmsontheintraluminalsurfaceofthecatheterandonce attachedtheyaredifficulttoeliminate.InpatientsonhomeTPN,ethanollocktherapyhasbeenshown tobeeffectiveinreducingtherateofcatheter-relatedinfection.

HepatobiliaryComplications

Althoughtheseabnormalitiesareusuallybenignandtransient,moreseriousandprogressivediseasemay developinasubsetofpatients,usuallyafter16weeksofCPNtherapyorinthosewithshortbowel syndrome.

Biochemical:Elevatedaminotransferasesandalkalinephosphatasearecommonlyseen. Histologicalterations:Steatosis,steatohepatitis,lipidosis,phospholipidosis,cholestasis,fibrosis,and cirrhosishaveallbeenseen. BiliarycomplicationsaslistedbelowusuallyoccurinpatientswhoreceiveCPNfor>3weeks:

Acalculouscholecystitis Gallbladdersludge Cholelithiasis

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Strategies to prevent hepatobiliary complications in patients receiving long-term CPN include providingaportion(20%–40%)ofcaloriesasfat,cyclingCPNsothattheglucoseinfusionisstopped for at least 8–10 hours per day, encouraging enteral intake to stimulate gallbladder contraction and maintainmucosalintegrity,andavoidingexcesscaloriesandhyperglycemia. If biochemicalor otherevidenceofliverdamageoccurs,evaluationforothercausesofliverdisease shouldensue. If mild hepatobiliary complications develop, parenteral nutrition should not necessarily be discontinued. Rather, the same principles used in preventing hepatic complications can be applied therapeutically. When cholestasis is present, copper and manganese should be removed from the CPN formula to prevent accumulation in the liver and basal ganglia. A 4-week trial of metronidazole or ursodeoxycholicacidcanbehelpfulinsomepatients.

MetabolicBoneDisease

MetabolicbonediseasehasbeenobservedinpatientsreceivingCPNfor>3months Patients may be asymptomatic. Clinical manifestations include bone fractures and pain. Demineralizationmaybeseenonradiologicstudies.Osteopenia,osteomalacia,orbothmaybepresent. The precise causes of metabolic bone disease are not known, but several mechanisms have been proposed,includingaluminumtoxicity,vitaminDtoxicity,andnegativecalciumbalance. Severaltherapeuticoptionsshouldbeconsideredinpatientswhohaveevidenceofboneabnormalities. Remove vitamin D from the CPN formulation if parathyroid hormone and 1,25-hydroxy vitamin D levelsarelow. Reduceproteinto<1.5g/kg/dasaminoacidscancausehypercalciuria. Maintain normal magnesium status because magnesium is necessaryfor normal parathormone action andrenalconservationofcalcium. Provideoralcalciumsupplementsof1–2g/d. Considerbisphosphonatetherapytodecreaseboneresorption.

SPECIALCONSIDERATIONS

Monitoringnutritionsupport

Adjustmentofthenutrientformulationisoftenneededasmedicaltherapyorclinicalstatuschanges. Whennutritionsupportisinitiated,othersourcesofglucose(e.g.,peripheralIVdextroseinfusions) shouldbestoppedandthevolumeofotherIVfluidsadjustedtoaccountforCPN. Vitalsignsshouldbecheckedevery8hours. Incertainpatients,bodyweight,fluidintake,andfluidoutputshouldbefolloweddaily. Serumelectrolytes(includingphosphorus)shouldbemeasuredevery1–2daysafterCPNisstarted untilthevaluesarestableandthenrecheckedweekly. Serum glucose should be checked up to every 4–6 hours by finger stick until blood glucose concentrationsarestableandthenrecheckedweekly. Iflipidemulsionsarebeinggiven,serumtriglyceridesshouldbemeasuredduringlipidinfusionin patients at risk for hypertriglyceridemia to demonstrate adequate clearance (triglyceride concentrationsshouldbe<400mg/dL).

Carefulattentiontothecatheterandcathetersitecanhelptopreventcatheter-relatedinfections.

Gauze dressings should be changed every48–72 hours or whencontaminated or wet.Transparent dressingscanbechangedweekly. Tubingthatconnectstheparenteralsolutionswiththecathetershouldbechangedevery24hours.

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A0.22-μmfiltershouldbeinsertedbetweentheIVtubingandthecatheterwhenlipid-freeCPNis infusedandshouldbechangedwiththetubing. A1.2-μmfiltershouldbeusedwhenatotalnutrientadmixturecontainingalipidemulsionisinfused. Whenasingle-lumencatheterisusedtodeliverCPN,thecathetershouldnotbeusedtoinfuseother solutions/medications(apartfromcompatibleantibiotics)ortomonitorcentralvenouspressure. Whenatriple-lumencatheterisused,thedistalportshouldbereservedsolelyfortheadministration ofCPN.

RefeedingtheSeverelyMalnourishedPatient

Refeedingsyndromemayoccurafterinitiatingnutritionaltherapyinpatientswhoareseverely malnourishedandhavehadminimalnutrientintake.

Hypophosphatemia, hypokalemia, and hypomagnesemia: Rapid and marked decreases in these electrolytesoccurduring initialrefeedingbecauseofinsulin-stimulatedincreasesincellular mineral uptakefromextracellularfluid.Forexample,plasmaphosphorusconcentrationcanfallbelow1mg/dL and cause death within hours of initiating nutritional therapy if not adequately replaced. Suggested replacementguidelinesarereviewedinseveralsources.

29-31

Fluid overload and congestive heart failure are associated with decreased cardiac function and insulin-induced increases in sodium and water reabsorption in conjunction with nutritional therapy containingwater,glucose,andsodium.Renalmassmaybereduced,limitingtheabilitytoexcretesalt orwaterloads. Cardiacarrhythmias:Patientswhoareseverelymalnourishedoftenhavebradycardia.Suddendeath from ventricular tachyarrhythmias can occur during the first week of refeeding in severely malnourished patients and may be associated with a prolonged QT interval and electrolyte abnormalities.PatientswithECGchangesshouldbemonitoredontelemetry,possiblyinanICU. Glucoseintolerance:Starvationcausesinsulinresistancesuch thatrefeedingwithhigh-carbohydrate meals or large amounts of parenteral glucose can cause marked elevations in blood glucose concentration,glycosuria,dehydration,andhyperosmolarcoma.Inaddition,carbohydraterefeedingin patientswhoaredepletedinthiaminecanprecipitateWernickeencephalopathy.

ManagementofSevereMalnutrition

Carefulevaluation ofcardiovascularfunctionandplasmaelectrolytes(history,physical examination, ECG,andbloodtests)andcorrectionofabnormalplasmaelectrolytesareimportantbeforeinitiation offeeding. Refeedingbytheoralorenteralrouteinvolvesfrequentorcontinuousadministrationofsmallamounts offoodoranisotonicliquidformula. Parenteral supplementation or completeparenteral nutrition may be necessaryif the intestinecannot toleratefeeding. During initial refeeding, fluid intake should be limited to approximately 800 mL/d plus insensible losses. Adjustments in fluid and sodium intake are needed in patients who have evidence of fluid overloadordehydration. Changes in body weight provide a useful guide for evaluating the efficacy of fluid administration. Weight gain >0.25 kg/d or 1.5 kg/wk probably represents fluid accumulation in excess of tissue repletion.Initially,approximately15kcal/kg(containingapproximately100gcarbohydrateand1.5g proteinperkilogramofactualbodyweight)shouldbegivendaily. Therateatwhichcaloricintakecanbeincreaseddependsontheseverityofmalnutritionandtolerance tofeeding.Ingeneral,increasingby2–4kcal/kgevery24–48hoursisappropriate.

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Sodiumshouldberestrictedtoapproximately50mEq/m2bodysurfacearea/day,butliberalamountsof phosphorus,potassium,andmagnesiumshouldbegiventopatientswithnormalrenalfunction. Allothernutrientsshouldbegiveninamountsneededtomeettherecommendeddietaryintake(Table

2-7).

TABLE2-7

MAJORMINERALDAILYREQUIREMENTS,DEFICIENCY,TOXICITY,ANDDIAGNOSTIC EVALUATION

Mineral Recommended

DailyEnteral Intake/Parenteral Intake

Signsand Symptomsof Deficiency

Signsand Symptomsof Toxicity

Diagnostic Evaluation

Sodium 1.2–1.5ga/1–

2mEq/kg

Encephalopathy, seizure,weakness, dehydration, cerebraledema

Encephalopathy, seizure

Sodium

(correctfor hyperglycemia) Sodiumu(will

oftenonly providea roughestimate [i.e.,toolow, toohigh])

Potassium 4700mg(47)a/1–

2mEq/kg

Abdominal cramping,diarrhea, paresthesias,QT prolongation, weakness

QRSwidening,QT shortening(sinewave morphologyinextreme cases),peakedT waves

Potassium

w,b

Calcium 1000–

1200mg/10–

15mEq

QRSwidening, paresthesias (Trousseausign), tetany(Chvostek sign),osteomalacia

Encephalopathy, headache,abdominal pain,nephrolithiasis, metastaticcalcification

Calcium

w,b

,24-

hcalcium

(correctfor albumins)

Magnesium 420mg/8–

20mEq

Tachyarrhythmia, weakness,muscle cramping,peripheral andcentralnervous system overstimulation (seizure,tetany)

Hyporeflexia,nausea, vomiting,weakness, encephalopathy, decreasedrespiratory drive,hypocalcemia, hyperkalemia,heart block

Magnesiums, magnesium

Phosphorus 700mg/20–

40mmol

Weakness,fatigue, increasedcell membranefragility (hemolyticanemias,

Metastatic calcification,theoretic higherriskof nephrolithiasis,

Phosphorus

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leukocyte+platelet dysfunction), encephalopathy

secondary hyperparathyroidism

Subscript:b,blood;p,plasma;s,serum;u,urine;w,wholeblood.

Note:Adequatedailyintake.

Body weight,fluid intake,urine output, plasmaglucose, andelectrolytevalues should be monitored dailyduringearlyrefeeding(first3–7days)sothatnutritionaltherapycanbe appropriatelymodified

whennecessary.

REFERENCES

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