I am excited that I will be starting my clinical rotation soon and am excited to conduct NFPE on real patients. I am saddened the patient is in the hospital, however, I will do what I can to conduct the NFPE with the utmost respect, dignity, and care. It's amazing how watching a video can prepare a dietetic student for the clinical setting. I am definitely better prepared after watching both the adult and pediatric NFPE videos.

The videos I chose to watch for this reflection were the Enteral Feed Calculations: Standard Formula, Enteral Nutrition Support: Oncology Case Study, Parenteral Nutrition Calculation: Custom 2-in-1 + Lipid Piggyback, and Parenteral Nutrition Case Study – Crohn’s Disease. Before watching these videos, I was not confident in my enteral and parenteral nutrition calculation ability as I had only calculated TPN once while taking a pre-requisite course to get into the MSND program. The Enteral Feed Calculations: Standard Formula video was very helpful, though I was a little confused at first. The video stated that though Mr. X had noted swallowing difficulties, his healthcare providers didn’t think the swallowing difficulties would be a long-term problem.(1) As a result, a short-term enteral feeding was planned and the patient would receive enteral feedings through a nasogastric tube (NG tube).(1) I learned that NG tubes are intended to be used for a few days up to a few weeks.(1) Due to the NG tube selection, the patient is most likely going to require enteral feeding for two-weeks or less.(1) I learned that overall energy needs (kcals) and protein needs are two important categories to focus on to ensure that enteral feeding will meet patient needs.(1) I was reminded that indirect calorimetry is the most accurate way to calculate energy needs, and I instantly wondered if I would have the opportunity to observe indirect calorimetry in-person. I was surprised to learn that even though indirect calorimetry is considered the “gold standard” and is one of the most accurate methods to determine energy needs, it is expensive and cumbersome, which leads practitioners to not choose this method even if it is available to them.(1) This led me to wonder how critically ill a patient must be in order for indirect calorimetry to automatically be considered. I became curious about the use of indirect calorimetry and wondered what scenario it is most likely to be used. I decided to research the literature and found an interesting study that suggested indirect calorimetry should be used in critically ill patients in the ICU as predictive energy equations have poor predictive value in all subgroups of ICU patients.(2) The study also suggested that when indirect calorimetry is not available, patients with very high and very low metabolic rates are at a significant risk of under- or over-feeding.(2) I thought this was quite interesting to learn and did not realize that if indirect calorimetry is not used in very severe ICU patients, over- and under-feeding may occur.(2) Interestingly, this study was contradicted by the Enteral Feed Calculations: Standard Formula video as the RD in the video stated that predictive equations are appropriate and can be used in critical care patients or patients on a ventilator.(1) I understand there are always nuances in science, and that one study alone does not make up the overall body of evidence – but I can’t help but wonder who is more accurate in this case. I know that working in a clinical environment, like I will during clinical rotations, should help me understand when predictive equations are and aren’t appropriate/helpful and when to use indirect calorimetry. Being in a clinical setting and observing/learning from experienced RDs will help me better understand these topics. I hope I have the opportunity to observe the indirect calorimetry process when I am in my clinical rotation. I now know that formula choice may be dependent on GI tract function, disease state, and/or volume tolerance.(1) I learned that patients who can’t handle large volumes and have fluid restrictions may need a higher concentration formula that contains all nutrients needed (meets the DRIs) but has limited free water and fluid.(1) I learned that some formulas may be created for specific disease states.(3) This reminded me of Modulen IBD, as it was created for Crohn’s Disease patients and is a big part of the Crohn’s Disease Exclusion Diet (CDED).(3) One thing that really stood out to me was that many enteral formulas contain fiber, and these fiber-containing formulas are important for patients with normal GI function to help maintain bowel health.(1) This may sound silly, but fiber in formula is not something I had thought about as the formulas I have received in the past did not contain fiber. However, I now recognize my previous formulas did not contain fiber because I suffered from altered GI function due to severe Crohn’s disease flares. What also stood out to me was ensuring the formula is appropriate to ensure the patient meets their micronutrient DRIs.(1) When I was prescribed TPN in the past, I distinctly remember two bags attached to the continuous feeding monitor (I now know I was fed with a custom 2-in-1 + lipid piggyback parenteral formula). However, I do not remember thinking about the importance of receiving micronutrients back then (this was in 2010 and I did not have an understanding of nutrition science). What I have learned from this is, if given the opportunity to work with TPN patients in a clinical setting, I will explain to them that they are receiving amino acids, dextrose and lipids (the small lipid bag is quite obvious, even to me 15 years ago!), but I will also explain that they are receiving the appropriate amount of vitamins and minerals to meet their micronutrient needs. The video Enteral Nutrition Support: Oncology Case Study was very interesting as it was a case study of a 57-year-old male with a history of head and neck cancer who was receiving radiation and was going to undergo a surgical resection in the future.(4) I wanted to watch this video for two reasons. First, our enteral worksheet presented a patient with esophageal cancer, so I wanted to further learn about how best to calculate enteral needs for cancer patients. Second, I wanted to better understand the nutritional needs that may occur in a cancer patient receiving radiation and/or chemotherapy. I learned that the first intervention this patient received was to try soft and/or pureed foods and was subsequently taught how to add protein and calories, though the patient experienced painful swallowing and difficulty eating and drinking.(4) I wondered if, in a real-world clinical situation, it would be the speech-language pathologist (SLP) who prescribed this diet modification because the patient experienced painful swallowing and difficulty eating and drinking.(4) It is my understanding that when it comes to swallowing difficulty or eating difficulty, it fell under the SLP scope of practice. I acknowledge I am not in a clinical situation and do not fully understand all nuances, however, I assess that if an esophageal cancer patient is having difficulty eating and drinking and it hurts every time he swallows, perhaps he should have been put on enteral nutrition to begin with vice trying the first intervention of soft/pureed foods.(4) For me, this is delaying much needed enteral feeding – but I fully acknowledge I do not understand the full why behind the first intervention. Perhaps the insurance company required this to occur first (kind of like step-therapy for medications), or maybe the medical clinic could not schedule the patient for a percutaneous endoscopic gastrostomy (PEG) tube in a timely manner. Either way, the patient in the case study suffered as a result. Additionally, the patient in the case study ended up presenting to the ED because he couldn’t eat or drink for ~3-4 days, which was 3-4 days after he was given the first intervention of soft/pureed foods.(4) He was then admitted for a PEG tube placement.(4) I then learned how to calculate the enteral formula needs of this patient. This video was very helpful in helping me learn not only how to choose the proper formula for the patient and how to calculate energy, protein and fluid needs, but also brought up the importance of how to initiate tube feeding. I didn’t realize that initiating tube feeding could pose such a significant risk to patients if they are malnourished or in a state of starvation.(5) I had read this in our text and also learned about it in the lecture, but a case study such as this that identified the patient as a “refeeding risk” brings it all – the lecture and text – full circle! This was very helpful for me to observe, and because I had learned about refeeding syndrome in both the text and our class lectures, and saw it again in this case study, I will not forget it. However, if I did not see refeeding syndrome in the case study, I may not have recognized a patient that may be at risk. For this, I am grateful! I will also remember that a patient at risk for refeeding syndrome also requires IV thiamine because these patients become thiamine deficient due to thiamine being a cofactor in many metabolic processes.(4) This is another example of reading about thiamine deficiency in the textbook and hearing it in the lecture, but it was the case study that brought the point full circle for me (so I won’t forget it)! The Parenteral Nutrition Calculation: Custom 2-in-1 + Lipid Piggyback video was extremely informative. The first thing that stood out to me in this video was that enteral feeding may be unsafe for an ICU patient that presents with small bowel perforation and the likelihood that the patient may require a surgical resection surgery within the next few days.(6) I was literally shocked to learn that enteral feeding may put the patient at risk for sepsis, infection, or GI tissue damage.(6) I would not have known that this could occur (again, I have never worked in a clinical setting), but this is great to know – especially since I’m going to begin my clinical rotations within the next year. This video was also a great reminder that certain medications may contain nutrients (lipids, dextrose, amino acids) and must be considered when calculating overall formula needs. In this case, the patient was on propofol. I learned that propofol is a lipid-containing sedative, and that calories are associated with the amount of propofol the patient receives.(6) I used to think that all parenteral nutrition bags were customized for the patient, but I now know that there are also standardized bags and also a variety of both custom and standardized bags.(6) This was good to know as when I was on TPN, the formula was created for my unique needs, so this led me to believe (incorrectly) that all parenteral nutrition was customized. I’m glad I learned this before starting my clinical rotation. I also didn’t realize that how the parenteral nutrition is administered is more important that simply “picking” a formula. For example, whole proteins cannot be administered directly into the bloodstream, therefore, protein is presented in the form of amino acids within the IV solution.(6) I was reminded that carbohydrates are provided as dextrose and was reminded that dextrose is 3.4 kcal/gram, which is different than the standard 4 kcal/gram for carbohydrates. It was interesting to learn that ~70% of non-protein calories can come from carbohydrates in a nondiabetic patient.(6) Equally as important, learning about the dextrose infusion rate was helpful, especially learning that the max is 5 mg/kg/min for adult patients to prevent hyperglycemia.(6) Prior to watching this video, I did not know how to calculate and account for medications that contained kcalories (in this case study it was propofol). I learned how to calculate and account for the lipids in this medication that the patient receives in a 24-hour period. It was shocking to learn that the patient was receiving 264 kcal of lipids from this medication alone! It was then I realized that if medications aren’t accounted for when calculating parenteral formula, over-feeding may occur! This was a very powerful example that I will not forget as 264 kcal is significant! It was also important to remind the patient’s care team to let the RD know when the medication (propofol in this case) is changing or if the patient is being taken off of the medication because parenteral formula needs may change as a result.(6) I understand how this can be a significant problem because if this patient was taken off of propofol, and the RD was not notified, this patient would not be receiving 264 kcal of lipids – which is significant! Something I also had not thought of prior to watching this video is that there are instances when a patient may not need as many lipids due to elevated triglycerides or another health concern.(6) In this case, a lipid piggyback may be withheld. I did not know this before and would have wondered where the patient’s lipids were if I was in a clinical environment and only saw dextrose and amino acids! I assess that if I was in a clinical setting, and had not been told this, I would have thought that the healthcare team was not doing their job as an entire macronutrient was missing! Again, this is another great example of how these videos provide an essential foundation prior to entering clinical rotations! I also now know that if a lipid piggyback is withheld for a week or more, it may be necessary to increase protein and carbohydrate provisions to ensure the patient is meeting their required energy needs to support healing.(6) I also learned that, depending on the healthcare facility, the RD may calculate electrolyte needs, but not always. I also learned that a pharmacist may instead oversee managing electrolytes. I also learned that the RD doesn’t always manage patient fluid needs, and that the ICU team may handle fluid needs instead, depending on the case.(6) The final video I watched was Parenteral Nutrition Case Study – Crohn’s Disease. The patient in this case study not only suffered from Crohn’s Disease (CD), but his CD was complicated by an enterocutaneous fistula.(7) Prior to watching this video, I had heard of fistulas but had not heard of an enterocutaneous fistula. I became curious so looked up images of an enterocutaneous fistula and was shocked and saddened by what I saw. As a Crohn’s patient, I am thankful I have not experienced this. This is another example of something I am glad I saw prior to walking into a clinical setting as I may have been quite shocked to see this for the first time inperson. I was familiar with the parenteral nutrition calculations presented in the video as this was the last video I watched. However, what stood out to me the most was that the CD patient was still losing weight despite being on parenteral nutrition for two weeks!(7) The case study patient continued to lose weight despite being on parenteral nutrition. I was not surprised that the case study patient suffered from malabsorption, but I did not know that this could persist, even if one was given parenteral nutrition. I thought parenteral nutrition rested the gut, but I then realized that the case study patient was also consuming food and drink orally. Also, the patient has a enterocutaneous fistula, which is contributing to his malabsorption.(7) My heart broke for this patient, and I was at the edge of my seat waited to see what the RDN would do next! Over the next several weeks, dextrose was increased several times and his feeds increased multiple times due to continued weight loss.(7) Over the course of several weeks, his dextrose was increased from 200 g, then up to 300 g, then up to 400 g.7 His protein increased from 100 g, then to 125 g, and again up to 150 g.7 Lastly, his lipids increased from 50 g, to 60 g, and then again up to 70 g.7 I also learned that during this time, his liver and kidney function was assessed to ensure they were not being stressed by the increase in formula (his kidney and liver function remained stable).(7) I was shocked to learn that despite feeding the patient 33 kcal/kg and 1.7 g/kg protein, he still lost weight.(7) His energy needs were then increased to 45 – 50 kcal/kg and protein was increased to 2 – 2.5 g/kg.7 With the new change, his dextrose increased from 400 g to 535 g (1819 kcal), protein increased from 150 g to 185 g (740 kcal), and his lipids increased from 60 g to 75 grams (750 kcal).(7) Thankfully, the patient finally started gaining weight with this updated TPN prescription.(7) It is an understatement to say that the increase in TPN prescription shocked me. I also felt overwhelmed and helpless for this patient as I shifted into “patient mode” and know how it feels to try to do everything “right” and continue to decline with no end in sight. (I want to insert a sad face emoji here, but that would be unprofessional – but that is exactly how I felt going through this case study). No other case study has impacted me so severely, but I assess it is because this case study is of a CD patient. I also learned what labs should be requested if a patient is on long-term PN. The labs are a baseline ferritin, total iron binding capacity, vitamin D-25(OH), RBC, folate, vitamin B12, vitamin E, vitamin A, zinc, copper, selenium, CRP, and manganese.(7) I learned to check these labs every six-months while long-term TPN is used.(7) In my assessment, six-months seems like a long time to wait to check labs for an ill patient on TPN, but again, I have a lot to learn. I also want to mention, my son watched this video with me and throughout the duration of the video he kept stating, “Poor Mr. M!” My son was very relieved to learn that the case study patient (Mr. M) healed at the conclusion of the case study. At the end of the video my son stated, “Wait – he healed? Phew – now he can start living a good life again.” To me, this underscores how much this CD case study patient suffered for several months. This also taught me that TPN is not necessarily a “quick” fix as it took this patient several months to heal, despite being on TPN. Overall, the enteral and parenteral calculation videos and case studies complimented the lecture and text reading assigned this week. They also really helped me develop an enteral and parenteral nutrition calculation foundation and, as a result, I feel more confident and prepared for my clinical rotation! References 1. Dietitians in Nutrition Support. Enteral Feed Calculations: Standard Formula. August 6, 2018. Accessed February 23, 2025. https://www.youtube.com/watch?v=tgIeGD9- _Ik&t=57s 2. Sundström Rehal M, Tatucu-Babet OA, Oosterveld T. Indirect calorimetry: should it be part of routine care or only used in specific situations?. Curr Opin Clin Nutr Metab Care. 2023;26(2):154-159. doi:10.1097/MCO.0000000000000895 3. Nestle Health Science. Modulen IBD: Explore the Benefits of Casein Protein Powder. 2024. Accessed February 23, 2025. https://www.nestlehealthscienceme.com/en/brands/modulen/modulen-ibd 4. Dietitians in Nutrition Support. Enteral Nutrition Support: Oncology Case Study. October 31, 2023. Accessed February 23, 2025. https:// https://www.youtube.com/watch?v=wck3YJLGoyk&list=PL4Q15OsBNWbS0zgbk0RJeeWhGvybnvfI&index=21 5. Nelms M, Sucher K. Nutrition Therapy and Pathophysiology. 4th ed. Cengage; 2020. 6. Dietitians in Nutrition Support. Parenteral Nutrition Calculation: Custom 2-in-1 + Lipid Piggyback. April 29, 2019. Accessed February 23, 2025. https://www.youtube.com/watch?v=bci5zL7yvWM&list=PL4Q15OsBNWb_fSYnoRsD59xGAW5ix55W&index=2 7. Dietitians in Nutrition Support. Parenteral Nutrition Case Study – Crohn’s Disease. October 24, 2024. Accessed February 23, 2025. https://www.youtube.com/watch?v=43kPg6NUWjs

As an Inflammatory Bowel Disease (IBD) patient myself who has also been on TPN twice, it's as interesting to "be on the other side" and learn how to calculate enteral and parenteral tube feeds. I learned so much watching these videos and case studies and feel that I will be better prepared for my clinical rotation as a result. The case study that had the most profound impact on me was the Crohn's disease Parenteral Case Study (I mention this in my reflection). I learned a great deal about the complications of IBD, complications I could not even imagine. Overall, I am looking forward to starting my clinical rotation and feel that I have a good foundation on tube feeding and parenteral nutrition!