What are the principles of feeding and nutrition (FNF) treatment in bedridden patients?

Principles of Feeding and Nutrition Treatment in Bedridden Patients

Bedridden patients require individualized nutritional support with early enteral nutrition when oral intake is insufficient, aiming for 27-30 kcal/kg/day and 1.1-1.5 g protein/kg/day to prevent malnutrition and improve clinical outcomes.

Nutritional Assessment and Screening

• All bedridden patients should undergo nutritional screening using a validated tool to identify malnutrition risk 1
• Assessment should include:
  • Current weight and weight history (loss >10% over 6 months indicates severe risk) 1
  • Serum albumin (<35 g/L) and prealbumin (<300 mg/L) as biochemical markers 1
  • Functional status and ability to swallow safely

Energy Requirements

• Energy needs can be determined by:

  1. Indirect calorimetry (most accurate method) 1
  2. If unavailable, VCO₂ from ventilator measurements (for ventilated patients) 1
  3. For elderly bedridden patients: approximately 27 kcal/kg actual body weight/day 1
  4. For severely underweight patients: 30 kcal/kg actual body weight/day (with caution to avoid refeeding syndrome) 1

• Avoid both underfeeding and overfeeding:

  • Underfeeding (<70% of requirements) increases complications and mortality 1, 2
  • Overfeeding (>110% of requirements) leads to metabolic complications 1

Protein Requirements

• Bedridden patients should receive 1.1-1.5 g protein/kg body weight/day 1
• Exception: For patients with impaired kidney function (eGFR <30 ml/min/1.73m²) not on kidney replacement therapy, target 0.8 g protein/kg/day 1
• Higher protein intake helps maintain muscle mass and functional status, particularly important in immobilized patients 1

Route of Nutrition Administration

1. Oral Nutrition (if swallowing is safe)

• First-line approach when possible
• Use oral nutritional supplements (ONS) when regular diet is insufficient 1
• High-protein ONS should be administered to maintain functional status and muscle mass 1
• Food fortification can be used if ONS is not tolerated 1

2. Enteral Nutrition (EN)

• Indicated when oral intake is insufficient despite ONS 1
• Should be initiated within 24 hours in critically ill bedridden patients 1
• Route selection:
  • Nasogastric tube: standard first-line approach 1
  • Nasojejunal: for patients with impaired gastric motility 1
  • Percutaneous endoscopic gastrostomy (PEG): superior to nasogastric tubes for long-term feeding (>4 weeks) 1, 3

3. Parenteral Nutrition (PN)

• Reserved for cases where enteral route cannot meet nutritional requirements 1
• EN is preferred over PN due to lower risk of infectious complications and maintenance of gut integrity 1

Special Considerations

Monitoring

• Regular monitoring of:
  • Nutritional parameters (weight, anthropometrics)
  • Biochemical markers (albumin, electrolytes)
  • Functional status
  • Fluid balance 1

Refeeding Syndrome Prevention

• At-risk patients (severely malnourished) should start at lower caloric intake and gradually increase 1
• Monitor and correct electrolyte abnormalities, especially phosphate, potassium, and magnesium 1

Drug-Nutrient Interactions

• Pharmacist-assisted management plan should be established 1
• Consider timing of medications relative to feeding

Post-Discharge Nutrition

• Nutritional support should be continued after hospital discharge to maintain or improve nutritional status 1
• Continued support with ONS or individualized nutritional intervention lowers mortality in malnourished patients 1

Common Pitfalls to Avoid

1. Unnecessary fasting practices that contribute to hospital malnutrition 2
2. Inadequate monitoring of nutritional status in long-term bedridden patients 4
3. Assuming standard feeding protocols are sufficient without individualization based on metabolic needs 5
4. Failure to recognize that even bedridden patients receiving calculated "adequate" nutrition may still become malnourished due to disease-related factors 4
5. Neglecting the importance of swallowing training when appropriate, as maintaining some oral intake (even if minimal) has psychological benefits 3

By implementing these principles, healthcare providers can optimize nutritional support for bedridden patients, potentially improving clinical outcomes, reducing complications, and enhancing quality of life.