Ch 10: Overview of Enteral Nutrition

Question 1

When does EN need to be initiated for a well nourished patient?

Answer 1

EN does not need to be initiated for a well-nourished patient until no or inadequate intake reaches 7-14 days

Question 2

For patients at risk for refeeding, what should be done first?

Answer 2

Before starting EN for at risk patients, serum electrolytes should be checked and repleted if needed.

Question 3

At what rate should stable (non critically ill) patients be started on EN?

Answer 3

At goal rate

Question 4

When is post pyloric feeding tube recommended?

Answer 4

In patients at high risk of aspiration; however, evidence for this is moderate and gastric feeding is considered safe for most patients

Question 5

Which deficiency is seen in almost all cases of refeeding?

Answer 5

Hypophosphatemia; other biochemic alabnormalities include hypokalemia, hypomagnesemia, hypocalcemia, and thiamin deficiency.

This is caused by increased use of nutrients for CHO metabolism

Question 6

According the SCCM/ASPEN guidelines, a target BG of _______ mg/dL is recommended for hospitalized patients.

Answer 6

140-180 mg/dL

Question 7

What is the typical repletion dose for thiamin in malnourished/ETOH abuse patients?

Answer 7

The typical dose for repletion is 100 mg for 5-7 days.

Question 8

What are the risk factors for refeeding syndrome?

Answer 8

Severe malnutrition, prolonged NPO status, GI/renal conditions resulting in electrolyte loss.

Use of meds that result in electrolyte depletion (diuretics) can also be a risk factor.

Question 9

What is SCCM/ASPENS stance on disease specific formulas?

Answer 9

Evidence supports the use of standard EN in most patient populations.

For patients with malabsorption, elemental or semi elemental formulas may be beneficial.

Question 10

To prevent refeeding, how should EN be started and advanced?

Answer 10

It is recommended to start EN at 25% of goal rate and advance over goal over 3-5 days; however, clinical judgment should be used?

Question 11

What are the contraindications to EN?

Answer 11

Severe short bowel syndrome (<100-150 cmremaining in small bowel in absence of the colon or 50-70 cm remaining small bowel in the presence of the colon), Severe malabsorptive conditions, Severe GI bleed Distal high output GI fistula, Paralytic ileus
Intractable V/D that does not improve with medical management , Inoperable mechanical obstruction, When GI tract cannot be accessed (ex: when upper GI obstructions prevent feeding tube placement)

Question 12

When is refeeding syndrome typically seen?

Answer 12

Within 2-5 days of starting nutrition

Question 13

Why is weight not always an accurate measure of nutrition provision?

Answer 13

Effects of inflammation/immobility in chronically critically ill patients will result in loss of LBM. This is not completely attenuated by adequate nutrition provision

Question 14

When should long term feeding tubes be considered?

Answer 14

When duration of EN is expected > 4-6 weeks

Question 15

Why are DM formulas not regularly recommended?

Answer 15

Efficacy of formulas for DM have not been established and general use of these formulas is not recommended b/c the higher fat content may delay gastric emptying affecting tolerance

Question 16

The presence of nutrients in the small intestine maintains normal what function?

Answer 16

Gallbladder function by stimulating the release of cholecystokinin

Question 17

What is ASPEN/SCCM stance on GRV?

Answer 17

If GRVs are checked, the SCCM/ASPEN guidelines suggest that in the absence of other s/s of intolerance such as vomiting or abd distention, EN should not beheld for GRV < 500 mL

Question 18

When should a feeding pump be used?

Answer 18

Pumps are preferred for feeding critically ill, mechanically ventilated using oro tracheal method, patients who at risk for refeeding, have poor glycemic control, are being fed via j tube, or have demonstrated intolerance to intermittent gravity drip or bolus feedings

Question 19

What factors increase the risk for clogging a feeding tube?

Answer 19

Fiber containing formulas, small diameter tubes, checking GRV, and improper med administration

Question 20

Drugs in microencapsulated bead or pellet form are most effectively administered through large-bore feeding tubes when mixed with what?

Answer 20

Orange juice; An acidic juice such as orange juice can reduce the risk of microencapsulated beads or pellets sticking to the tube. 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.

Question 21

True or false; liquid dosage forms should be diluted with water prior to administration

Answer 21

True; many liquid medications are hyperosmolar which can lead to diarrhea and/or may have high viscosity which can lead to tube clogging, so liquid dosage forms should be diluted with water prior to administration