The Great(er) White(er) North: Baby's First...Tube Feed

That's a bit misleading, actually. I didn't tube feed a baby. That said, I did do my first very own tubefeed and observed my first TPN. SO COOL.

For those not in the know, an enteral or tube feed is when liquid formula is fed straight to the stomach or intestine via a tube through the nose or through an opening in the abdomen. TPN is known as total parenteral nutrition, so the actual elements of nutrition: amino acids, dextrose, and fatty acids, are put via IV right into the bloodstream. It blows my mind a little bit that we can even do this. Anyway, the acute care RD emailed my preceptor to say she had a new TPN and a new tubefeed, AND they were both at risk for re-feeding syndrome. Basically what happens here is that the person is malnourished to the point where electrolytes can go pretty haywire if you give them too much too quickly. My preceptor was like 'Yeah....you probably won't get to see too many of these. Howsabout we lend you to her?'

I don't have much to write about the TPN because as it's still technically beyond my scope in clinical 1, I just watched. The patient had an ileus, so basically their colon wasn't working temporarily. Ergo, tube feed won't help much since you need a working gut. There was pretty well a whole page of calculations, if not two, because one of the problems with the north is they don't stock all the nice convenient products you can get in the south, so the dietitian was frantically trying to figure out SOMETHING that would work. You have to try to get the right ratio of everything, but in this case you couldn't have too MUCH of fat, liquid or carbs because of the refeeding. Oi.

But the tube feed - my FIRST tubefeed. This patient was having a very difficult time with weight gain, so they decided to give them a continuous tube feed and still allow some oral foods as possible. Basically, the dietitian gave me the patient's chart and the enteral feeding form, and said 'I'm going to go talk to the patient. Write her up a tubefeed prescription.' Oh. Em. Gee. So after sitting stunned for a couple minutes, I just...did it. Just like that! I had the formulas, I had the guidelines for refeeding, it was just a question of walking myself through. Protein, carbohydrate, fat and fluids: how much do they need vs how much can they have.

Here's what all those calculations look like. It's too bad I can't show the finished form, but that's rather confidence breach-y.

I should frame this.

If someone is that malnourished, you actually start out by feeding them only about half of their estimated requirements for calories. You also only get 2 g carbs/kg (not much, considering most of us easily eat 200 g of carbs in a day, I imagine), and 1 g of fat/kg (which in this case can actually seem like a lot, almost 50% of their calories coming from fat!), and only 1L of fluid (for most people you need around 1.5 L, but in this case you're worried about messing up electrolytes.) I also got to order the required labs - daily labs for glucose and electrolyes, and weekly iron studies, etc. Electrolytes has to be daily for the 1st 3 days because you MUST correct them if they're really off. Anyone know what having messed up electrolytes does? Basically, your nervous system is not appreciative if anything is off. Google it for gory details if you're feeling nerdy.

I felt very smart, especially after a nurse leaned over and said, 'Whoa. I had no idea there was that much calculation involved.'

So we did get some snow shortly after my last post, although it's pretty warm now. Here are some pictures :)