12: Nutrition Support

Question 1

What is the most common g-tube complication?

Answer 1

peristomal infection

Question 2

If a patient was going to do blenderized tube feedings, what size tube do they need?

Answer 2

larger than 14 Fr

Question 3

What is important to supplement with during refeeding syndrome?

Answer 3

Thiamin — 100 mg/d for 5-7 days

Question 4

What is a concern with a patient that is malnourished and starting on NS? What are signs/symptoms and how do you manage it?

Answer 4

Refeeding syndrome
S/S: hypophos/K+/Mg, severe glucose ranges, fluid shifts/retention, cardiac dysfunction and respiratory failure
25% of energy needs to start, gradually increase over 3-5 days until labs/clinical signs are resolved

Question 5

What are some ways to avoid having clogged tube?

Answer 5

larger Fr – common in 8-10 Fr
interactions between meds and formula are common issues — avoid meds down tube if possible

Question 6

What are some ways to unclog a tube?

Answer 6

5 mL of warm water as near to clog as possible for up to 15 minutes

Use a gentle push/pull motion with 30-60 ml syringe plunger to help dislodge the clog and attempt to aspirate or flush with warm water

Us a solution of pancrelipase mixed with sodium bicarb

commercial unclogging device or things like clog zapper (medical supervision needed)

Question 7

What are some EN specific concerns with medications for: anti-diarrheals

Answer 7

Cholestyramine isn’t recommended – particularly for small bore tubes

Use loperamide liquid instead or diphenoxylate hydrochloride and atropine sulfate

Question 8

What are some EN specific concerns with medications for: antiemetics

Answer 8

Concerns with aprepitant and ondansetron orally disintegrating tablet (better to take orally by letting it dissolve on tongue and swallow)

Use liquid versions instead

Question 9

What are some EN specific concerns with medications for: antibiotics

Answer 9

cirpofloxacin and levofloxacin aren’t recommended to go down a tube but there are no recommended alternatives — oral if possible

Question 10

What are some EN specific concerns with medications for: appetite stimulants

Answer 10

Dronabinol isn’t recommended

Use other dissolvable tablets or liquids of other options

Question 11

What are some EN specific concerns with medications for: pain meds

Answer 11

extended release pills are an issue, but a lot have liquid (or patch) form

Question 12

What are some EN specific concerns with medications for: Laxatives

Answer 12

methycellulose or psyllium, cholestryamine, or biscodyl tablets are not recommended

use liquids, senna, lactulose, or suppositories

Question 13

What are some EN specific concerns with medications for: PPIs

Answer 13

Pantoprazole and Rabeprazole tablets not recommended (but can do a packet)

Dexlansoprazole capsules and disintegrating table – others have tablets as well

Question 14

What are some EN specific concerns with medications for: vitamins

Answer 14

Slow Mag, K-Dur, Micro-K not recommended —- can usually get liquid versions of vitamins/minerals no problem

Question 15

What are some EN specific concerns with medications for: Sucralfate

Answer 15

May bind with protein left in the tube from formula — change to a different PPI or H2 blocker formulation

Question 16

What are some EN specific concerns with medications for: pancreatic enzymes

Answer 16

open capsule and mix with small amount of applesauce if oral available, otherwise suspend in water or nectar-thick juice NOT something alkaline like yogurt

Question 17

What is the highest the final concentration of PPN can be?

Answer 17

900 mOsm/L, dextrose of 5-10% and max of 3% amino acids

Question 18

What is the minimum dose of dextrose you can give daily to avoid ketone production?

Answer 18

50 g/d

Question 19

What type of lipid can help reduce common PN issues like liver disease?

Answer 19

Change from normal soybean-oil based to SMOFlipid (mixed oil— 30% soybean oil, 30% medium-chain triglycerides, 25% olive oil, and 15% fish oil)

Question 20

What are some medications that can be added directly to PN?

Answer 20

H2-receoptor antagonists, insulin, heparin

Question 21

What is the ASPEN recommendations for initial insulin dosing?

Answer 21

0.05 to 0.1 units per g of dextrose in the PN solution or 0.15-.2 for patients already hyperglycemic