Artificial Feeding Flashcards
What drives problem of malnutrition?
Lack of education and ‘poor knowledge’ by doctors, nurses medical students etc
How many patients are affected by malnourishment?
- 40% malnourished on acute admission
- 70% on discharge
When does total starvation occur in normal fit adults?
Between 60-70 days
How much body weight needs to be lost to cause death?
Acute weight loss of 1/3 of body weight
What can malnourishment lead to?
- Prolonged recovery / hospital stay
- Fatigue depression
- Poor mobility (increase DVT, poor wound healing, pressure sores)
- Increased morbidity and mortality
What is MUST?
Malnutrition Universal Screening Tool (developed by BAPEN 2003)
Assessment of malnutrition and malnutrition risk
3 measurements:
- BMI (Weight/Height2)
- Recent weight loss (%)
- Acute illness with, or likely to be, no nutritional intake for 5 days
Score 0-6 (0=low), more than 2=high
When should adult malnutrition be assessed?
- Within 24 hours of admission
- Repeated weekly
Trigger questions
- Have you lost weight recently?
- Have you noticed a reduction in appetite?
- Will this admission have impact on patient’s nutritional intake (e.g. swallowing problems, multiple injuries)
MUST should be completed if ‘yes’ to ANY trigger questions
What are high risk medical conditions for malnutrition?
- Swallowing problems
- Poor absorption from gut
- High nutrient loss
- Increased nutritional needs
Key point about overweight people
Overweight people can be malnourished as well (high BMI=0 points, sudden weight loss and lack of intake can = points using MUST)
How is anthropometry used to assess nutrition?
- Tricep skinfold thickness
- Mid arm circumference
- Mid arm muscle circumference
How are biochemical measurements used to assess nutrition?
- Poor
- Albumin is not a marker of poor nutrition
- Can measure levels of vitamins/ trace elements etc
What do nutritional requirements depend on?
Age group, gender, clinical condition, job, activity levels etc
Who should have artificial nutrition?
- Can’t eat (stroke, head and neck surgery)
- Can’t eat enough (burns, sepsis, pre-operative malnutrition)
- Shouldn’t eat (bowel obstruction, leaks after surgery, prolonged paralytic ileus)
What are types of artificial feeding?
- Enteral (into gut) –> if gut works, use it
- Parenteral (into vein)
When might enteral feeding be required?
- Persistent and poor oral intake for > 3 days
- Dysphagia (difficulty in swallowing)
- Head injury with prolonged recovery
Need a functioning gut
What are the types of short-term enteral feeding?
- Naso-gastric feed (tube in nose and sits in stomach)
- Nasojejunal feeds (if problem with stomach e.g. gastric outlet obstruction/delayed emptying)
What are problems of nasal tubes?
Can be sore –> usually <4 weeks for nasal tubes
What is used for longer term enteral feeding?
- PEG (percutaneous endoscopic gastrostomy)
- RIG (radiologically inserted gastrostomy)
What is PEG?
Scope into stomach, shine bright light so can see through abdominal wall, press finger in
Should be able to see light from outside and sharp indentation of finger from inside
If whole bowel pushes on stomach then implies problem (e.g. transverse colon pushing on stomach)
Needle into stomach and wire passed through and pulled out of mouth (patient sedated)
When would RIG be used instead of PEG?
If cancers in upper GI tract e.g. mouth
When would intravenous nutrition be used?
When guts don’t work (e.g. after operation, little bowel left)
What is intravenous nutrition typically called?
TPN (total parenteral nutrition)
- So actually PN (patients often eat)
- Feeding into vein
Define parenteral
Administered or occurring elsewhere in the body than the mouth and alimentary canal.
When is PN used?
- Last resort as riskiest feed
- Inability to establish any other route for nutrition
- Inability to meet nutritional requirements via the oral or enteral route
e.g. obstruction, short bowel syndrome, fistulae, complications post surgery
Typical indications for PN
- Obstruction
- Short Bowel Syndrome (after surgical resections)
- Fistulae (abnormal connections, often between bowel and skin)
- Complications post-surgery
(Prolonged paralytic ileus and anastomotic leaks)
What are the routes for IV feeding?
- Short-term –> peripheral feeding (midline) e.g. into arm
- Medium term –> central feeding (PICC - peripherally inserted central catheter)
- Long-term –> Tunnelled lines (Hickman)
What are complications of IV feeding?
- Pneumothorax
- Infection
- High blood sugar - may require insulin (e.g. due to 12 hour feed overnight)
- Electrolyte disturbance
- Refeeding syndrome
- Abnormal liver tests/liver failure
What is refeeding syndrome?
‘Too much too soon’ (eating after prolonged fast)
Patients at risk:
- Malnourished
- No recent intake
- Alcoholic
What happens?
- Fluid shifts
- Electrolyte shifts
What are the main effects of starvation?
- Decreased insulin secretion
- Increased glucagon secretion
- Switch from glucose to ketones for energy
What are the other effects of starvation?
- Glycogen stores used
- Basal Metabolic Rate (BMR) decreases
- Brain adapts to ketones
- Atrophy of all organs
- Reduced lean body mass
- Deficiency of vitamins and trace elements
What electrolytes are most at risk during starvation? Why?
- Potassium
- Magnesium
- Phosphate
Sit inside cell. When you measure blood level they will appear to be normal as they leak out of cell into blood to maintain levels. During feeding, they reenter cells (reactivation of Na/K pump) and get catastrophic drops. Leads to confusion, cardiac arrest etc
What can an acute thiamine (vitamin B1) deficiency lead to?
Wernicke-Korsakoff syndrome (WKS)
- Vision changes
- Impaired memory
- Disorientated
If left untreated, can lead to irreversible loss of short-term memory
What is WKS usually 2ary to?
Alcohol abuse
How is refeeding syndrome treated?
Give pabrinex (iv Vit B and C - thiamine)
Feed slowly and build up
Check daily electrolytes
Long-term monitoring of PN?
Temperature/pulse/BP + weight daily Blood sugars 6 hourly Daily FBC, U&E, Mg, Ca initially Then 3X week Ca, Mg, Phosphate, LFT Regular trace elements (Copper, Zinc and Selenium)
What colour trays are used for malnourished patients in hospital?
Red
What are the physical effects of poor nutrition?
- Reduced muscle mass/function
- Increased risk of chest infections
- Difficulty in weaning from ventilator
- Reduced cardiac output
- Reduced mobility –> increased risk of DVT/PE, bed sores
What are the immune effects of poor nutrition?
- Increased risk of infection;
Altered gut function → translocation of gut bacteria
What are the psychological effects of poor nutrition?
Depression, Apathetic (showing no enthusiasm), Irritable, Reduced mental concentration
If albumin is not a marker of poor nutrition, what does it indicate?
-ve acute phase protein e.g. Albumin goes down in rheumatoid arthritis/sepsis whilst inflammatory markers go up
What are -ve acute phase proteins?
Negative acute-phase proteins decrease in inflammation
