Link: S/s & Labs | See: Signs of Deficiencies | Basal Metabolic Requirements | Malnutrition | Drug-induced Vitamin Deficiency & ICD-9 |
Protein Calorie (Energy) Malnutrition (PEM or PCM): a term used to describe the effects of inadequate protein and energy intake. In children may see Kwashiorkor syndrome if there is a physiologic stress such as an infection in a malnourished child (edema, irritable mood, poor appetite). Marasmus: occurs when there is marked depletion of subcutaneous fat and muscle mass (60-80% expected body wt for age, no edema, good appetites but at <60% body wt).
S/s of Malnutrition: Dietary changes relative to usual intake, duration of changes and type of diet (hypocaloric, starvation, suboptimal solid), supplements taken. GI sx’s that have persisted >2 wks (N/V/D/ pain). Functional capacity (bedridden, ambulatory, working suboptimally). Medical dz and its relation to nutritional requirements (no stress, moderate stress, high stress such as burns/ trauma/ sepsis). Physical status (wasting, ascites, edema, mucosal lesions, cutaneous changes, loss of SC fat).
Hair: Dull, dry, thin, fine, straight, and easily plucked; areas of lighter or darker spots and hair loss.
Face: Generalized swelling, dark areas on cheeks and under eyes, lumpy or flaky skin around the nose and mouth, enlarged parotid glands.
Eyes: Dull appearance; dry and either pale or red membranes; triangular, shiny gray spots on conjunctivae; red and fissured eyelid corners; bloodshot ring around cornea.
Lips: Red and swollen, especially at corners.
Tongue: Swollen, purple, and raw-looking, with sores or abnormal papillae.
Teeth: Missing or emerging abnormally; visible cavities or dark spots; spongy, bleeding gums.
Neck: Swollen thyroid gland.
Skin: Dry, flaky, swollen, and dark, with lighter or darker spots, some resembling bruises; tight and drawn, with poor skin turgor.
Nails: Spoon-shaped, brittle, and ridged.
Musculoskeletal system: Muscle wasting, knock-knee or bowlegs, bumps on ribs, swollen joints, musculoskeletal hemorrhages.
Cardiovascular system: Heart rate above 100 beats/minute, arrhythmias, elevated blood pressure.
Abdomen: Enlarged liver and spleen.
Reproductive system: Decreased libido, amenorrhea.
Nervous system: Irritability, confusion, paresthesia in hands and feet, loss of proprioception, decreased ankle and knee reflexes.
Labs:
1. Albumin: T-½ = 3wks. 2.8-3.5g/dL mild depletion, 2.1-3.7 mod, <2.1 severe malnutrition / depletion of visceral protein. Can be deceptive, as with pre-albumen both may be normal in starvation, or be markedly low in an acute illness or increase with dehydration. Must use in combo with other clinical assessments. Level does not change with aging.
Pre-albumen: T-½ = 2-3 days. Best lab to use in monitoring nutritional recovery. Order whenever note that albumen level <3.2 g/dL. Normal pre-albumen is 15-30 mg/dL (150-350 mg/L). Poor prognosis if <5 mg/dL (<50mg/L). Significant risk (need aggressive nutritional support) if 5-11 mg/dL, incr risk if 11-15 (monitor status biweekly. False elevation with renal dysfunction. Zinc, alcoholism and steroid use affect the level. Transferrin has T-½ = 8-10d. All three will decrease with microvascular permeability and stress.
2. Nitrogen (Protein) Balance (g): the difference between nitrogen intake, in the form of amino acids or protein, and nitrogen losses in urine, stool, skin, and body fluids.
= Nin – Nout = (protein intake(g) / 6.25) – (UN (on 24hr UUN collection) + 4). The “4” is added to represent the insensible nitrogen lost other than UUN, >2/3 of nitrogen derived from protein breakdown is excreted in the urine. If the UUN is > 30 (g/24 hours), a factor of 6 is more appropriate for the daily nitrogen losses other than UUN Since protein is 16% nitrogen, each gram of urinary nitrogen (UN) = 6.25mg of degraded protein. The goal of nitrogen balance is to maintain a positive balance of 4-6g. 85% of the nitrogen in the urine is contained in urea, the remainder in ammonia and creatinine. UUN can underestimate the urinary nitrogen losses in ICU pts (may need to add the urinary ammonia excretion). Normal metabolism you want 0.8-1g/kg protein intake, if hypercatabolism, you need 1.2-1.6g/kg. Growing children need 2g/kg/d. The healthy 70kg adult excretes (urea, feces, skin) 30g of protein/d = 0.4g/kg, not all dietary protein is digestible, thus the RDA calls for 0.8g/kg/d. The first step in achieving a positive nitrogen balance is to provide enough nonprotein calories to spare proteins from being degraded to provide energy. A negative nitrogen balance of 1 g/day represents a 6.25 g/day (16% of 6.25 g protein = 1 g nitrogen) loss of body protein, which is equivalent to a 30 g/day loss of hydrated lean tissue. In practice, nitrogen balance studies tend to be artificially positive because of overestimation of dietary nitrogen intake and underestimation of losses caused by incomplete urine collections and unmeasured outputs.
Calorie-Nitrogen Ratio: A calorie-nitrogen ratio of 100:1 to 150:1 (i.e., 100 to 150 nonprotein calories per gram of nitrogen) is required for protein synthesis in healthy persons. The calorie-nitrogen ratio changes in different disease states; in sepsis, increased nitrogen and decreased nonprotein calories are appropriate (100:1), whereas in uremia, a ratio of between 300:1 and 400:1 (calorie per gram of nitrogen) has been advocated. The manner of investigation is critical; that is, keeping nitrogen adequate and varying the calorie-nitrogen ratio is the preferred method. When inadequate amounts of protein are given and caloric intake varies, erroneous data and conclusions may result.
3. Total Lymphocyte Count: <1000-1200 /uL =mod to severe malnutrition.
4. Serum Transferrin: < 100-200 = mod to severe malnutrition. Transferrin, with a half-life of 8 to 10 days, can be used instead of albumin when acute nutritional perturbations are under evaluation.
5. % Weight loss: compare current to usual outpatient/ pre injury wt (not IBW):
%Wt change = (usual wt / actual wt) /usual wt X100.
Significant wt loss –> 2% @1wk, 5% @1mo, 7.5% @3mo, 10% @6mo. Severe wt loss if higher.
% Ideal Body Weight = actual wt/ IBW X 100.
6. Total Cholesterol: <160 mg/dL in the frail elderly is associated with poor nutritional intake as well as increased mortality.
Other –> thyroid binding globulin, retinol binding protein (half-life is ~10 hours, but its sensitivity to even minor stress limits the clinical utility of its measurement), delayed cutaneous hypersensitivity (anergy), Triceps skinfold (Men should have 8-23mm, women 10-30mm). See Carbohydrates |
Nutritional Status by BMI in Adults:
<16 = Severely malnourished.
16-16.9 = Moderately malnourished.
17-18.4 = Mildly malnourished.
Biochemical Tests Useful for Assessing Vitamin and Mineral Status:
Vitamin A: Serum retinol, retinol-binding protein.
Thiamina Erythrocyte (red blood cell) transketolase activity, erythrocyte thiamin pyrophosphate.
Riboflavin: Erythrocyte glutathione reductase activity.
Vitamin B6: Urinary xanthurenic acid excretion after tryptophan load test, erythrocyte transaminase activity, plasma pyridoxal 52-phosphate (PLP).
Niacin: Plasma or urinary metabolites NMN (N-methyl nicotinamide) or 2-pyridone, or preferably both expressed as a ratio.
Folateb Serum folate, erythrocyte folate (refl ects liver stores).
Vitamin B12: Serum vitamin B12, serum and urinary methylmalonic acid, Schilling test.
Biotin: Urinary biotin, urinary 3-hydroxyisovaleric acid.
Vitamin C: Plasma vitamin C, leukocyte vitamin C.
Vitamin D: Serum vitamin D.
Vitamin E: Serum ±-tocopherol, erythrocyte hemolysis.
Vitamin K: Serum vitamin K, plasma prothrombin; blood-clotting time (prothrombin time) is not an adequate indicator.
Minerals:
Phosphorus: Serum phosphate.
Sodium: Serum sodium.
Chloride: Serum chloride.
Potassium: Serum potassium.
Magnesium: Serum magnesium, urinary magnesium.
Iron: Hemoglobin, hematocrit, serum ferritin, total iron-binding capacity (TIBC), erythrocyte protoporphyrin, serum iron, transferrin saturation.
Iodine: Serum thyroxine or thyroid-stimulating hormone (TSH), urinary iodine.
Zinc: Plasma zinc, hair zinc.
Copper: Erythrocyte superoxide dismutase, serum copper, serum ceruloplasmin.
Selenium: Erythrocyte selenium, glutathione peroxidase activity.
Normal Values for Serum Proteins:
Albumin (g/dL) 3.5–5.4
Transferrin (mg/dL) 200–400
Transthyretin (mg/dL) 23–43
Retinol-binding protein (mg/dL) 3–7
IGF-1 (¼g/L) 300
NOTE: Levels less than normal suggest compromised protein status.
Links: Refeeding Syndrome | Enteral Support | Oral Formulations | TPN | PPN | Healthy Diet | Nutrition & Vitamins | Basal Metabolic Requirements | Types Of Venous Devices (Ports) | Best (Recommended) Outpatient Diet | Special diets | Assessment of Malnutrition | Common Nutrients |
Oral nutritional supplementation (995 kcal and 100% of the RDA, protein and micronutrients) of acutely ill hospital pt’s improved nutritional status and led to a statistically significant reduction in the number of non-elective readmissions (Am J Med 2006;119:693-699) (readmission rate of 29% Vs 40%)….the supplement group received 2 bottles (200 mL each) daily at 8:00 a.m. and 12 noon in addition to the standard hospital diet for a period of 6 weeks.
Goals of Nutritional Support:
Most hospitalized often have an increased metabolic demand that quickly lead to a malnourished state if the pt is not nutritionally supported.
1. Determine BMR for age, sex, and BSA (BMR in kilocalories per day).
2. Determine the percentage of increase in metabolic rate due to the injury.
3. If active, add 25% × BMR for hospital activity (walking, physical therapy, sitting, tx).
4. The sum of steps 1 to 3 is an estimated daily caloric requirement for maintenance of body weight.
5. Divide step 4 by 150 to determine nitrogen requirements (convert to protein = 6.25 × nitrogen).
6. Give ~ 70% of caloric requirement as glucose. Give remaining caloric requirement as fat. Reassess energy and nitrogen needs at least twice weekly.
7. If nutritional support seems inadequate because of progressive weight loss, consider direct measurement of oxygen consumption or measurement of nitrogen balance.
Hungry bone syndrome (the opposite of tumor lysis syndrome). Occurs with refeeding of pt’s with severe wt loss, anorexia (main cause in USA), cancer, chronic infections (including HIV), starvation conditions (kwashiorkor and classic marasmus), chronic underfeeding, chronic alcoholism, morbid obesity with massive weight loss, prolonged fasting or underfeeding (>7-10 days) (common in inpatient rehabilitation units after transfer from a severe illness in the hospital).
PP: During a period of suboptimal oral intake, a loss of lean tissue mass, water, and minerals ensues, and this results in total body depletion of phosphorus. When a malnourished pt is administered nutrition, typically in the form of carbohydrates, insulin release leads to transcellular shifts of phosphorus, potassium, and magnesium, resulting in hypophosphatemia, hypokalemia, and hypomagnesemia, respectively. In addition, increased tissue anabolism leads to increased cellular demand for phosphorus, glucose, potassium, and water. Synthesis of adenosine triphosphate, 2,3-diphosphoglycerate, and creatine phosphokinase may also contribute to phosphorus depletion. Carbohydrate loading also leads to sodium and water retention, which results in volume expansion and edema, which can lead to circulatory overload and heart failure. Hyperglycemia is common and can lead to osmotic diuresis, acidosis, and increased susceptibility to bacterial infection. Phosphorus deficiency can lead to suboptimal adenosine triphosphate production, which can result in cardiac myocyte dysfunction, altered leukocyte chemotaxis, poor skeletal and diaphragmatic muscle function, and cell membrane breakdown.
S/s: Hypokalemia, hypomagnesemia, severe hypophosphatemia, vitamin deficiency (thiamine deficit) and fluid shifts (edema). Refeeding adds carbohydrates to blood, increased insulin secretion, carbs cause incr uptake of electrolytes (phosphorus, K+, Mg2+) into cells with depletion of phosphorylated intermediates (ATP, 2,3 DPG). If there is concern for development of refeeding syndrome, check a full panel electrolytes including phosphate, Ca2+, Mg2+ qd x 1 week, begin low calorie feeding with gradual increase, administer vitamins routinely including thiamin >100mg/day and follow urinary electrolytes including phosphate. Oral or parenteral supplementation of potassium, magnesium, and phosphorus should also be considered to avoid significant declines in serum levels. In pt’s with established RFS, slowing the rate of caloric intake, decreasing sodium and IV fluids, treating hyperglycemia with insulin, and supplementing electrolytes are typically successful. Discontinuing nutritional support altogether is usually not necessary and places the pt at increased risk of malnutrition and its complications.
Enteral Nutrition Support:
Links: Initiation and Complicatins | Common Supplements | Feeding Tubes | PEG (Gastrostomy) | PEGJ | DPEJ & Placement Techniques | Refeeding Syndrome | Assessment of Malnutrition | Dysphagia Management & Swallowing Eval | Textures | Special diets |
By tube or by mouth. Medicare covers 80% of cost if needed >3mo and pt requires >20 cal/kg/d because of an anatomic defect (poor appetite and anorexia nervosa not covered). Early enteral feeding improves clinical outcomes in critically ill and trauma pt’s, likely related to the immune modulating effects of nutrients such as arginine, glutamine, nucleotides and omega-3 fatty acids (J of Critical Illness 2001;16:2). Routine oral protein energy supplementation to a normal hospital diet does not improve outcomes in pt’s admitted with a recent stroke (Lancet 2005;365:755-63).
Requirements: hemodynamically stable, no massive GI bleeds, intestinal obstruction, Abx induced/ severe idiopathic diarrhea, high-output enteric fistula or abd distention.
Assess GI function: GI output should be <600ml/d via NGT, ostomy or rectal tube. Check bowel sounds (does not correlate with peristalsis), passage of flatus or stool is better marker.
Start Tube Feed infusion –> “Start TF with XX (often use high fiber agents such as Jevity) @ 25ml/hr.
Incr rate by 15ml q8hr until goal of 75ml/hr, hold for 1hr if residual >200ml.”
Some recommend starting @ 10-20ml/hr of isotonic solution (300mOsm/kg) for 1st 24h.
Day #1 at up to 30ml/h, 60ml on day #2, 90ml on day #3. If intragastric can go up to 480 mOsm/kg (max of 300 if intra jejunal). All pt’s have incr risk of aspiration, place pt in semi-recumbent position with HOB elevated to 30-40 deg. Small-bowel tube (beyond the pylorus) is associated with a reduction in regurgitation and a trend toward less pulmonary aspiration (Crit Care Med 2001;29:1495). Monitor for tube migration into the stomach.
Residual volumes: An imprecise measurement of gastric emptying, gastric volume and aspiration risk.
• In a randomized study, routine gastric monitoring (checking for residuals q6hrs) reduced nutritional intake while conferring no important benefit (JAMA 2013;309:283)……Residual volume >250 mL in the monitored group, or vomiting in both groups, was considered a sign of intolerance and triggered treatment with a prokinetic drug and a decrease in tube feeding rates. Despite more vomiting in the unmonitored group than the monitored group (40% vs. 27%), no difference was reported in the incidence of VAP (16.7% and 15.8%). Unmonitored patients were significantly more likely to achieve their caloric goals. No differences occurred between groups in duration of mechanical ventilation, length of stay, or mortality.
Traditional order is to “Check q6hr” –> Before each feeding, delay feeding if >200-300ml. Re-ck in 2hr. If persistently high, may need tube that is distal to the ligament of Treitz and HOB is elevated. If incr aspiration risk, get tube into jejunum by 1st placing tube in stomach (confirm by pH of aspirate), then placing pt on their R side for 2h and 1-2X in next 24h, then check X-ray. If still not passed, give 10mg Reglan IV. Can add 3-5ml of contrast into tube to verify position. May need endoscopy. Consider a prokinetics or avoiding narcotics to prevent gut stasis. Consider using a low fat formula. Flush tube with 100 ml of water after each bolus. Check BS <200 as hyperglycemia causes gastroparesis. IV dopamine may cause gut dysfunction. May need to switch to a NJ tube.
Hyperglycemia is the most common metabolic abnormality seen. Try to use a formula with 30-50% of calories as fat. May need insulin SC @ 5 U q4-6h for glucose 200-250mg/dL, 7.5 U if 250-300, 10 U if 300-350. When the next days solution is ordered give half the SC quantity of insulin added to the bag. If need >100 U/d give a separate insulin drip/ infusion. If severe glucose intolerance, limit the rate of administered glucose to 5mg/kg/min (~500mg/d) and give extra calories as a fat emulsion. Need to monitor serum triglycerides and hold emulsion temporarily if it exceeds 500 mg/dL.
Indications of Intolerance: May need parenteral nutrition if –> vomiting, severe cramps, residual volume >50% of administered volume in past 4h, increasing distention, worsening diarrhea.
Complications: Large bore NGT causing pharyngeal irritation, otitis media, sinusitis. Obstruction of tube lumen, gastric aspiration, tube displacement.
Aspiration –> Avoid by proper tube placement, adequate pt positioning and residual check. Not necessarily a reliable test, but some recommend adding food coloring (blue food coloring at 1ml/L) or methylene blue to liquid, see if detect in pharyngeal or tracheal secretions. Sept 29, 2003, the FDA reports 12 deaths related to this practice as well as the risk of discoloration of body fluids and skin.
Risks: depressed sensorium, incr GERD, h/o aspiration, meds such as theophylline, CCB, anticholinergics, beta adrenergic agonist, alpha antagonist. Delayed gastric emptying evident in many critically ill pt’s might result from hypersensitivity to small-intestine nutrient feeding that leads to motility changes (Gut 2005;54:1384-90)…..postpyloric delivery of enteral nutrition might be more effective. This is coupled with ICU pt’s having virtually nonexistent lower esophageal sphincter pressure and severely impaired secondary peristaltic motor response to reflux (Gastroenterology 2005; May 10).
Symptomatic Medications:
If get N/V, cramping, bloating –> reduce rate or concentration, use lactose free formula, bring formula to room temp before use. May need to switch to a NJ tube.
If get diarrhea –> (=stool wt >300g/d or volume >30ml) –> incr rate or concentration, use continuous infusion, mix formula better, r/o Abx induced. Use a lactose free or elemental diet, clean equipment. Can add an antidiarrheal such as Kaolin-pectin 30ml or in J-tube q3-6h followed by 25ml NS irrigation. If not improved in 48h add Paregoric (opiate) @1ml/100ml formula. Check C. diff assay and fecal fat content. Avoid H2 blockers as may lead to bacterial overgrowth, if need them, titrate to gastric pH of 4.5-6.5). Or Loperamide (Imodium) 24 mg PO or in J-tube q6h, max 16 mg/d PRN OR Diphenoxylate/atropine (Lomotil) 5-10 mL (2.5 mg/5 mL) PO or in J-tube q4-6h, max 12 tabs/d.
Constipation –> increase free water intake, stool softener, fiber containing formula, prune juice, increase physical activity.
Tube clogging –> add routine irrigation with 20-25ml of NS or water after each feeding.
Special Medications: Metoclopramide (Reglan) 10-20 mg PO, IM, IV, or in J tube q6h. Cimetidine (Tagamet) 300 mg PO tid-qid or 37.5-100 mg/h IV or 300 mg IV q6-8h OR Ranitidine (Zantac) 50 mg IV q6-8h or 150 mg in J-tube bid.
Other info: Essential amino acid and carbohydrate supplementation (6.5 g essential amino acids and 30 g carbs TID) maintains muscle protein synthetic capacity and reduces lean muscle loss in pt’s who are immobile or confined to bedrest (J Clin Endocrinol Metab. 2004;89:4351-4358) (counterbalances the catabolic response of prolonged inactivity (28 days). In critically ill mechanically ventilated medical pt’s, early enteral feeding (within 48 hours of the onset of mechanical ventilation) significantly reduces ICU and hospital mortality, mainly in the sickest pt’s in spite of higher rates of ventilator-associated pneumonia in the early feeding group (Chest. 2006;129:960-967).
Specific Oral Nutritional Support:
Links: Dysphagia | Common Supplements | Special diets |
Nutrient intake is increased due to the increased nutrient density of the supplements. Intermittent bolus feeding via 8-10F NGT. Avoid aspiration by elevating the HOB and checking for residuals. If need long-term feeding such as in dementia, neurological impairment a gastrostomy tube may be placed.
Caloric density: of most is 1 kcal/ml.
Polymeric Feeds: Suitable for those with a normal or near normally functioning bowel. They contain whole protein as the nitrogen source—most provide 500 g/l of nitrogen and energy of 1 kcal/ml, although they can range from 0.5–2 kcal/ml. Commercial feeds are now clinically lactose and gluten-free and contain enough vitamins, trace elements, and essential fatty acids to prevent deficiencies. Some pt’s may need extra micronutrients and macronutrients.
Elemental Feeds: contain either pure amino acids or predigested protein and provide oligopeptides and amino acids. Amino acid solutions taste unpleasant and are relatively expensive, so unless there is extensive impairment of GI digestive and absorptive functions they appear to offer little additional benefit. Their use is increasing in a variety of situations in research institutions.
Disease specific feeds: generally play little part in long term enteral nutrition. They can be used in severely ill pt’s, such as those with multiple burns or trauma, respiratory failure, advanced cirrhosis, or acute renal failure. Renal specific diets can be useful in chronic renal failure.
Modified diets: elemental diet. Hepatic, stress and renal diets.
Hepatic formula: if in failure or hypercatabolic or encephalopathic. Have increased amounts of branched-chain AA’s (BCAA’s) as they undergo little metabolism by the liver (also beneficial if septic or critically ill). Also have decr aromatic AA’s (phenylthaline, tyrosine, tryptophan) and sulfur containing (methionine). For impaired liver function use Hepatic-aid II, Nutri hep or Travasorb Hepatic.
Renal Formula: all essential AA’s, but no nonessential. Indicated if renal failure and do not need dialysis and not on broad-spectrum Abx.
Most give 2cal/ml. Deliver 2.0, Magnacal Renal, Nepro, Nova source renal, Suplena or Renal cal.
GI dysfunction: use medium chain triglycerides (MCT’s) as more easily absorbed and metabolized than long-chain (LCT’s).
Diarrhea –> Isotonic, lactose free 1cal/cc formulas such as Isosource standard, Isosource HN, Isocal, Isocal HN, Osmolite, Osmolite HN, Promote or Nutren 1.0.
Impaired Fat absorption –> use MCT’s. Lipisorb, Subdue, Peptamen, Sandosource peptide, Reabilan or Travasorb MCT.
Constipation/ Diarrhea –> use high fiber formula. Ensure/f, Boost/f, Nuren/f, Replete/f, Nubasics/f, Sustacal/f, Fibersource, Fibersource HN, Jevity 1.5, Jevity Plus, Poralance or Ultracal.
Fluid Restriction –> use 2 cal/cc products. Deliver 2.0, TwoCal HN, Nutren 2.0 or Nova source 2.0.
Diabetes/ hyperglycemia –> use formula with high fat and low carbs. Choice DM, DiabetiSource, Glucerna, Glyctol, Resource Diabetic.
Stress –> use peptides or free AA’s as protein source. Criticare HN, Tolerex, Petamen, Vital HN, Sanosource peptide, Vivonex Plus or TEN.
High stress and hypermetabolic –> use peptides/ free AA’s. Alitraq, Crucial, Peptamin VHP or 1.5, Perative, Reabilan HN or Replete.
HIV Infection –> use omega-3 fatty acids. Advera, Impact or Impact 1.5
Glutamine: the most abundant AA in the body. Acts as the main fuel source and as a biosynthetic precursor in the gut and immune system. Forms glutathione for antioxidants, used in acid base metabolism to release ammonia in the kidney. Has been shown to reduce infection and hospital stay; decr pouchitis; improve 6mo survival in ICU pt.
Glutamine (OTC as Enterex Glutapak-10; NutreStore; Resource GlutaSolve; Sympt-X): approved by the FDA for the tx of short bowel syndrome when used in combination with nutritional support and growth hormone therapy. Considered a “conditionally essential” amino acid during metabolic stress and injury. Dose @ 30 g/day administered as 5g 6 times/day (every 2-3 hours while awake) for up to 16 weeks. Mix each packet (5 g) with ~240 mL of water prior to administration. May be given with meals or snacks. May also be mixed in hot or cold beverages, applesauce, or pudding. If administering via feeding tube, mix with 60-120 mL water.
Arginine: required for growth and secretion of GH, insulin, glucagon, prolactin, and somatostatin. Antihypertensive, improves wound healing and spermatogenesis, increases myocardial perfusion and cerebral blood flow as well as perfusion to ischemic areas.
Omega-6 fatty acids should be avoided as they reduce the immune response and incr infections as well as accelerate CV dz. (Nutritional pharmacotherapy in surgical pt’s. Am J Surg 2002;183:350).
