Block 2: Enteral Nutrition Flashcards
What are the types of nutrition support?
What is eneteral nutrition?
Food fomrulated to be consumed or administered enterally under the supervision of a physician that is intended for the specific dietary management of a disease or condition
Exempt from regulations on labeling and health claims
T/F: Critically ill patients can’t digest food?
Malnutrition in Critically Ill
Still Capable of Food Ingestion/Digestion
Why is enteral preferred over parenteral nutrition?
- Fewer infectious complications
- Minimize incidence of organ failure
- Fewer metabolic complications
What is EN indicated for?
- PO intake is impossible
- Poor appetite due to chronic condition or tx
- Dysphagia
- Major trauma, burns, critically ill
- Preoperative patients who are malnourished
Appropriate for patients with sufficient functioning GIT
CI in EN? CI in tube placement?
EN: Intestinal obstruction, bowel ischemia, necrotizing entercolitis
Tube: Active peritonitis, coagulopathy
What are the functions of the small and large intestine?
Small:
* Duodenum: absorption of fat, iron, folate, copper
* Jejunum: Nutrient absorption
* Ileum: Reabsorbs bile acid and Vit B12
Large: Absorbs fluid and electrolye
What is the difference between NG/NJ and G/J tube placement?
NG/NJ: manually at bedside
G/J: Surgically
Nasogastric or orogastric tube
Duration, Advantages, Disadvantages
D: Short term
Advantages: Allows for all methods of admin
Disadvantages: Increased aspiration risk
Nasojejunal or orojejunal
Duration, Advantages, Disadvantages
Duration: Short term
Advantages: Reduced aspiration risk
Disadvantages: Potential tube displacement or clogging, bolus or intermittent feeding not tolerated
Percutaneous endoscoic gastrostromy
Duration and Indication, Advantages, Disadvantages
D and I: Long term with normal gastric emptying
Advantages: Allows for all methods of admin
Disadvantages: Aspiration risk
Percutaneous endoscopic jejunostomy
Duration and Indication, Advantages, Disadvantages
D and I: Long term with impaired gastric motility or emptying
Advantages: Reduced aspiration risk
Disadvantages: Bolus or intermittenet feeding not tolerated
When do you start enteral nutrition?
Critical ill patients: Initiation between 24-72 hr decreases stress response and reduce dx severity and infection (includes malnutrition)
Healthy patients: Wait 5-7 days
Who should not get an early start to EN?
Patients with hemodynamic instabilities due to bowel necrosis from low gastric perfusion and increased O2 demand
What is early feeding?
Startign within the first 24-48 hr of admission: Goal is reaching 50-65% of caloric needs by the first week
What are the types of EN products?
- Standard polymeric
- High protein
- High caloric density
- Elemental
- Peptide-based
Standard polymeric EN
Features, Indications
Features:
* Isotonic
* NPC:N 125:1-150:1
* 1.2 kcal/mL
Indication:
* Majority of patients
* Functional GIT
* Not for oral use
High protein EN?
Features, Indications
Features:
* NPC: N <125:1
Indication:
* Protein requirement >1.5g/kg/d (burns, trauma, sores)
* Patient is recieving propofol
High caloric density EN?
Features, Indications
Features:
* 1.5 kcal/mL
* Lower electrolyte content per calorie
* Hypertonic
Indications:
* Patients requiring fluid/electrolyte restriction (kidney insufficiency)
Elemental EN
Features, Indications
Features:
* High proportion of free amino acids
* Low in fats
Indications:
1. Pateints who require low fat
2. Malabsorption syndromes: pancreatic insuficiency
Peptide-based EN?
Features, Indications
Features:
* Contains dipeptides, tripeptides, medium change triglycerides
* Contains MCTs
Indications:
* Protein malabsopritive syndromes (cirrhosis)
What is the desirable NPC:N ratio?
80: 1 in most stressful patients
100:1 in severe stressful patients
150:1 in an unstressed patients
How do you calculate NPC:N ratio?
NPC: N = Total non-protein calories/Total of N
total non-protein calories = total calories – protein calorie
1g N = 6.25 g protein
Carbohydrate- 4 kcal/gram
protein – 4 kcal/gram
Lipid – 9 kcal/gram
What is polymeric formulations?
Nutritionally complete, made up of mostly intact nutrients
Whole proteins, carbs from oligo or starch, lipids from veggie oil
What is oligomeric formulation?
Macronutrients that have been enzymatically hydrolyzed
Smaller, more numerous macronutrients -> higher osmolality
What is monomeric formulation?
Free amino acids, glucose, oligosaccharides
Kidney specific formulations?
- Calorie dense
- Low electrolyte content
Liver specific formulations?
- Decreased aromatic amino acids (phenylalanine, tryptophan, tyrosine)
- high amount of branched chain amino acid (leucine, isoleucine, valine) for patients with hepatic encephalopathy
Lung specific formulations?
- High anti-inflammatory lipid profile
- Low CO2 production- low carbohydrate and high fat to provide calories
DM specific formulations?
Low carb
Immune modulating formulations?
- Supplemented with glutamine, arginine, nucleotides and omega-3 fatty acids
- Conditionally essential aa for crit ill
When do we switch to disease specific EN formulations?
If condition is not controlled by pharm or appropriate treatments
Why are patients with ventilators given low carb formulations?
Carbs can increases CO2 production
What are the steps to dose EN?
- Calculate energy needs (TEE = BEE X Activity factor X Stress factor)
- Calculate protein needs (Protein stress factor)
- Calculate fluid needs (Add additional sterile water to reach target amount)
What are the macronutrient and total fluid needs?
Carbohydrate- 4 kcal/gram
protein – 4 kcal/gram
Lipid – 9 kcal/gram
Fluid: 30 mL/kg/day
How do you calculate total energy ecpenditure (TEE)?
TEE = BEE (basal energy expenditure) x Activity factor x Stressor factor
What is the activity factor of non and ambulatory patients?
Non: 1.2
Am: 1.3
Where do stress factors come from?
- Minor surgery
- Infection
- Major trauma, sepsis, burns
What are the types of tube feed admin?
- Bolus
- Intermittent
- Continuous
- Cyclic
Bolus Tube Feed admin
Indication, Admin, CI
Indication: Gastrostomy in home or long term care
Admin: Delivered 5-10 minutes with syringe or gravity
* Initiate with full strength formula 3-8 times per day
CI:
* Delayed gastric emptying
* High aspiration risk
* Jejunal feeding
Intermittent Tube Feed Admin
Indication, Admin
Indication: Gastric feeding who don’t tolerate bolus
Admin:
* Delivered over 20-60 min Q4-6H
* Admin using a reservoir bag and enteral pump or roller clamp
Continuous Tube Feed Admin
Indication, Admin
Indication: Required for small-bowel feeding and preferred for gastric feedings in crit ill patients
Admin:
* Initiate full-strength formulas at 10-40 mL/hr
* Increase 10-20 mL/hr every 8-12 hrs as tolerated
* Target rate: 50 to 125 mL/hr
Cyclic Tube Feed Admin
Indication, Admin
Indication: Allow PO intake and decrease on enteral feeds
Admin: Pump admin <24H, minimizes incontinences with pump and continue feeding
What complications are we monitoring with EN?
- Metabolic: Refeeding syndrome
- GI: aspiration, diarrhea, gastric residual volume
- Infectious: aspiration pneumonia
- Mechanical: tube occlusion malposition
Most common risk of tube feeding is aspiration
What are the risk factors for aspiration?
- Documented previous episodes
- Decreased level of consciousness
- Neuromuscular dx
- Endotracheal intubation
- Vomiting, regurgitation, reflux
- Prolonged supine position
- Persistently high gastric residual volumes
What are the strategies to prevent aspiration?
- Head-of-bed elevation (30-45)
- Tube placement
- Monitoring GI motility
What is GRV?
Volume of fluid in stomach after feeding
When is it appropriate to check GRV?
Not a reliable marker for aspiration pneumonia unless combined with vomiting, sepsis, sedation, or pressor agents
Check Q4H for the first 48hr and Q6-8H after goal rate
When should prokinetic agents be considered for feeding? What are the agents?
if ≥ 2 GRVs are > 250 mL
1. Metoclopramide
2. Erythromycin
Metoclopramide
Brand, MOA, Dosing, BBW
Reglan
MOA: relaxes pyloric sphincter and duodenal bulb and enhances peristalsis of duodenum and jejunum
Dosing: 10-20 mg T-QID
BBW: Tardive dyskinesia (Psychiatric meds and Parkinsons)
Erythromycin
MOA, Dosing
MOA: Stimulates smooth muscle cells by calcium-mediated event and direct motilin receptor
Dose: 200-250 mg IV Q6-12H
What are the factors to take into account by drug delivery?
- Length of functional bowel
- Internal diameter and length of tube
- Tube composition
- Flushing regimen
- Location of distal end of the tube
- Size of the distal opening
- Compatibility of drug with feeding formula
How should drugs be delivered by a tube?
- Do not add medication directly to an enteral feeding formula
- Don’t crush certain drugs
- Avoid puncturing liquid filled gel capsules
- If NPO, most of the time change to liquid form if available, however, liquid formulations are not always the answer
What drugs should not be crushed?
- Enteric and film coated tablets
- Sublingual forms, modified-release dosage forms
- Teratogenic, carcinogenic, or cytotoxic drugs
Why is liquid drugs not always an option in feed tubes?
Some must be further diluted depending on viscosity and osmolarity -> excessive fluid intake
Not optimal for those with fluid restrictions
How do you prepare solid drugs for tube feeding?
- Prefared into a very fine powder
- Mixed with 15 to 30 mL of water or other appropriate solvent before administering through the tube
How do you prepare liquid for feed tube delivery?
- Elixirs or suspensions are favored over syrups
- Always draw up in an oral syringe – NOT a syringe intended for injection
- Consider volume: Children may require a dosage adjustment
What drugs interact with nutrient? How should we counsel patients on these meds?
- Warfarin
- Phenytoi
- Tetracyclines, Quinolones and Levothyroxine
- Ciprofloxacin: oral suspension
Counsel patient Flushing the tube prior and post medication administration if home EN
How does warfarin interact with nutrient feeding?
enteral products binds to warfarin & amounts of vitamin K -> low INRs
Might require warfarin increase with tube feeding
How does phenytoin interact with nutrient feeding?
binds to the feeding solution reducing drug level
Separate tube feeds by 2 hr
How does Tetracyclines, Quinolones and Levothyroxine interact with nutrient feeding?
Chelate polyvalent cation (cal, mag, iron)
Avoid jejunal administration
How does Ciprofloxacin (suspension) interact with nutrient feeding?
Oil base adheres to tube
IR tablet is crushable though
