• Inadequate protein-energy intake related to esophageal cancer and 6-month history of progressive dysphagia as evidenced by dietary recall (low protein and energy intake), loss of appetite and 25 lbs weight loss.
• Inadequate oral intake related to 6-month history of progressive dysphagia as evidenced by loss of appetite, dietary history (consumption of ~500 kcal/day) and 25 lbs weight loss.
• Malnutrition related to a 6-month history of esophageal cancer resulting in progressive dysphagia as evidenced by low serum lab values (potassium, phosphorus, BUN), poor oral intake, dietary history (consumption of ~500 kcal/day), physical assessment and 25 lbs weight loss.

• Current weight: 59 kg
• Carson’s nutrition requirements:
  • Energy: 1770-1800 kcal/day (~30 kcal/kg/day)
  • Protein: 71-77 g/day (1.2-1.3 g/kg/day)
  • Fluid: 2065 mL/day (35 mL/kg/day)
• Formula selection: Isosource 1.2 (standard formula)
• Continuous feeding: over 20 hours
  • It is common to start enteral nutrition on a patient like Carson with a continuous feeding schedule.  He has had a prolonged period of low intake and he is at risk of refeeding syndrome. A continuous feeding schedule will allow us to assess GI and metabolic tolerance.
  • We are feeding over 20 hours because there is a drug-nutrient interaction with levothyroxine, so we need to hold feeds 2 hours before and after administration. Check your institution’s policy about holding feeds for drug-nutrient interactions.

Review the requirements and practice calculating Carson’s enteral feeding plan using the formulary sheet provided.

Calculations:

• Formula amount: 1800 kcal ÷ 1.2 kcal/mL = 1500 mL/day (at goal volume the DRIs are met)
• Goal rate: 1500 mL ÷ 20 hours = 75 mL/hr
• Provides:
  • Energy: 1.2 kcal/mL × 1500 mL/day = 1800 kcal/day (30 kcal/kg)
  • Protein: 0.054 g/mL × 1500 mL= 81 g/day (1.3 g/kg)
  • Carbohydrate:  0.16 g/mL × 1500 mL = 240 g/day
  • Fat: 0.04 g/mL × 1500 mL = 60 g/day
  • Free water: 80% of 1500 mL = 1200 mL/day
    • For this amount of formula, there is 1200 mL of free water, which does not meet his estimated requirements for fluid. This is important to keep in mind when calculating water flushes and evaluating other sources of fluid.

Prior to calculating Carson’s water flushes, liaise with his MD/NP to change his IVF to 0.9% NS and decrease his rate to 10 mL/hr. Carson will be receiving ~1200 mL free water from his enteral feeds (at goal rate) and will have a continuous source of CHO (does not require ⅔ + ⅓).  Patients typically receive 10-25 mL/hr TKVO (to keep vein open).

He is also receiving ~300mL of water for his medication administration. This is information you obtained from his nurse.

Calculate water flushes required for a total fluid intake (TFI) of ~2065 mL/day (35 mL/kg)

• Current sources:
  • IV 0.9% NS @ 10 mL/hr = 240 mL/day.
  • ~1200 mL free water from his enteral feeds (at goal rate)
  • ~300 mL from medication administration
• Current total fluid delivery: IV (240 mL) + medications (300 mL) + feeds (1200 mL) = 1740 mL/day (29 mL/kg)
• Fluid deficit = 2065 mL − 1740 mL = 325 mL/day needed via flushes
  • 325 mL ÷ 50 mL flushes (for tube patency) = ~6 times per day
• TFI to meet needs: 240 (IV) + 300 (meds) + 1200 (feeds) + 50×6 (water flushes) = 2040 mL/day (35 mL/kg)
• Order water flushes: 50 mL via G-Tube q 4 hours

It is common practice to flush the feeding tube for patency every 4-6 hours with a minimum of 25 mL of water. For Carson, we will order 50 mL water flushes q 4 hrs to meet his needs of approximately 35 mL/kg of fluid per day.

Carson is at risk for refeeding syndrome: start conservatively and advance nutrition slowly.

• Liaise with team to replace low electrolytes:  K⁺ (3.3), PO₄ (0.7) – prior to initiation of enteral feeds and 6 hours after. Ensure electrolytes are ordered daily × 5 days and monitor for further replacements
• Liaise with team to order: multivitamin (daily) and 100 mg thiamine (for 3 days)
• Starting rate: Isosource 1.2 @ 25 mL/hr × 20 hrs (holding 2hrs pre & post Levothyroxine administration)
• Starting rate provides: 600 kcal (10 kcal/kg), 27 g protein/day (0.46 g/kg), 78 g CHO/day – these amounts align with guidelines for refeeding syndrome
• Progression: if tolerated × 24 hrs, increase 10 mL q 12 hrs to goal rate of 75 mL/hr × 20 hrs

In Carson’s case, the amount of protein he is receiving when initiating enteral feeds is low.

Based on the current plan, Carson will not meet his goal rate until ~day 3 of enteral feeding (this is if there are no complications/interruptions to progressing towards goal). It may be worthwhile to incorporate additional protein (Beneprotein®) until the goal rate is reached. Beneprotein is a protein module (1 pkg = 25 kcal & 6 g protein).

• Starting protein intake: 27 g/day from Isosource 1.2 @ 25 mL/hr × 20 hrs/day.
• Estimated protein requirement: 1.2 g/kg = 71 g/day (aim for lower end of target range).
• Protein deficit: 71 g requirement − 27 g from feeds = 44 g to meet 1.2 g/kg.
• Calculation: 44 g ÷ 6 g per pkg = 7 pkgs required (use 6 pkgs for nurse ease). 6 pkgs provides 150 kcal and 36 g of protein.
• Starting rate: Carson will receive 750 kcal (13 kcal/kg/day) and 63 g protein (1.1 g/kg/day) from feeds and Beneprotein.
• Order: Mix 2 pkgs of Beneprotein with 100 mL of water and administer via G-tube TID. Plan to discontinue or decrease Beneprotein when enteral feeds are near or at goal.

Review the final summary for Carson’s nutrition care plan before commencing the simulation activity below.