Ch 10: Overview of EN Flashcards
Indications for EN
- Stroke/other neuro disorders that impair swallowing ability
- Oral intubation for mechanical ventilation preventing PO intake
- Feeds distal to obstruction or high-output fistula
Consideration of ethical issues with EN
- Patient/family wishes
- QOL
- GOC
- Risk/benefits of nutrition therapy in the context of diagnosis, prognosis, and long-term are goals
Benefits of EN
- Maintains gut integrity
- Undergoes first-pass metabolism → promotes efficient nutrient utilization
- Presence of nutrients in the small intestine maintains gallbladder function by stimulating CCK → reducing risk of cholecystitis during NPO/PN
- Luminal nutrients provide GI structural support; helps maintain gut-associated and mucosa-associated lymphoid tissue vital to immune function
- IgA, which is secreted within the GI tract in response to intraluminal nutrients, can prevent bacterial adherence and translocation
- Reduces infectious complications from sepsis, intra-abdominal abscess and PNA
- Less expensive than PN
Contraindications to EN
When GI tract can’t be utilized
* Severe SBS (<100-150 cm remaining SB in absence of colon OR 50-70cm SB in presence of colon)
* Paralytic ileus
* Severe GI bleed
Short term enteral access
- Stomach
- Past pylorus into duodenum
- Distal to Ligament of Treitz and into jejunum
Long-term enteral access
EN >4-6 weeks
G-tube, J-tube, or G/J-tube
* Should be placed using percutaneous endoscopic methods
* Placement with radiological methods using fluoroscopy, ultrasound, or computed tomography (CT)
* Open or laparoscopic placement can be done if necessary or convenient with other abdominal surgery
Benefits of small-bore, flexible tubes
- Limit patient discomfort
- May reduce risk of upper GI bleed
- May be appropriate in overly anticoagulated pts and those with esophageal varices
Which type of pts may require surgically placed tubes?
Patients with significant ascites, unusual GI anatomy, or hiatal hernias
Risk factors for refeeding
- Severe malnutrition
- Prolonged NPO
- GI or renal conditions that cause electrolyte depletion
- Use of diuretics can be a risk factor d/t electrolyte depletion
100mg thiamine should be provided for how many days in pts at risk for refeeding?
5-7 days
TF recs in high risk patients (refeeding)
Initiate EN at 25% of goal and advance to goal over 3-5 days
Aspiration of gastric vs oral secretions
Aspiration of gastric contents is less likely to result in bacterial colonization of respiratory tract than oral secretions
Evidence re: EN, aspiration, and PNA
- Moderate-quality evidence suggesting 30% lower rate of aspiration in post-pyloric feeds vs gastric feeds
- Evidence that post-pyloric feeds reduces the risk of PNA is less clear
- Most research suggests that while incidence of PNA may be higher in gastric feeds, there is no difference in LOS or mortality in gastric vs NI feeds
- Gastric feeds considered safe for most patients
- Post pyloric feeds recommended for pts at high risk aspiration
Early EN within 24 to 48 hours in critically ill patients shows positive outcomes in which patient populations?
moderate to severe acute pancreatitis, post op liver transplant, trauma, TBI, open abdomen, burns, and sepsis
Burn patients may benefit from EN within
4-6 hours of injury if possible
When should you initiate EN in a nourished patient?
Little has been published on initiating EN in well-nourished patients, anywhere between 5-14 days of inadequate intake
Continuous feeds
- Pump assisted continuous drip is preferred in critically ill, ventilated, jejunal feeds, at risk for refeeding or poor glycemic control
- Can switch to gravity drip outside hospital setting
- Best to describe volume of feeds in terms patient/family understand –
- 60 mL/hr = ¼ cup = 4T of formula infused x1 hour = 1 mL/minute
Cyclic feeds
Increase intake during the day or give pt free time from being connected to pump
Intermittent feeds
- Delivers 1-3 cups at a time via infusion pump or gravity drip
- Can be provided 4-6 x per day
Bolus feeds
- Use a feeding syringe or gravity, usually provides 240 mL over 4-10 min, 3-6 times per day
- Rate of infusion controlled using gravity drip bag is regulated by adjusting a roller clamp
- Usually least expensive delivery option
Absence of bowel sounds/movements + EN
Do not delay EN for absence of overt signs of GI contractility (lack of bowel sounds or BMs), even in critically ill patients
Stable non-critically ill patients
Can generally tolerate EN started at goal
* Standard EN protocols for non-critically ill patients include starting full strength feeds at 50 mL per hour and advancing by 15 mL Q4H to goal
* Bolus feedings can be advanced by volumes of 60 to 120 mL every 8 to 12 hours until goal volume is reached
Critically ill patients
Can often tolerate rapid advancement to goal within 24-48 hours
* Commonly started at 10-40 mL/hr, advanced 10-20 mL every 8-12 hours
When should you delay initiation of EN support in a critically ill patient?
Delay EN in hemodynamically unstable patients
While rare, ischemic bowel may occur as a result of reduced blood flow to the gut
* MAP <50
* Increasing pressor requirements
In high risk populations,
meet 80-100% within 48-72 hours
Critically ill obese patients
may benefit from high protein, hypocaloric feeding 65-70% of energy needs
In sepsis
provide 60-70% of energy needs the first week and 80% after the first week
What is more closely correlated with positive outcomes?
Protein provision > energy provision
FWF - ASPEN 2009 EN practice guidelines
feeding tubes should be flushed with at least 30 mL of water every 4 hours during continuous feeding or before and after intermittent or bolus feedings in adult patients to help prevent tube obstruction
Increased risk of clogging the feeding tube:
- FIber-containing formulas
- Use of small-diameter tubes
- Use of silicone > polyurethane tubes
- Checking GRV
- Improper medication administration
Medication Admin
- Give liquid or suspension forms unless diarrhea occurs
- Consult pharmacist to make sure medications can safely be crushed and provided in tube
- Stop EN when giving meds
- Flush 30ml before and after medication administration
- Flush with 5 mL warm water between medications
- Avoid giving crushed meds in tubes smaller than 12 French
Does ASPEN/SCCM recommend checking GRVs?
No
Factors which compromise accuracy of GRV:
- Feeding tube type, diameter, position
- Viscosity of GRVs
- Technique, including size of syringe and time/effort spent
- Position of patient
GRVs
- GRVs have not been found to correlate with PNA or aspiration
- Can increase incident of tube occlusions and reduce total volume delivered, takes up nursing time
- Holding EN for prolonged periods – increase risk of ileus
Other methods of assessing GI function
- Passage of flatus and stool
- Stool frequency and consistency
- Physical exam to assess bowel sounds and abdominal girth
- Abdominal radiographs
If GRVs are checked, ASPEN/SCCM recommends
EN should not be held for GRV <500mL in the absence of other signs of intolerance (vomiting/abd distention)
How can EN contribute to dehydration?
If formula provided is highly osmolar → osmotic diuresis r/t increased renal solute load
Assess for signs of dehydration:
- Poor skin turgor
- Dry mucous membranes
- Elevated BUN, Cr, sodium
Hyperglycemia negatively affects patient outcomes which leads to
higher infection rates, longer LOS, increased mortality
Why is use of high-fat, low-CHO formulas with fiber not recommended?
- Higher fat content may delay gastric emptying
- Affect tolerance and limiting ability to achieve goal rate/volume TFs
Changes in LBM in acute setting are more likely result of
immobility and increased protein losses 2/2 inflammatory process
Nitrogen balance (NB)
Can be used as a tool to assess adequacy of protein provision
* Involves 24 hours urine collection
* Measurement of protein intake during collection period
* Most accurate in EN and PN patients
* Positive NB reflects adequate protein provision
