ICU GUIDELINE: ENTERAL NUTRITION (EN): THE REFEEDING SYNDROME

IS PT MALNOURISHED? Risk factors (any or all) NO • NPO/clear fluids >7-10 days YES • Chronic ETOH use/abuse Refeeding Syndrome • > 10% wt loss over past 6 mths The metabolic and physiologic • Physical signs of malnourishment processes that occur as a consequence of depletion during starvation and repletion during refeeding. Initiate/titrate EN 1) Obtain routine blood work including serum K, PO4 ,Mg May result in profound to caloric goal prior to EN initiation. Follow serum K, PO4,Mg daily and for hypophosphatemia, hypokalemia, as per ICU 3 days after goal rate achieved. Replete as per protocol. hypomagnesemia as well as protocol (refer Note: correct low serum K, PO4, Mg prior to EN initiation sodium retention/fluid to Calorie 2) Initiate and titrate EN as follows: overload, and thiamine Calculator for Day 1-2: 20 kcal/kg x 24 h. See Table below. deficiency. goal rate). Day 2-3: 25 kcal/kg x 24 h. See Table below. Day 3-5: Goal rate. (See Calorie Calculator for goal rate). 3) Provide thiamine (100 mg) daily x 5 - 7 days.

TABLE 1: ISOSOURCE (1.2 kcal/mL) TABLE 2: RESOURCE 2.0 (2 kcal/mL)

Wt 20 Isosource 25 Isosource Wt 20 Resource 25 Resource NOTE: GUIDELINE ONLY (Kg) kcal/ ml/hr kcal/ ml/hr (Kg) kcal/ 2.0 ml/hr kcal/ 2.0 ml/hr Slower feed rate progression may be Kg Kg Kg Kg required in the following situations: 1) Severe malnourishment. 40 800 30 1000 35 40 800 15 1000 20 2) Absence of metabolic stress. 50 1000 35 1250 45 50 1000 20 1250 25 3) Inability to access bloodwork daily. 4) Expected delayed electrolyte 60 1200 40 1500 50 60 1200 25 1500 30 replacement. 70 1400 50 1750 60 70 1400 30 1750 35

80 1600 55 2000 70 80 1600 35 2000 40

Developed by: J. Greenwood, RD. Critical Care Program – Vancouver Coastal Health Authority. Reviewed by the ICU QI/QA Committee 10/9/07 (Update 7/4/2010).

DETERMINING ENERGY REQUIREMENTS: CALORIE CALCULATOR

HOW TO USE: 1. Go to Table A and select pt age and sex. 2. Go to Table B and select stress level. 3. Return to Table A and identify corresponding kcal and goal rate. (Table A based on 60-65 kg females and 70-75 kg males. Refer to Table C for direction how to adjust for very small – very large wt. Use corrected body wt for obese pts).

Table A Table B Table C

AGE SEX STRESS ENERGY GOAL RATE GOAL RATE STRESS EXAMPLES WT BODY WT (Kg) ADJUST ADJUST GOAL FEED LEVEL (kcal) (mL/hr) (mL/hr) LEVEL Use CBW if GOAL RATE Isosource HN Resource 2 obese ENERGY 1.2 kcal/mL 2 kcal/mL MILD <10% burn; mild infection; minor surgery VERY F <40 -250 kcal ↓ Isosource HN 10 mL/hr 18- M Mild 2150 75 45 SMALL M <55 ↓ Resource 5 mL/hr 25 Mod 2300 80 50 MOD 10-20% burn; significant SMALL F 40-50 -125 kcal ↓ Isosource HN 5 mL/hr High 2650 90 55 surgery M 55-65 Resource 2 (same) F Mild 1700 60 35 LARGE F 70-80 +125 kcal ↑ Isosource HN 5 mL/hr Mod 1580 65 40 HIGH 20-40% burn; severe infection; major surgery; M 90-100 Resource 2 (same) High 2150 75 45 multiple trauma; severe pancreatitis; severe CHI VERY F >80 +250 kcal ↑ Isosource HN 10 mL/hr 26- M Mild 2050 70 45 LARGE M >100 ↑ Resource 5 mL/hr 35 Mod 2200 75 45 SEVERE Individual assessment High 2600 90 55

F Mild 1650 60 35 OBESE PATIENTS: Mod 1800 65 40 Use corrected body wt (CBW), not ideal body wt (IBW) or actual body wt (ABW) High 2100 70 45 How to calculate CBW: (ABW – IBW) x 0.25 + IBW How to calculate IBW: 36- M Mild 1950 70 40 Female: Use 100 lb (45 kg) and add 5 lbs (2.5 kg) for every inch (2.54 cm) above 5 ft (152 cm) 50 Mod 2100 75 45 Male: Use 106 lb (48 kg) and add 6 lbs (3 kg) for every inch (2.54 cm) above 5 ft (152 cm) High 2400 85 50 ENTERAL NUTRITION FORMULARY F Mild 1600 55 35 FORMULA ISOSOURCE HN RESOURCE 2 ISOSOURCE VHP NOVASOURCE PEPTAMEN Mod 1700 60 35 RENAL 1.5 High 2000 70 45 kcal/mL 1.2 2.0 1.0 2.0 1.5 51- M Mild 1800 65 40 PROTEIN (g/ 44 42.5 62 45.5 45 70 Mod 1950 70 45 1000 kcal) High 2250 80 50 FAT 35 44 34 50 37 (g/1000 kcal) F Mild 1450 50 30 Mod 1550 55 35 CHO 126 110 113 92.5 125 High 1850 65 40 (g/1000 kcal) H O 670 342 850 358 513 71- M Mild 1650 60 35 2 (mL/1000 kcal) 90 Mod 1800 65 40 K 38 20 38 12 32 High 2050 70 45 (mEq/1000 kcal) F Mild 1400 50 30 MODIFICATION Standard feed Fluid restriction High Protein Low K Pre-digested Mod 1500 50 35 Fluid restriction High 1750 60 40 Calorie calculator developed by J. Greenwood, RD. Critical Care Program: VCHA – VA. Update Feb 2012