Transcript Nutrition in Liver Diseases

Nutrition and Disease &
Injury States
Barbara Magnuson, PharmD BCNSP
Nutrition Support Service
Disease Specific Enteral Products
Patient Specific products/modifications
 Renal disease
 Liver disease
 Malabsorption
 Surgery, Trauma, Burns
 Respiratory
 Diabetes
Acute vs. Chronic
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Acute Kidney Injury (AKI)
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Decrease GFR over days – weeks
Quick accumulation of creatinine, nitrogen waste
(BUN), fluid volume, and electrolytes * * *
Etiology – drugs, shock, volume
Usually reversible
Chronic Kidney Disease
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Structural or functional changes over > 3 months
Usually does not improve
AKI
Not hypermetabolic by itself
 Calories: Assess patient by their primary injury or
current nutritional status and needs, @ 2030kcal/kg
 CHO:
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Often hyperglycemic with insulin resistance
Fats:
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Often elevated triglycerides (TGLY), monitor levels if
receiving IV lipid emulsions
AKI
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Protein:
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Hypercatabolism – usually b/c of concomitant issues
Dose - specific for injury or type of dialysis used
BOTH Essential and Non-essential amino acids
Fluids:
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May need concentrated nutrition/fluids if low urine
output and no other losses (GI)
May require high volume replacement if high output,
dilute urine
AKI – Electrolytes, TE, MVI
Sodium: Often impaired Na elimination
 Potassium, Magnesium, & Phosphorus:
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Accumulates until dialysis
Usually restricted or eliminated in TF or TPN until
dialysis initiated
Trace elements: No adjustments until dialysis
 Vitamins: No adjustments until dialysis
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1980’s Historical Perspective
HD patients had EXTREME protein restrictions
to postpone HD or minimize uremia
 TPN and EN provided only essential AA
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Lacks arginine (only conditionally essential)
Thought was: the body can synthesize all the
remaining non-essential amino acids
Ammonia elevated & Urea still increased
Resulted in protein malnutrition
Poor wound healing of diabetic wounds
Nutrition with HemoDialysis (HD)
Hemodialysis: 2-4 hours, 2-4 times weekly
 Calories:
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HD itself may slightly increase metabolism
20-30kcal/kg, lower end for obesity and higher end if
underweight. May need up to 35kcal/kg if severly
malnourished
Glucose calories absorbed from dialysate (200600kcal)
Nutrition with HemoDialysis (HD)
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Protein:
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Electrolytes:
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Do NOT restrict protein in AKI to reduce urea accumulation to
avoid dialysis (unless temporary)
Nitrogen is lost during HD
Increase protein: 1-1.5g/kg/d
K & Mg: can be liberalized once dialysis initiated
Phosphorus: accumulates - restrictions needed & drug binders
Trace elements/Vitamins:
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Replace water soluble (B’s and C) due to loss in dialysis.
Do not replace fat soluble Vitamin A & D
Supplement Vitamin D only if deficient
Nutrition with Chronic Renal
Replacement Therapy (CRRT)
Continuous Dialysis over 24 hours
 Calories:
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Depends on injuries, disease states, or nutritional status
Often hypermetabolic unless chemically paralyzed or sedated
(propofol)
Protein:
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Aggressively removes nitrogen
Replace protein with 1.5-2.5g/kg/day to maintain
positive nitrogen for protein synthesis
Nutrition with Chronic Renal
Replacement Therapy (CRRT)
Continuous Dialysis over 24 hours
 Electrolytes:
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Often requires K, Mg, and Phos replacements
Vitamins/Trace elements
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Selenium supplements
copper and zinc removed by dialysis but not always
supplemented.
Do not restrict
Chronic Kidney Disease
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Pre-dialysis: commondly elevated BUN and Cr
Calories:
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Protein:
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Depends on GFR and nutritional status
Hyperglycemia often present
Option: Reduction to 0.6g/kg/day
If malnourished or wounds present – increase to 1-1.2g/kg until wound
healing begins
Peritoneal dialysis 1.3 g/kg/d
Fat:
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Often elevated triglycerides
Carnitine: amino acid needed to transport fatty acids across mitochondria –
removed by dialysis
No current guidelines for carnitine supplement
Chronic Kidney Disease
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Sodium: 1 to 4 g/day – depends on comorbidity
Potassium: restriction is based on serum values
Phosphorus: restricted
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stages 1 and 2: (if > 4.6) 8-12 mg/g protein
stages 3-5: 800-1,000 mg/d
Foods with Phos: dark colas, beer, dairy, fish, and beans
Calcium:
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stages 1-3: 1.2-1.5 g/d
Phosphorus Binders
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Avoid these medications 3hr after or 1hr before binding agents
Calcium Carbonate (Tums®) OTC
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Calcium acetate (PhosLo®) Rx capsule with powder
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800mg TID with meals
Lowers LDL cholesterol also
Lanthum Carbonate (FosRenol®) Rx
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667mg TID with meals (168mg elemental Ca)
1gram Calcium acetate binds to 45mg phos
Sevelamer Carbonate (Renvela®) Rx VERY Expensive
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500mg TID with meals (200mg elemental Ca)
1gram Calcium carbonate binds to 39mg phos
500-1000mg TID with meals, VERY expensive (@$750 for 90)
Aluminum hydroxide – NOT first line therapy
Enteral Products – Renal Failure
Volume concentrated
 Electrolytes:
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Low in sodium
 Potassium varies
 RenalCalR - very calorically concentrated, NO
electrolytes, very low protein (used as a pre dialysis
formula when electrolytes are elevated)
 NeproR - low electrolytes, volume concentrated, high
protein formula
Renalcal®
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High caloric density (2.0 kcal/ml)
Low protein
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34.4g/L (7% kcal from protein)
High CHO load (58%)
Contains no Na, K, Ca, Phos, Mg, or Vit K
Indications:
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Patients with Acute renal failure requiring a protein restriction
(pre-dialysis)
Appropriate for patients with hyperkalemia
Not appropriate for patients receiving dialysis
Does NOT meet 100% of RDIs
Dialysis products
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Novasource ® RENAL
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Nepro®
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Calories: 2.0 kcal/mL (calorie dense)
Protein: 90.7g/L (18% Calories)
Calories:1.8 kcal/mL (calorie dense)
Protein: 84g/L (18% Calories)
Low K, Mg, and Phos
Indications:
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Acute and chronic renal failure
Dialysis (IHD)
Nutrition in Liver Disease/Cirrhosis
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End Stage Liver Disease:
– Impaired detoxification of metabolites
– Often malnourished pt. – especially protein
and vitamins
– Typically poor dietary protein intake
– Serum Albumin usually low
 poor
protein intake
 poor synthesis
Nutrition in Liver Disease/Cirrhosis
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High aldosterone & ADH levels
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Edema present
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Sodium and Water retained
Potassium wasted
low albumin
alkolosis
Weight – varies from underweight malnourished, obese,
or edematous weight – be cautious
Serum ammonia can be elevated
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Nitrogen from protein
Nitrogen from endogenous amino acid breakdown
Hepatic Encephalopathy (HE)- Etiology
Hepatic encephalopathy is a worsening of brain
function that occurs when the liver is no longer
able to remove toxic substances in the blood.
 Symptoms: Confusion, Altered level of
consciousness  coma
 Causes: Infections, Sepsis, Spontaneous
bacterial peritonitis
 Ammonia accumulation  blood brain barrier
– Ammonia  glutamine  astrocyte swelling
 HE
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Hepatic Encephalopathy (HE)- Etiology
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Aromatic amino acids (AAA)  false neurotransmitters
Branch Chain amino acids - depleted
Increase benzodiazepine receptor expression (GABA)
Exogenous factors – narcotics & sedatives
Zinc deficiency
Constipation
Variceal & GI bleed
Azotemia
Alkolosis
Nutrition in Liver Diseases:
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Calories:
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Use Ideal body weight if ascites present
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Hyper-metabolism with acute hepatitis
30-40kcal /kg or HBE x 1.2 if underweight
20-25kcal /IBW kg if obese
50-60% calories from CHO
10-20% calories as fat
CHO:
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Poor glycogen reserves and utilization
Often hyperglycemic due to insulin resistance
4-6small meals/day with CHO rich late evening snack
Nutrition in Liver Diseases:
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Fat:
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Elevated triglycerides because of increased lipolysis for
primary fuel (75% fuel instead of 35% for healthy liver)
Fat malabsorption – inadequate bile delivery to the
duodenum and pancreatic lipase deficiency often
accompanies cirrhosis
Essential fatty acid deficiency due to fat malabsorption
Fluids/Electrolytes:
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Restricting sodium in diet is critical
Fluid restriction if edema is present
Potassium supplements (caution for spironolactone therapy)
Magnesium supplements (worsen diarrhea)
Nutrition in Liver Diseases:
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Protein:
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1.2-1.5g/kg/day (ESPN guidelines)
Protein Calories provide 20-30% total
If Encephalopathic and protein intolerant:
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Increase vegetable and diary protein
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Low levels of AAA, methionine, ammoniagenic AA
Reduce protein to 0.5-0.8g/kg until HE resolves
Add branch chain amino acids
***Severe chronic protein restriction in liver disease will
result in Protein Calorie Malnutrition ***
Liver Disease & Micronutrients
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At risk for folate and magnesium deficiency
Thiamine deficiency  Wernicke’s encephalopathy
Vitamin A, D, & E deficiency: Fat malabsorption – due to
pancreatic exocrine insufficiency & cholestasis
Zinc deficiency: diuretics, protein restrictions, diarrhea
Zn and Mg deficiency  distorted taste sensation (dysgeusia)
Zinc – supplement 600mg/day – may improve amino acid
metabolism and HE grade
Selenium - Supplement 40mcg/day
Manganese & Copper
o Elimination via the bile
o If cholestasis present - reduce or eliminate from TPN
Branch Chain Amino Acids
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Essential AA are depleted
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Normalization promotes protein synthesis and reduces ammonia
concentrations
Aromatic Amino Acids – elevated
BCAA – possibly compete with AAA to cross the BBB
Leucine potent stimulator of HGF (Human Growth Factor)
production & hepatic regeneration
Possibly improves protein catabolism in cirrhosis
ESPEN – recommends BCAA for decompensated liver
cirrhosis
Unpalatable & Costly
Fail to consistently improve HE
Enteral Nutrition Liver Disease
??? efficacy
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Low Sodium formulas
Low protein (11% of calories)
Added Branch Chain amino acids
Low aromatic amino acids
Low fat
Medium Chain Triglycerides
Ex. HepaticAid IIR, NutraHepR
TPN: Liver Disease
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HepatAmine 8%
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Mixture of essential and nonessential amino acids
High concentrations of the BCAA
Low concentrations of methionine and AAA
The rationale for HepatAmine is based on
observations of plasma amino acid imbalances and
on theories which postulate that these abnormal
patterns are causally related to the development of
hepatic encephalopathy.
Special Disease States
Chronic Malabsorption
 Short bowel syndrome
 Radiation enteritis
 Enteric fistulas
 Inflammatory Bowel Disease
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Short Bowel Syndrome
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Short bowel syndrome
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Must have 100cm of small bowel
Must have 60cm of small bowel & colon
TPN may need to be used for weeks to
months following resection of ischemic or
diseased bowel
 Enteral nutrition should be initiated as soon
as the bowel is healthy enough to feed
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Short Bowel Syndrome
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Calories:
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25-30kcal/kg (less if obese)
If the bowel is diseased, it may take 50kcal/kg
ingested to absorb 50%
CHO:
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AVOID Simple sugars  create a high osmotic
load  diarrhea
Fiber  short chain fatty acids in the colon for
energy  flatulence
Short Bowel Syndrome
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Fat:
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Malabsorption due to low pancreatic enzymes and bile salt
malabsorption in the ileum
No dietary fat restrictions if lacking a colon and more ileum
(absorption site)
Fat restriction and supplemental complex CHO if colon is
present
Supplement Medium Chain Triglycerides
Protein
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Single amino acids – saturate absorption
Peptides and Standard Protein - optimal
Short Bowel Syndrome
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Fluids & Electrolytes:
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High losses of most all electrolytes, and water (2-4L/day diarrhea)
Supplement Na, K, & Mg (caution: supplements may exacerbate
diarrhea)
Unabsorbed fatty acids bind calcium in the GI  Elevated
oxylates absorption (because GI calcium unavialable to bind) 
may increase renal oxylate stones
Vitamin D deficiency exacerbates calcium deficiency
Vitamins & Trace elements:
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Supplement trace elements in TPN & may need extra zinc
Vitamin B12 injections may be necessary montly
Oral multivitamin with minerals is critical
Semi-elemental Formulas
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Simple and small carbohydrates
Low residue – no fiber (some EN has fiber)
Small di and tri-peptides (best absorbed)
Low total fat (long chain fatty acids)
Supplemented with medium chain fatty acids
Preferred products for malabsorption or short
bowel syndrome, radiation enteritis, or chronic
diarrhea
Example: Peptamen® Vital HN ®
Peptamen 1.5
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1.5 kcal/ml
67.6g/L protein (18% kcal from protein)
1500kcal meets 100% of RDIs
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77 % Free Water
Contains no fiber
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Semi-Elemental formula – uses:
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GI impaired patients with malabsorption
Chylothorax or chylo-acsitis
Transitioning patients from TPN to enteral nutrition
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Peptide-based formula with whey protein
MCT oil for easy absorption.
May be consumed orally with flavor packets
Short Bowel Syndrome
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Transitioning from TPN or EN
Small volumes every 2-3 hr with oral rehydration
solutions
No sugar sodas
Sodium and potassium often necessary to add to sports
drinks
Medications – NO SORBITOL!
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Loperamide and lomotil may be life-time requirements
PPI or H2 RA – reduces gastric acid hypersecretion
rhGH and glutamine – enhance bowel adaptation
Surgery, Trauma, Burns
Hypermetabolic – high calories (25-35kcal/kg)
 Hypercatabolic & wound healing: very high
protein (1.5-2.5g/kg)
 High potassium & phosphorus needs for burns
 Supplemented: vitamin C, glutamine, arginine,
selenium, branch chain amino acids
 Increased zinc for wound healing
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Immunonutrition/Pharmaconutrition
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Supplemented arginine:
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Supplemented glutamine:
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Enterocytes utilize for fuel
Enhances cellular immune
Supplemented Omega 3 fatty acids
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Restores T-cell function
Pathway to nitric oxide
low inflammatory component
Improves postooerative outcomes in GI surgery
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Imapact AR® - given TID preop x 5days
Immunonutrition/Pharmaconutrition
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Impact ® Peptide 1.5
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Calories: 1.5 kcal/mL
Protein: 94g/L (25% Calories)
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L-arginine 18.7 g/L
L-glutamine 8.1 g/L
Nucleotides 1.8 g/L
Fats: MCT:LCT Ratio: 50:50 (n6:n3 Ratio: 1.4:1)
+ DHA 4.9 g/L
Pivot 1.5®
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Calories: 1.5 kcal/ml
Protein: 94g/L protein (25% calories)
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Arginine (13 gm/L)
Glutamine (6.5 gm/L)
Omega-3 fatty acids
EPA
Juven®
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Supplements enteral feeds or PO diet
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Arginine (7gm) and Glutamine (7gm)
Orange and Fruit juice flavors
Not a complete protein supplement
To drink or administer via FT
Used to promote wound healing.
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Appropriate for trauma, burns, and skin breakdown
Helps build and maintain lean body mass
Chronic Obstructive
Pulmonary Disease (COPD)
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Emphysema/COPD - the walls between the air sacs are
damaged and destroyed leading to fewer and larger air
sacs instead of many tiny ones
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Reduced gas exchange & Accumulation of CO2
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CHO – metabolized primarily to CO2
Low CHO diet– to decrease CO2 accumulation
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Calories – HBE x 1.3 or 25kcal/kg unless obese
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Challenge to increase calories without excessive
CHO
Overfeeding  increased CHO  CO2
Chronic Obstructive
Pulmonary Disease (COPD)
Fat  least amount of CO2
 Enteral products with Low CHO
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Remaining calories - high fat
Example: Pulmocare® - 55.2% fat
???? Efficacy, Massive diarrhea
 Protein – dosed for nutritional status
 Ventilator Dependant Bedridden
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Decrease calories but maintain high protein diet
Acute Respiratory Distress Syndrome
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ARDS:
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Poor oxygenation
Life threatening
Severe inflammatory process
Calories & Protein
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Likely extremely hypermetabolic & hypercatabolic
unless pharmacologic paralysis or sedation
25-30kcal/kg
1.5g/kg/day protein
Acute Respiratory Distress Syndrome
Theory:
 Decrease or eliminate pro-inflammatory
precursors: ie. Omega 6 Fatty acids
 Supplement Omega 3 fatty acids
 Recent Study showed increase mortality with
Oxepa compared to TwoCal HN, ?? Study
design and propofol used for sedation
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Example: Oxepa®
Oxepa®
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Moderate kcal (1.5 kcal/ml)
Moderate protein
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Contains a unique fat blend of high
Omega-3 fatty acids to modulate the inflammatory
response. Low Omega-6 fatty acids
ONLY Indication:
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62.7g/L (16.7% kcal from protein)
ventilated patients with ARDS (possibly SIRS and Sepsis)
1420kcal meets 100% of RDIs
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Contains no fiber
79% Free Water
Diabetes
 Carbohydrate
Consistent diets
 Less total CHO and simple sugars
 More complex carbohydrates & fiber
 Supplement or Substitute meal???
 Avoid excess calories and excess total
carbohydrates for overweight patients!
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Ex. Glucerna® – 22% protein (high), 45% fat,
complex CHO
Glucerna 1.5 ®
Calorically dense (1.5 Cal/mL)
 High protein 82.5g/L protein (22% of calories)
 Prebiotics - scFOS® (2.4 g/8 fl oz)
 omega-3 fatty acids from canola oil (3 g of
ALA per 1500 Cal), AHA recommendations
 Beneficial for diabetics or hyperglycemia in
ICU patients requiring high protein doses
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TPN Case  TF
CD is a 35yo male, 5'10", 80kg admitted to
UKMC for severe dehydration.
 CD has excessive drainage from a duodenal
fistula resultant from a gun shot wound to the
abdomen he received 3 months ago.
 Transitioning from TPN to Enteral Nutrition
 Which formula type is optimal?
 What rate will meet his needs?
 Needs: 2089- 2263Kcal/day, 112g/d - 128g/d
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TPN Case  TF
Transitioning from TPN to Enteral Nutrition
 Which formula type is optimal?
 A semi-elemental product is likely to be best
tolerated after 3 months of bowel rest
 Ex. Peptamen 1.5
 Rate @ 60ml/hr provides 2160kcal & 97g/day
protein
 Add 2 beneprotein daily (12g/day & 50kcal)
 Or 2 Juven daily (28g or glutamine &
Arginine)

Case #2
is a 20yo, 86kg, 75” multi-fracture
trauma patient in the ICU and requires:
 AJ
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2150-2580 kcal/d
120-150g/d of protein
 Which
of the given example enteral
products and rate will best meet his
needs?
Enteral Products
Product
Kcal/ml
 Fibersource HN® 1.2
 Peptamen 1.5 ®
1.5
 Glucerna 1.5®
1.5
 Pivot ®
1.5
 Nutren 2.0®
2.0

Prot (g)/L
54
67.6
82.5
94.0
80
Case #2
Calories: 2150-2550 kcal/d
Protein: 120-150g/d
Rate
Product
(ml/hr)
Fibersource HN ® 85
Glucerna 1.5® 65
PivotR
65
Nutren 2.0®
50
Total
(Kcal/d)
2448
2340
2340
2400
Protein
(Gm/d)
110
129
147
96
Case
What if AJ, a 20yo, 86kg, 75” has 25% fullthickness burns in addition to his trauma
injuries?
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Increase calories to (30-35kcal/kg) 2580-3010kcal
Increase Protein to 2-2.5g/kg (172-215g)
Increase Pivot to 80ml/hr
 2880kcal
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& 180g/day protein
Add 2 Juven packets daily (14g glutamine & 14g
arginine) for additional wound healing