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[Mine] core curric - 2016 > Ch 10: Overview of EN > Flashcards

Ch 10: Overview of EN Flashcards

1
Q

Indications for EN

A
  • Stroke/other neuro disorders that impair swallowing ability
  • Oral intubation for mechanical ventilation preventing PO intake
  • Feeds distal to obstruction or high-output fistula
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2
Q

Consideration of ethical issues with EN

A
  • Patient/family wishes
  • QOL
  • GOC
  • Risk/benefits of nutrition therapy in the context of diagnosis, prognosis, and long-term are goals
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3
Q

Benefits of EN

A
  • 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
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4
Q

Contraindications to EN

A

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

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5
Q

Short term enteral access

A
  • Stomach
  • Past pylorus into duodenum
  • Distal to Ligament of Treitz and into jejunum
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6
Q

Long-term enteral access

A

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

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7
Q

Benefits of small-bore, flexible tubes

A
  • Limit patient discomfort
  • May reduce risk of upper GI bleed
  • May be appropriate in overly anticoagulated pts and those with esophageal varices
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8
Q

Which type of pts may require surgically placed tubes?

A

Patients with significant ascites, unusual GI anatomy, or hiatal hernias

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9
Q

Risk factors for refeeding

A
  • Severe malnutrition
  • Prolonged NPO
  • GI or renal conditions that cause electrolyte depletion
  • Use of diuretics can be a risk factor d/t electrolyte depletion
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10
Q

100mg thiamine should be provided for how many days in pts at risk for refeeding?

A

5-7 days

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11
Q

TF recs in high risk patients (refeeding)

A

Initiate EN at 25% of goal and advance to goal over 3-5 days

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12
Q

Aspiration of gastric vs oral secretions

A

Aspiration of gastric contents is less likely to result in bacterial colonization of respiratory tract than oral secretions

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13
Q

Evidence re: EN, aspiration, and PNA

A
  • 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
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14
Q

Early EN within 24 to 48 hours in critically ill patients shows positive outcomes in which patient populations?

A

moderate to severe acute pancreatitis, post op liver transplant, trauma, TBI, open abdomen, burns, and sepsis

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15
Q

Burn patients may benefit from EN within

A

4-6 hours of injury if possible

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16
Q

When should you initiate EN in a nourished patient?

A

Little has been published on initiating EN in well-nourished patients, anywhere between 5-14 days of inadequate intake

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17
Q

Continuous feeds

A
  • 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
18
Q

Cyclic feeds

A

Increase intake during the day or give pt free time from being connected to pump

19
Q

Intermittent feeds

A
  • Delivers 1-3 cups at a time via infusion pump or gravity drip
  • Can be provided 4-6 x per day
20
Q

Bolus feeds

A
  • 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
21
Q

Absence of bowel sounds/movements + EN

A

Do not delay EN for absence of overt signs of GI contractility (lack of bowel sounds or BMs), even in critically ill patients

22
Q

Stable non-critically ill patients

A

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

23
Q

Critically ill patients

A

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

24
Q

When should you delay initiation of EN support in a critically ill patient?

A

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

25
Q

In high risk populations,

A

meet 80-100% within 48-72 hours

26
Q

Critically ill obese patients

A

may benefit from high protein, hypocaloric feeding 65-70% of energy needs

27
Q

In sepsis

A

provide 60-70% of energy needs the first week and 80% after the first week

28
Q

What is more closely correlated with positive outcomes?

A

Protein provision > energy provision

29
Q

FWF - ASPEN 2009 EN practice guidelines

A

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

30
Q

Increased risk of clogging the feeding tube:

A
  • FIber-containing formulas
  • Use of small-diameter tubes
  • Use of silicone > polyurethane tubes
  • Checking GRV
  • Improper medication administration
31
Q

Medication Admin

A
  • 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
32
Q

Does ASPEN/SCCM recommend checking GRVs?

A

No

33
Q

Factors which compromise accuracy of GRV:

A
  • Feeding tube type, diameter, position
  • Viscosity of GRVs
  • Technique, including size of syringe and time/effort spent
  • Position of patient
34
Q

GRVs

A
  • 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
35
Q

Other methods of assessing GI function

A
  • Passage of flatus and stool
  • Stool frequency and consistency
  • Physical exam to assess bowel sounds and abdominal girth
  • Abdominal radiographs
36
Q

If GRVs are checked, ASPEN/SCCM recommends

A

EN should not be held for GRV <500mL in the absence of other signs of intolerance (vomiting/abd distention)

37
Q

How can EN contribute to dehydration?

A

If formula provided is highly osmolar → osmotic diuresis r/t increased renal solute load

38
Q

Assess for signs of dehydration:

A
  • Poor skin turgor
  • Dry mucous membranes
  • Elevated BUN, Cr, sodium
39
Q

Hyperglycemia negatively affects patient outcomes which leads to

A

higher infection rates, longer LOS, increased mortality

40
Q

Why is use of high-fat, low-CHO formulas with fiber not recommended?

A
  • Higher fat content may delay gastric emptying
  • Affect tolerance and limiting ability to achieve goal rate/volume TFs
41
Q

Changes in LBM in acute setting are more likely result of

A

immobility and increased protein losses 2/2 inflammatory process

42
Q

Nitrogen balance (NB)

A

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

[Mine] core curric - 2016 (22 decks)

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