60 Enteral Nutrition
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Selenium (after 20 days of continuous TPN) . . . . . . . . . . . . . 80 mcg/d
Intralipid 20%, 500 mL/d IVPB; infuse in parallel with standard solution at 1
mL/min for 15 min; if no adverse reactions, increase to 100 mL/hr once daily
or 20 mg/hr continuously. Obtain serum triglyceride 6h after end of infusion
(maintain <250 mg/dL).
Cyclic Total Parenteral Nutrition:
-12h night schedule; taper continuous infusion in morning by reducing rate to
half of original rate for 1 hour. Further reduce rate by half for an additional
hour, then discontinue. Finger stick glucose q4-6h; restart TPN in afternoon.
Taper at beginning and end of cycle. Final rate of 185 mL/hr for 9-10 h and
2 hours of taper at each end for total of 2000 mL.
Peripheral Parenteral Supplementation:
-3% amino acid sln (ProCalamine) up to 3 L/d at 125 cc/h OR
-Combine 500 mL amino acid solution 7% or 10% (Aminosyn) and 500 mL
20% dextrose and electrolyte additive. Infuse at up to 100 cc/hr in parallel
with:
-Intralipid 10% or 20% at 1 mL/min for 15 min (test dose); if no adverse
reactions, infuse 500 mL/d at 21 mL/h over 24h, or up to 100 mL/h over 5
hours daily.
-Draw triglyceride level 6h after end of Intralipid infusion.
7. Special Medications:
-Cimetidine (Tagamet) 300 mg IV q6-8h or 1200 mg/day in TPN OR
-Ranitidine (Zantac) 50 mg IV q8h or 150 mg/day in TPN.
8. Extras: Nutrition consult.
9. Labs:
Daily labs: SMA7, osmolality, CBC, cholesterol, triglyceride, urine glucose
and specific gravity.
Twice weekly Labs: Calcium, phosphate, SMA-12, magnesium
Weekly Labs: Serum albumin and protein, pre-albumin, ferritin, INR/PTT,
zinc, copper, B12, folate, 24h urine nitrogen and creatinine.
Enteral Nutrition
General Considerations: Daily weights, inputs and outputs, nasoduodenal
feeding tube. Head-of-bed at 30
while enteral feeding and 2 hours after
completion.
Enteral Bolus Feeding: Give 50-100 mL of enteral solution (Pulmocare, Jevity,
Vivonex, Osmolite, Vital HN) q3h. Increase amount in 50 mL steps to max of
250-300 mL q3-4h; 30 kcal of nonprotein calories/kg/d and 1.5 gm
protein/kg/d. Before each feeding measure residual volume, and delay
feeding by 1h if >100 mL. Flush tube with 100 cc of water after each bolus.
Continuous enteral infusion: Initial enteral solution (Pulmocare, Jevity,
Vivonex, Osmolite) 30 mL/hr. Measure residual volume q1h for 12h then tid;
hold feeding for 1h if >100 mL. Increase rate by 25-50 mL/hr at 24 hr intervals
as tolerated until final rate of 50-100 mL/hr. Three tablespoonfuls of protein
