ASPEN Self-Assessment: Intro to EN

Question 1

What is the maximum hang time for closed-system enteral formulas?

Answer 1

48 hours

Question 2

What are the fluid needs for an adult over the age of 65?

Answer 2

30 mL/day with a minimum of 1500 mL

Question 3

What percent water are standard enteral formulas?

Answer 3

~84%

Question 4

What are the benefits of early enteral feeding in critically ill patients?

Answer 4

• Decreases translocation of gut bacteria
• Reduces atrophy of intestinal villae
• Reduces risk for infectious complications.

It does not increase intestinal permeability.

Question 5

What are the 2 most important factors in assessing the adequacy and efficacy of enteral feedings in pregnancy?

Answer 5

1. Maternal weight gain

2. Fetal growth

Question 6

(TRUE/FALSE)

There is a strong correlation between infant birth weight and maternal weight.

Answer 6

TRUE

Question 7

Why is serum albumin not recommended for assessing the adequacy and efficacy of EN during pregnancy?

Answer 7

Serum albumin is not recommended due to diluational effects associated with normal plasma expansion and alterations in plasma protein production.

Question 8

Lactose is a common ingredient in which type of enteral formula?

Answer 8

Standard infant formula

Lactose is used to mimic the carbohydrate found in human milk.

Question 9

What EN formula is appropriate for patients with chyle leaks? Why?

Answer 9

Elemental

Goal of nutrition mgmt:

• Reduce the quantity and duration of chyle loss
• Determine patient’s response to an elemental, low-fat diet before initiating PN

Question 10

What are 3 important parameters for predicting tolerance of EN in patients with pancreatitis?

Answer 10

1. APACHE II score (disease severity; most important)
2. Duration of NPO (Greater than 6 days have shown poor tolerance)
3. Increasing abdominal pain

Question 11

(TRUE/FALSE)

Triglyceride level is an appropriate parameter for EN tolerance in patients with pancreatitis.

Answer 11

FALSE.

Serum TG levels are used to measure tolerance of PN, not EN

Question 12

When should EN be initiated?

How long should it last?

Answer 12

When patients are expected to (or have) not received adequate oral intake x 7 - 14 days.

Duration of EN should not be less than 5 to 7 days in the malnourished patient or 7 to 9 days in the adequately nourished patient.

Question 13

(TRUE/FALSE)

It is safe to provide EN in patients with open abdomen.

Answer 13

TRUE.

In patients requiring open abdomen mgmt after laparatomy, PN should be deferred until EN is not tolerated x 7 or more days.

PN should be indicated in patients with high output mid-jejunal fistula, intractable obstipation and vomiting and short bowel syndrome.

Question 14

Why would placement of a jejunostomy feeding tube NOT be beneficial for patient’s with short bowel syndrome?

What is recommended instead?

Answer 14

Infusion of EN into the jejunum will result in increased stool output and decreased absorption.

Slow continuous infusion into the stomach is recommended to maximize absorption and increase intestinal transit time.

Question 15

What is the best intervention to assist with the appropriate placement of an NG tube in an alert patient?

Answer 15

Elevate the HOB to a sitting position, having the patient flex their head slightly forward once the tube tip is in the posterior nostril.

Having the patient swallow small sips of water may prevent respiratory misplacement.

IV metoclopramide is a prokinetic agent that may assist with transpyloric tube passage.

Question 16

(TRUE/FALSE)

Bedside electromagnetic imaging systems have shown greater than 90% success with placement.

Answer 16

TRUE.

Weighted tube tips are the LEAST likely to facilitate transpyloric placement of an NG tube.

Question 17

What is the primary advantage of a direct PEJ (percutaneous endoscopic placed jejunal tube) VERSUS PEG-J (percutaneous endoscopic transgastric-placed jejunal tube)?

Answer 17

Reduced incidence of migration or flipping back into the stomach in the PEJ.

Although gastric outlet obstruction may occur may in the PEG-J method, that is NOT the primary advantage of using PEJ.

Bleeding risk is no different

The ability to place PEG-J depends on the skill of the endoscopist.

Question 18

What characteristic of enteral formulas is the MOST likely to increase splanchnic blood flow in a critically ill patient?

Answer 18

Research has shown that blood flow to the bowel is maximized with the use of HIGH FAT formulas over high CHO formulas.

An isotonic, fiber-free formula is ideal for patients at high risk for intestinal ischemia as adequate bowel perfusion is necessary for tolerance of high fiber, high osmolarity feedings.

Question 19

What two interventions reduce the risk of aspiration with EN?

Answer 19

1. Elevate HOB to 30-45 degrees
2. Oral hygiene

No benefit to holding the TF during brief periods of supine positioning or elevated gastric residuals.

Question 20

What is the effect of alpha-2 adrenergic agonist meds in EN?

Answer 20

Alpha-2 adrenergic agonists, such as clonidine, have been shown to have significant antimotility effects and often prolong instead of reducing intestinal transit time.

Question 21

(TRUE/FALSE)

Metoprolol administration requires changing TF schedules.

Answer 21

FALSE, does NOT.

Question 22

(TRUE/FALSE)

The bioavailability of warfarin, phenytoin, carbamazepine, and fluoroquinolones, such as ciprofloxacin, may be altered with EN and the EN feeding is often held for up to 2 hours, before and after administration to reduce interactions.

Answer 22

TRUE, but there is controversy surrounding holding TF

Many practitioners do not recommend holding TF around medication administration due to suboptimal nutrition delivery and lack of evidence. Many will justify continuing EN around medications that could potentially interact, and for adjustment of meds to help maintain therapeutic serum drug levels.

Question 23

(TRUE/FALSE)

An acidic juice such as OJ can reduce the risk of microencapsulated beads/pellets sticking to the tube.

Answer 23

TRUE.

The tube should be flushed with 30 mL water before and after administration of the drug-juice mixture to avoid physical interactions between the acidic juice and the EN formulation.

Mixing drugs with carbonated beverages may be problematic due to the physical drug-nutrient interaction with the EN formulation.

The use of water or an oral electrolyte solution to administer granules may cause them to become sticky and adhere to the tube, thereby increasing the risk for feeding tube occlusion.

Question 24

What is the hang time for blenderized formulas?

Answer 24

2 to 8 hours depending on if it’s homemade or commercial

Question 25

What is the hang time for reconstituted enteral formulas?

Answer 25

Hang-time for powdered formula is limited to 4 hours (at room temperature)

Hang-time for canned or bottled sterile, liquid formulas is 8 hours.

Must be prepared aseptically and by trained personnel

Question 26

What is the hang time for closed system EN?

Answer 26

24 to 48 hours, depending on the connection set.

Question 27

What is the best method to assess protein requirement and adequacy?

Answer 27

The gold standard for assessing adequacy of protein intake in the hospitalized patient is NITROGEN OUTPUT.

-Derived using UUN and requires a 24-hour urine collection.

N balance = N intake (intake in nutrition support divided by 6.25) - N output (UUN x urinary volume / 100 + 20% urinary urea losses + 2g)

Example: EN provides 136g protein

N balance = 21.8g - [16+3.2(20%) +2] = 0.6 or N equilibrium

Question 28

(TRUE/FALSE)

Elemental and semi-elemental formulas are designed for patients with GI dysfunction, including patients with known malabsorptive disorders or those having difficulty absorbing or digesting standard polymeric formulas.

Answer 28

TRUE.

Polymeric formulas may also have more benefits than elemental formulas in patients with intestinal failure as these formulas are more isotonic and may better enhance intestinal adaptation.

Question 29

Immune-modulating EN formulas should be reserved for which patients?

Answer 29

Trauma, TBI and, surgical ICU patients.

Question 30

(TRUE/FALSE)

Immune-modulating EN formulas are contraindicated in septic patients.

Answer 30

TRUE.

Due to adverse effects are seen with arginine supplementation in these individuals.

Question 31

(TRUE/FALSE)

Immune-modulating EN formulas are recommended for routine use in the medical ICU.

Answer 31

FALSE, are NOT recommended

Question 32

Which of the following are modular products?

 Safflower oil
Protein
Glucose
Selenium
MCT oil
Fiber
Glutamine
Cholecalciferol

Answer 32

MCT oil, glucose, fiber, and protein

Modular products are commonly used to fortify enteral nutrition regimes or meals served
-Are typically single-nutrient products and are available for use in addition to the selected oral or enteral products.

Question 33

(TRUE/FALSE)

There is believed to be an increased ratio of AAA (aromatic AA) to BCAAs in patients experiencing hepatic encephalopathy.

Answer 33

TRUE, therefore, the use of EN enriched with BCAAs may benefit patients with refractory encephalopathy.

But the use of these hepatic formulas be limited to patients with encephalopathy that is unresponsive to standard medical therapy (lactulose, non-absorbed abx)

Question 34

Why may EN be contraindicated in the early post-transplant period with hematopoietic cell transplants?

Answer 34

Because of potential mucosal toxicities related to the conditioning regime.

GI toxicities such as: N/V/D/delayed gastric emptying seen in the 2-3 weeks post-stem cell transplant may preclude EN.

Question 35

Which type of medications can be crushed for administration via EN tube?

Answer 35

Only immediate-release tablets

Question 36

(TRUE/FALSE)

Modified release dosage (such as XL, XR, SR, CD) are inappropriate crush and give via EN tube because crushing these dosage forms destroys their modified releasing properties.

Answer 36

TRUE. This may lead to an excessive dose of the drug being released at one time (instead of slowly over a longer period of time), which can lead to adverse effects and has even been reported as a cause of death.