Chapter 10: Overview of EN Flashcards
Name 6 benefits in EN feeding.
Nutrients provided via the enteral route undergo first-pass metabolism, 1. promoting efficient nutrient utilization. The presence of nutrients in the SI maintains normal gallbladder function by stimulating the release of cholecystokinin, 2. reducing the risk of cholecystitis that may occur if patients are kept NPO.
- Luminal nutrients provide GI structural support and
- help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
((this is via: IgA, which is secreted within the GI tract when there are nutrients, can prevent bacterial adherence and translocation)) - EN reduces infectious complications
- less expensive than PN
Name 8 contraindications for EN.
- Severe Short Bowel Syndrome (<100-150 cm remaining small bowel in the absence of the colon, OR 50-70 cm remaining small bowel in the presence of the colon).
- Other severe malabsorptive conditions
- Severe GI bleed
- Distal high-output GI fistula
- Paralytic ileus
- Intractable vomiting and/or diarrhea that does not improve with medical mgmt
- Inoperative mechanical obstruction
- When the GI tract cannot be accessed – ie: when upper GI obstruction prevent feeding tube placement
Placement of long-term feeding tubes is indicated if EN is expected to last longer than..?
4-6 weeks
Define standard EN formulas
meet normal requirements for most patients; energy density of 1-2 kcal/ML; may or may not contain fiber
Define disease-specific EN formulas
Designed for patients with renal/hepatic disease, diabetes, pulmonary (COPD, ARDS) disease, and immunocompromised patients; elemental and semi-elemental options available
Define modular components.
Can be co-administered via feeding tube to provide additional:
- Energy (maltodextrin, hydrolyzed corn starch)
- Fat (fish oils, MCTs, etc)
- Protein (powdered calcium caseinates, whey protein concentrates)
- Individual AA (glutamine, arginine)
Note these are not mixed directly with EN formulas because they may clog the feeding tube.
What is the typical dose for thiamin supplementation?
100 mg thiamin daily for 5-7 days
(True or False) Aspiration of gastric contents is less likely to result in bacterial colonization of the respiratory tract than oral secretions.
TRUE
What type of EN route of delivery reduces risk of aspiration?
Post-pyloric; which reduces the volume of stomach contents; shown to have a 30% lower rate of aspiration than gastric feeding
(True or False) Gastric feeding is considered safe for most patients.
TRUE
(T/F) Gastric feeding is preferable if waiting for migration of a feeding tube tip past the pylorus will delay the early initiation of EN.
TRUE
**What is the ASPEN recommendation for when EN needs to be initiated in a well-nourished patient?
**NPO/Inadequate oral intake x 7-14 days
**What is the ASPEN recommendation for when EN needs to be initiated in a high-risk critically ill patient?
***Within 24 - 48 hours of initial insult (mechanical ventilation, surgery, neurologic injury) (“Early EN initiation”
Pump-assisted continuous drip infusions
Preferred method for critically ill patients, who are vented (using oro-tracheal method), at risk for refeeding, have poor glycemic control, have jejunostomy tube, or have an intolerance to intermittent gravity or bolus feeding
Gravity drip method
(Without use of a pump), may be used to provide continuous drip feedings to the non-critically ill patient living at home or outside the hospital setting
Cyclic feedings
Uses pump or gravity drip, over a time period that is less than 24 hours. Minimum infusion time per day is 8 hours, depending on volume tolerance
Intermittent feedings
Uses infusion pump or gravity drip; selected for patients with feeding tubes that terminate in the stomach to accommodate the larger volumes administered in a shorter time period
Volumes range from 240 - 720 mls (1 - 3 cups)
Administered time period ranges from 20 - 60 mins
Can be provided from 4 - 6 times / day, depending on volume required
Bolus feedings
Provide a set volume of formula at specified time intervals over a VERY SHORT period of time, usually with a feeding syringe.
Typical feeding: 240 mL of formula over a 4 - 10 min. period, with infusions 3 - 6 times/day, with at least 3 hours between feedings
These can also be administered with the gravity drip method, which the rate of formula is regulated by adjusting a roller clamp.
What is the recommended EN initiation for critically-ill patients?
Start at 10 - 40 mL/hr, increasing by 10 - 20 mL/hr Q 8 - 12 hours to goal rate.
Many critically-ill patients can tolerate rapid advancement of EN to goal rate within 24 - 48 hours, minimizing energy and protein deficits.
Volume-Based feeding
prescribed in terms of the goal volume per day, rather than goal volume per hour; more recent feeding method used in the critically-ill patient population
EN formulas are typically started at goal rate, or rapidly advancing to the goal
Define hemodynamically unstable.
Defined as those with a mean arterial BP of less than 150 mmHg, or those who are starting vasopressor meds, or require increasing doses to maintain BP
Ischemia bowel may occur as a result of reduced blood flow to the gut, a potential consequence of low BP
Hypocaloric feeding
Defined as 65 - 70% of energy needs as estimated by IC (or calculations); provided as high-protein hypocaloric EN, designed for critically-ill obese patients to minimize the metabolic complications of feeding, preserve LBM and mobilize fat stores
What are the energy recommendations for critically-ill patients w/ sepsis, starting EN?
Provide 60 - 70% of energy needs (with 100% estimated protein needs), during the first week of EN. Then advance to more than 80% of estimated energy needs after the first week.
Define trophic feeding. When is it indicated, and for which patients?
10 - 20 mL/hr or up to 500 kcal/day; indicated for patients with ARDS or acute lung injury who are expected to be vented for more than 72 hours AND not high nutrition risk or malnourished.
List factors that increase the risk for clogging of the feeding tube.
- Use of fiber-containing formulas
- Use of small-diameter tubes
- Use of silicone, rather than polyurethane tubes
- Checking GRVs
- Improper medication admin via the tube
**What is the ASPEN recommendation for flushing feeding tubes?
**At least 30 mL water Q 4 hours during continuous feeding
OR, before and after intermittent or bolus feedings in adult patients
AND, 30 ml of water, before and after GRV checks
What is the #1 method for preventing contamination of open feeding systems?
Hand-washing
Contamination of TF formula, can cause, what?
Abdominal distention, diarrhea, and bacteremia
Sepsis, PNA, infectious enterocolitis
What is the ENfit Connector?
A newly designed EN connector, made to help prevent enteral tubing misconnections
**What is ASPEN/SCCM recommendations for checking GRVs in critically-ill patients?
- **It is not recommended, because a number of factors can compromise the accuracy of GRV checks:
- feeding tube type, diameter and position
- viscosity of GRVs
- technique, including size of syringe and time and effot spent
- position of the patient
*GRVs have not been found to correlate with incidence of PNA or aspiration, and checking them increases episodes of feeding tube occlusion, reduce the total volume of EN delivered, and take up RN time
**If GRVs are checked, what are the ASPEN/SCCM recommendations?
**In the absence of other signs of intolerance (vomiting or abdominal distention), EN should not be held for GRVs of less than 500 mL.
In what patient populations, is checking GRVs helpful?
Patients that are high risk for GI dysfunction, in the surgical ICU and the most severely ill patients
What methods should be used routinely for checking GI function?
- Passage of flatus and stool
- Stool frequency and consistency
- Physical exam to assess bowel sounds, abdominal girth, and abdominal radiographs
What methods are used to assess for dehydration?
- Poor skin turgor
- Dry mucous membranes
- Elevated [BUN], [Cr], and [Na2+]
What are causes for hyperglycemia in the ICU?
Causes are multifactorial and include:
- Increased release of counterregulatory hormones that stimulate gluconeogenesis
- Proinflammatory cytokines that result in IR
- Provision of steroid and adrenergic meds
- Excess dextrose admin via IV fluids and meds
**What are SCCM/ASPEN guidelines for acceptable blood glucose control in hospitalized patients?
**140 - 180 mg/dL
BG levels should be checked every 4 - 6 hours for patients with diabetes OR in patients with BG over 180 mg/dL
How should optimal BG control be achieved in the hospital setting?
Continuous insulin drip; hyperglycemia is not an indication to delay initiation of EN
Note: oral meds and SSI should not be used because they can delay the achievement of BG control and are associated with a higher incidence of renal dysfunction
If an MD recommends switching the EN formula to a higher-fat content formula, what would you say?
It is not recommended because the higher fat content may delay gastric emptying, affecting tolerance and thereby limiting the ability to achieve goal volumes.
If an MD notes serum albumin and prealbumin as indicators of nutrition status, what would you say?
They are now known as indicative of inflammatory status and not nutrition intake. No serum lab values indication nutrition status or adequacy of nutrition provision.
should specialty / disease specific formulas be used in the critically ill
no
EN formulas containing omega three fatty acids (immune modulating) can be recommended when
surgical care unit
Symptoms of GI Intolerance during EN
abdominal distention, increased NGT output, high GRV’s over 250mL, decreased passage of stool, increased metabolic acidosis
If a patient has prolonged NPO status the gut will atrophy loosening the tight junctions allowing pathogens to enter the blood circulation possibly causing sepsis. Therefor what is recommended
start early enteral nutrition within 24-48 hours of ICU admission
Uses for MCT Oil
Fat malabsorption (impaired GI tract, IBD, chylous ascites, enteropathies, pancreatitis, SBS, intestinal resection)
What are designer triglycerides that are chemically synthesized or genetically engineered containing more EPH and DHA which are more easily absorbed
Structured lipids
Where are structured lipids used in the US
enteral nutrition formulas
where are structured lipids used in Europe
parenteral nutrition
Function of hydrolyzed EN formulas
peptide based (Di and Tri peptides) , used in impaired GI function so they are more readily absorbed
formulas with arginine should not be used when
severe sepsis (is the pre cursor to nitrous oxide which can cause hemodynamic instability)
EN formulas that contain arginine, EPA, DHA and glutamine
immune modulating formulas
% water in 1 kcal/mL EN formulas
83% water
% water in 1.2 kcal/mL EN formulas
80% water
%water in 1.5 kcal/mL EN formulas
76-78% water
% water in 2 kcal/mL EN formulas
70-75% water
indications for nutrition support
oropharyngeal dysfunction
use of PN _____ mortality in burn patients compared to EN
increases
contraindications to enteral feeding
intractable nausea/vomiting
high output proximal fistula
acute necrotizing pancreatitis
ileus
Are adult TF products lactose free
yes
the majority of carbohydrates in EN formulas come from
hydrolyzed cornstarch
when should branch chain amino acid EN formulas be used in hepatic encephalopathy
when severe encephalopathy persists after trial of lactulose/neomycin
what percentage of water do 1kcal/mL EN formulas supply
75-85% water
formulas made of free amino acids are _____ formulas
elemental
elemental formulas are indicated in
short bowel syndrome
enteral formulas that have intact macronutrient, require normal digestive/absorptive function
polymeric
isotonic EN formulas are ___ free
fiber free
low osmolarity (300 mOSm), fiber free, EN formula used for high risk intestinal ischemia 2/2 inadequate bowel function
isotonic formula
formula with small peptides, free amino acids
hydrolyzed protein EN
are broken down proteins/free amino acid EN formulas recommended for Chron’s remission
no, intact protein formulas
are intact protein EN formulas okay to use in critically ill
yes
EN formulas recommended for patients with inadequate enzyme release, short bowel syndrome or other malabsorption syndromes
peptide based EN formulas
Phenylkeotnuria (PKU) is a metabolic disorder with a deficiency in the _____ enzyme
Phenylalanine Hydroxylase
Phenylalanine Hydroxylase coverts phenylalanine to
tyrosine
in PKU, this amino acid becomes essential so is added to PKU formulas
tyrosine
what is the primary use for enteral nutrition
providing nutrition directly to patients who cannot or are unwilling to get adequate nutrition by mouth
inadequate intake or expected intake for 7-14 days
critically ill patients, working gut, hemodynamic stability are recommended for _______ nutrition
enteral
early nutrition in the ICU
start EN within 24-48 hours
when should EN be started when not on the ICU
after 7-14 days in a well nourished patient who cannot meet nutrition needs by mouth orally
typically, how long after PEG or PEJ placement, can EN feedings start
2 hours or per surgeon
short term enteral feeding is considered how long
= 4 weeks
long term enteral feeding is considered how long
> 4 weeks
benefits of enteral feeding
immune function, prevents bacterial translocation, preserves gut permeability, decrease risk of infection, decrease length of stay decreases mortality
contraindication to EN
expected duration of use <7-10 days in nourished patient, <5-7 days in malnourished patient, short bowel syndrome (<100-150 cm bowel), severe GI bleed, severe malabsorption, distal high output fistula, intractable N/V, paralytic ileus, mechanical obstruction
Fermented Oligosaccharides (FOS) and inulin in En formulas help stimulate
good bacterial growth
if a patient has gastroparesis, consider this EN formula to help with gastric emptyin
low fiber, peptide based/hydrolyzed
this formula has 100% free amino acids
elemental formulas
in adults, elemental formulas still contain allergens true or false
true (soy and milk protein)
EN formula that is low in carbohydrate, high in fat and fiber
diabetic EN formula
are diabetic EN formulas recommended for routine use
No
only consider using renal formulas in AKI if
there are electrolyte abnormalities
are renal EN formulas recommended for routine use
no
renal formulas have high ____ and ___ which limits their use in post pyloric tubes
osmolarity/viscosity
this type of EN formula is low in carbohydrate, high in omega 6 fatty acid
pulmonary EN formula
this EN formula contains branched chain amino acids
hepatic EN formula
are EN formulas with omega 3 fatty acids recommended for routine use in ARDS/ALI
no
these EN formulas contain omega 3 fatty acids, glutamine, arginine, nucleotides and antixoidants
immune modulating EN formulas
are immune modulating EN formulas recommended for routine use in the MICU
no
why are immune modulating EN formulas contraindicated in septic patients
they contain arginine which is a precursor to nitrous oxide which can cause hemodynamic instability
when are immune modulated EN formulas recommended
surgical ICU, TBI and peri operative trauma patients, post op patients
types of modulars
protein (powder or liquid), carbohydrate powder, MCT oil for fat, soluble/insoluble fiber
these type of schedule for EN feedings can be provided by syringe, gravity or the pump
intermittent
type of feeding schedule where EN runs for 24 hours
continuous
when is a pump recommended for EN provision
jejunal feedings
in the critically ill what feeding method for EN is recommended
continuous
how should an EN feeding be started and advanced in the ICU
start 10-40ml/hr advance 10-20mL q8-12 hours until goal
when started on bolus feedings how should EN be started and advanced
60-120 mL per feedings then advance 60-120mL per feeding q8-12 hours
bolus feeding is considered this schedule type of feeding
intermittent
what should be written on the EN order
- Name of the Formula
- What type of tube will be used (PEG,PEJ etc)
- What method of feeding (continuous, bolus)
- What additives are needed
- Extra safety measures (aspiration precautions)
what is the best method to unclog a tube feed
water flushes and prevention
should medications be mixed with enteral formula
no
can creon or zenpepare be used to unclog a feeding tube
no because they are enterically coated
what is the recommended enzyme for de clogging a tube feed
Viokace mixed with 324 mg of sodium bicarb or 1/8 teaspoon of baking soda mixed with 5 mL of water
Viokace should be mixed with _____ to remove a TF clog
324 mg sodium bicarbonate
Bionix
a feeding tube declogger that requires a trained professional to use. Only for gastrostomy or jejunostomy not naso or oral tubes
what is the definition of diarrhea
2-3 liquid stools >250 grams per day
high osmolarity medications or formulas, fiber, sorbitol are all possible causes of
diarrhea
what is recommended for fiber when a patient is having diarrhea
add or remove fiber
what are methods to reduce diarrhea in the enterally fed patient (in order)
- Rule out infection
- Reduce sorbitol containing meds (1st line)
- Decrease TF rate
- add or remove fiber
Insoluble fiber ____ transit time by adding to fecal weight
increases (makes it longer)
insoluble fiber works by
adding weight to stool
When a patient is at risk for bowel ischemia fiber should
be avoided
fermentable oligosacchardies that help the growth of bacteria are called
pre-biotics
are routine use of pre-biotics recommended
not at this time
what is fiber’s role in constipation
can increase BM frequency when baseline BMs are low
ways to alleviate constipation in enterally fed patients
- add water
- increase physical activity
- add fiber
- try prune or pear juice flushes
Likely the main cause of nausea and vomiting in EN patients is
delayed gastric emptying
what can be done to help alleviate nausea/vomiting in EN patients
decrease TF rate, start pro kinetic, trial anti emetic
dry skin, dry mucous membranes, constipation and skin tenting, increased heart rate, decreased blood pressure are signs of ____ in EN patients,
dehydration
what is the best method for PEG or PEJ tube site care
clean with soap and water, keep open to air
is swabbing the stoma of EN the best method to test for infection
no, other normal bacteria will be there
what are possible signs of PEG tube site infection
fever, induration, redness, malaise
what is recommended standards of care for patients with EN who are at risk for aspiration
- Elevate head of bed >30-45 degrees
- good oral care
- continuous feeding
- consider post pyloric feeding
- don’t routinely check GRVs
how should EN formulas be stored at _______ _____
room temperature
once open sterile EN formulas can last ___ hours in the fridge
24 hours
EN bags should only be used for
24 hours
what is the hang time for sterile, open system EN formulas
12 hours (tetra packs)
If powders are added to a sterile open system feeding, how long should the hang time be decreased from 12 hours
4 hours
what is the hang time for powdered formulas
4 hours
what is the hang time for sterile closed system EN feedings
24-48 hours
what is the hang time for blenderized tube feeding
2 hours
Case: a 25 year old F with traumatic brain injury s/p MVA. She is preparing to dc to rehab and still has an NG tube. The RDN recommends transitioning to intermittent feeding to mimic real meal times. The patient develops water diarrhea on day1 of intermittent feeding. What should be done first
obtain a chest x ray to verify that the tip of the tube has not migrated to the jejunum where a large volume feeding would cause diarrhea
Indications for home EN feeding
motility disorder, malabsorption disorder, head/neck cancer, dysphagia, pancreatitis, obstruction, failure to thrive
what makes a good EN candidate
- patient/caregiver is able to administer the EN independent of care staff
- pt has easy access to medical care follow up
- safe home environment
- adequate education
what is involved in a safe home environment for EN
clean water, electricity, refrigeration, access to a phone, good lighting
what is needed to document medical necessity (by the physician)
tube type
swallow eval
gastric emptying study
fat malabsorption
for medicare how many days in considered permanent
90 days (3 months)
in order to have medicare reimbursement what conditions are covered under non functioning gut or disease of the structures that permit food reaching the small bowel)
- non functioning gut or disease of the structures that permit food reaching the small bowel
- Dysphagia
- Esophageal cancer with obstruction
- Gastroparesis
in order to have medicare reimbursement what conditions are covered under disease of the small bowel which impairs digestion / absorption of an oral diet
- Small bowel disease/Chron’s
2. SOLE source of nutrition
For medicare reimbursement what needs to be documented to be covered for a non standard formula
severe diarrhea trialing both fiber containing and fiber free formulas
feeding <750 kcal or >2,000 kcal/day to maintain appropriate weight
What is not covered under medicare for enteral nutrition
- anorexia from mood/psych disorder
- end stage disease
- weight loss
- failure to thrive
- malnutrition in the absence of functional impairment
HME provider stands for
Home Medical Equipment proivder
which foundation provides donations to help support costs of EN
Oley foundation
What can food stamps be used to buy
oral supplements
what should be on the education checklist for EN feedings
- how to order supplies
- goals of HEN for the patient
- specifics about the tubes, replacement and care
- feeding schedule, administration, formula , water medication’s
- troubleshooting issues
- Hangtime/storage
- Support for home resources (Oley foundation, feeding tube awareness foundation)
What is the best method to assess patient’s grasp of education in the home enteral nutrition session
teach back
when providing tube feeds by cans, you can improve success by having _____ number of cans
rounded (ex. 2 instead of 1.5)
after starting HEN of oftenshould follow up occur
every 3 months
for successful HEN, it best to have a _____ approach
multidisciplinary approach
DME stands for
Durable Medical Equipment company (Supplies pumps, materials and formulas)
A 70 year old male with dysphagia s/p stroke is now discharged home after 1 month of a rehab stay. When is the ideal time to provide HEN education
throughout the rehabilitation stay
this type of feeding tube is placed at skin level, good for cosmetic appearance, more comfortable for active individuals
low profile tube
short term feeding tubes (< 4 weeks)
nasogastric, orogastric tube
small bore feeding tubes are recommended for _____ while large bore/stiff tubes are recommended for _____
feeding, suction
Nasogastric tubes are contraindicated in
head/neck/esophageal pathology, injury preventing safe insertion
what is the gold standard for checking NGT placement
chest x-ray
how are NGTs measured before insertion
NEMU: nose to earlobe to mid umbilicus
Nasal Enteric Tubes tips end
the distal stomach towards the pylorous
In order to help place nasal enteric tubes which terminate by the pylorus of the stomach, what can aid in the placement
prokinetics, IV erythromycin 200-500 mg
This type of tube is placed in the nasal cavity, terminates past the ligament of Treitz
Nasojejunal tube
What is the most reliable method to place NJ tubes
endoscopy or fluroscopy
feeding tubes that are placed endoscopically require
sedation
How long will tube feed be needed to consider percutaneous placement
> 4-6 weeks, long term
are testing of coagulation parameters (INR etc./ platelets) required for patients undergoing enterostomy tube placements
no; unless they are on anticoagulation medications, have excessive bleeding or on recent abx
patients who have had excessive bleeding, recent abx, and on anticoagulation meds may need this checked before percutaneous tube feeding placement
INR/platelets
patients who are at thromboembolic risk are on clopidrel/thienopyridines should have these meds held ___ to ___ days before percutaneous placement
5-7 days
how long should warfarin be held before PEG placement. What medication can they be bridged with in the mean time
5 days, short acting heparin
obstruction proximal to the GI tract, ascites, gastric varicies, active head/neck cancer, and morbid obesity are contraindications to ____ placement
PEG tube placement
impaired gastric motility, pancreatitis/pancreatic surgery and stomach decompression are recommended to have these types of percutaneous feeding tubes placed
PEJ
Fluoroscopic percutaneous tube placement must be done where
in a radiological suite
how long after placement can percutanous tubes be removed to ensure stoma maturity
1-2 weeks or 4-6 in extra tenuous patients
if PEG tubes or PEJ tubes are removed to early what are the risks
bowel contents/stomach contents can leak into the peritoneum
how should stomas be routinely cleaned
warm water, mild soap
Are routine use of antibiotics recommended for PEG tube site care
no
what is the best way to prevent tube feed clogging
Adequate flushing of at least 30mL of water
other ways of preventing tube clogging
don’t check GRV’s too often, avoid very concentrated formulas, don’t mix meds with EN formula
what type of pills are more likely to promote TF clogs
crushed pills
medications should be given all at once or separately to prevent TF clogs
SEPERATELY with flushes in between
complications of NG tube placement
Epistaxis, aspiration, pneumothorax
reducing narcotics, low fiber/fat formulas, room temp enteral formulas, pro kinetic agent, small volume feedings and anti emetics are all solutions to this complication of tube feeding
nausea
abdominal distention during tube feeding can result from
ileus, obstruction, ascites, rapid formula administration of very cold formulas/high fiber
weight loss, steatorrhea, diarrhea, vitamin/mineral deficiencies, and glossitis could be signs/symptoms of _____ during enteral feeding
malabsroption
measuring fecal fat, serum citrulline, or examine intestinal transit can rule out/ identify _______of the gut
maldigestion
what is the most common reported GI side effect with Enteral Nutrition
diarrhea
medicatiosn high in sorbitol (amantadine, doxycycline, lasix, metoclopramide, isonazid and tylenol liquid meds) can cause
diarrhea
what items should be evaluated when a patient on enteral feeding experiences diarrhea
- Review medications for sorbitol or pro kinetic agents
2. Check for bacterial causes (CDiff)
If medications/infectious causes of diarrhea are ruled out, what can be added to the EN regimen to reduce diarrhea
Soluble fiber and or anti diarrheal meds
fiber modulars have a high risk of ______ en tubes
clogging
what is the PRIMARY intervention to treat EN associated diarrhea
use fiber containing formula
what is the LAST RESORT intervention for EN associated diarrhea
switch to a peptide based formula
this test helps identify Small Intestinal Bacterial Overgrowth (SIBO)
hydrogen breath test
EN formulas are at highest risk of contamination when
they are mixed, diluted or reconstituted (powdered)
EN formulas that are at the lowest risk of contamination
sterile or closed systems
liquid formula that is provided via syringe or poured into a bag and delivered by gravity or pump is considered a _______ system
open system
what is the hang time of open systems (syringe, or pouring into a bag)
4-12 hours
this type of EN formulas is powdered or formula with added modulars provided by gravity or pump
reconstituted
reconstituted enteral feedings can only hang for a maximum of
4 hours
powdered EN formula should be mixed with _____ water
sterile
this type of EN formula system are contained in pre filled sterile bottles with spike or screw tops
closed system
closed system enteral feedings can be hung for
24-48 hours
what is the proper technique for preparation of formula
hand washing, gloves, aseptic technique, clean , maximum barrier precautions
formulas should be used _____ after opening or being reconstitution with water
immediately
if you have left over formula from a sterile bottle how long can it be stored in the fridge
24-48 hours
A sterile tube feeding formula is running at 25mL/hr for 8 hours. 200 mL of formula is left over after the feeding bag is filled where should the formula go
in the refrigerator
how often should TF bags be changed
every 24 hours
how can checking GRVs cause contamination
introducing pathogenic microorganisms when pulling back stomach contents, infecting the TF hub/port
Implementing Prevention Policies for EN
- visually inspect each TF bottle for expiration date/damage
- use proper hand washing technique, wear clean gloves
- Prepare the formula in a clean area
- wipe flip top bottles with isopropyl alcohol
- Assess the TF formula for separation, thickening or curdling
- use sterile water to prepare powdered formulas
- Minimize frequent disconnections and reconnections of the tubes
- keep equipment dry and clean
dehydration, excessive or inadequate fiber, and fluid restriction cause ________
constipation
if a patient is on a fluid restriction but suffering from constipation on tube feeding what can be used
stool softener
increasing fiber in constipation propels waste through the colon
constipation
Inadequate _____ can result in infrequent bowel movements and cause significant buidldup in the colon
fiber
firm collection of stool in the distal colon where liquid stool will seep around an impaction
obstipation
a rare TF complication associated with fiber modular that are formed in the stomach
bezoar
sings of EN Intolerance
abdominal distention, nausea, vomiting
dyspnea, wheezing, hypoxia, anxiety, fever, leukocytosis or new/progressing infiltrates are signs os
aspiration PNA
is blue dye recommended
NOOOOOOO
if GRV’s ARE checked when should tube feeding be held
when >500 mL with vomiting or diarrhea for more than 48 hours
are checking GRVs routinely used to monitor ICU patients on EN
No
what can be used for oral care in the ICU to prevent aspiration of tube feeding
chlorhexidine
what populations are at risk for refeeding syndrome
malnourishment, diarrhea, high output fistula, ETOH intake, poorly controlled DM, anorexia nervosa, IBD low birth weight, prematurity
if an enterally fed and at risk for refeeding syndrome EN should only provide _____ of the goal on Day 1 with attention to energy contribution from ______ and advance to goal within ____ to ____ days pending elytes and clincal status
25%, 3-5 days
tube fed patients are at risk for ____ because EN formulas don’t contain total fluid needed and require additional water flushes
dehydration
dry mouth, eyes and lips, light headedness when standing, headache, fatigue, heat intolerance dark urine, orthostatic hypotension, increased heart rate, poor skin turgor and sunken eyes are signs of
dehydration
an increased BUN:Cr ratio of 20:1 can indicate ________ when there are no renal issues
dehydration
typical urine output
0.5 to 2 mL/kg/hr
1 kg of weight = ______ liter of fluid
1
when a patient has a fever increase water provision by ____% per degree Celcius above 37.8 degrees
12%
this type of nasal feeding tube allows the most digestion as the nutrients mix with gastric juices
nasogastric
this type of tubing for PEGS hangs out
standard profile
during PEG placement, an endoscope goes down the _______, a _____ is shone through at the placement site in the stomach and the _____ is pushed through the cutaneous layer.
esophagus
light
bolster
what type of feeding is not recommended for jejunal feedings
bolus
bolus-ing tube feed into the jejunum can cause
vomiting, excessive diarrhea
an incorrectly positioned feeding tube, where the balloon or silicone cuff is inside the abdominal wall while the bolster is on the outside indicates
Buried Bumper Syndrome
pain at a PEG tube site and weight gain can indicate this complication
Buried Bumper Syndrome
when a tube feeding formula is accidentally connected to a ventilator or IV this considered a ____ event
sentinel
ENFIT was developed by this company
GEDSA Global Enteral Device Supply Association
ENIFT tubes prevent ________
enteral tubing misconnections
A patient gets an NG tube placed and is immediately started on a standard formulas of 10mL/hr. The patient develops coughing, an inability to speak and decreased O2 saturations
rule out lung placement of NG tube with a CXR
bleeding, peritonitis, or colo-cutaneous/colo-gastric fistulas are complications of
PEG placement
dislodgement of this type of tube requires immediate replacement because the tract can close quickly
dislodged jejunotomy tube
the dislodgement of a jejunostomy tube needs to be replaced by
a physician at the hospital as it requires radiographic verification with contrast medium to confirm placement
what is a common contributor to the occlusion of small bore feeding tubes
aspiration for measurement of gastric residuals
ways to ensure patency to avoid clogged feeding tubes
use proper TF administration
flush 15-30mL before/after each med
use digestive enzymes with sodium bicarb
use a mechaical de clogging device
the primary cause of diarrhea in an enterally fed patient are
medications containing sorbitol elixirs
a majority of enteral formulas are ___ free so patients with lactose intolerant do not have to worry about using them
lactose
what is the most common cause of diarrhea
bowel impaction/obstipation
the passage or secretion of fluid around a stool impaction that can cause loose stool/diarrhea
obstipation
GI mucosal edema 2/2 hypo-albuminemia may result in
severe diarrhea
the most common cause of diarrhea in EN formula fed patients
sorbitol containing meds/elixirs as a flavor enhancement
if a patient is experiencing significant diarrhea, this type of fiber can help decrease diarrhea
soluble fiber: will absorb fluid
An elderly nursing home resident w/ a hx of constipation with a new PEG, how can you ensure that they do not become constipatied
provide 1kcal/mL of formula with fiber and adequate water
an enterally fed patient suffering from constipation may benefit from additional
water/water flushes
causes of constipation in EN patients
dehydration, long-term fiber free feedings, prolonged bed rest, prolonged bed rest, narcotic use
65yo who is bed bound s/p CVA with dysphagia on 1.5 cal/mL formula at 50mL/hr, is 70 inches tall, 150 lbs and gets 60mL of water 5x/day. He develops constipation. How do you improve bowel function . What are the patient’s fluid needs
- 1mL/kcal (1800mL) or 30ml/kg (2045mL)
- Water flushes provide 300mL total a day and the TF formula provides about900mL of water (75% H2O in 1.5 kcal formula). This is a total of 1650mL of water which is below his needs.
- You would need to increase free water flushes for extra hydration
methods to help with gastroparesis in TF patients
- discontinue narcotics (slows GI transit)
- Try lower fat/lower fiber formula (fat/fiber slows GI emptying)
- Administer TF at room temperature
- administer jejunual feedings
what is the most likely etiology of gastric emptying in diabetics
hyperglycemia
enteral formulas used for diabetic gastroparesis are low in
fat and fiber and are isotonic
rapid bolus infusion, feeding tube migration, excessive feeding volume, gastroparesis are all possible causes of ___ in EN patients
nausea/vomiting
what should be done when an EN patient experiences nausea and vomiting
- treat nausea/vomiting with regaln/zofran
2. decrease TF rate or volume
A potentially fatal condition caused by a feeding regimen given through a tube that provides too little water and too much protein in the diet is called
tube feeding syndrome
azotemia, hypernatremia and dehydration are symptoms or signs of
tube feeding syndrome
what is the etiology of tube feeding syndrome
high protein tube feeding without enough water causing a high renal solute load so nitrogen builds up in the blood stream
how can tube feeding syndrome be prevented
provide adequate fluid and don’t use a protein load over 1.5 g/kg body weight unless warranted (burns, CRRT)
granulation/scar tissue can form within the feeding tube tracts and grow out onto the surface of the skin usually where
the exit site
how is hypergranulation around a PEG tube site prevented
- keep PEG tube exit site dry and clean
- Makes sure the tube is stabilized and doesn’t move more than 1/4 of an inch from the stoma
- non occlusive dressings
- add triamcinolone cream
risk factors for buried bumper syndrome
weight gain especially in the abdomen
Increased weight gain and increased abdominal girth puts extra pressure on the bolster of a PEG tube increasing the risk for pressure necrosis and ulceration can lead to ___ ___ __
buried bumper syndrome
pain and pressure on the inside of the stomach, pain, bleeding, obstruction, cellulitis or abscess around the PEG site
buried bumper syndrome
buried bumper syndrome can be life threatening as
it can cause tube feeding formula to leak into the abdomen
what starting a continuous feeding start with ___ strength at ___ to __ mL/hr and gradually increase toward _____
full strength
15-20mL/hr
goal
why is it NOT recommended to dilute enteral formulas
can cause diarrhea or microbial contamination
reduces osmolality
decreases total calories and decreased protein
when chyme enters the small intestine, bile salts, pancreatic enzymes, bicarb and water are released in increasing amounts to make EN formula isotonic is called
autotonicity
what is the reason for early EN
to attenuate the rapid depletion of nutrient stores after metabolic stress or to maintain immune function
when should EN be avoided
not fully volume resuscitated
not hemodynamically stable
mesenteric profusion is not restored
what method of tube feeding delivery is preferred on the ICU
pump assisted
this type of enteral feeding methods is easy to control the rate and volume, establishes better tolerance, has fewer gastric complaints, and possibly reduces the risk for aspiration
continuous pump assisted
what types of feeding methods are allowed for gastric feedings
bolus, intermittent, or continuous feeding
this type of enteral feeding method provides 200-300mL of formula over 30-60 minutes every 4-6 hours
intermittent (gravity, bolus)
this method of administering enteral feedings provides EN over 8-20 hours during the day or night depending on the tolerance of the patient, allowing the patient time off the pump
cycled EN feedings
if a patient on a continuous EN formula will be transitioning to PO intake and EN at the same time. What can help mitigate full ness during day time feeding
cycling at night
if a patient is bolused into the jejunum with a PEJ or NJ what would be the consequences
diarrhea, bloating
when is it appropriate to start transitioning a patient from a cycled EN feeding to an oral diet
has normal GI function
not ventilated
tolerating a polymeric formula for at least 1-2 days
when EEN meets at least 60% of needs/clinical judgement
most enteral tubes are made out of this material
polyurethane
what should be performed to assess feeding tube placement prior to the initiation of enteral feeding
chest x-ray to confirm placement
for a post-op patient with a proximal small intestinal enterocutaneous fistula who is to be enterally fed, what is considered to be the ideal location for placement of the feeding tube in relation to the fistula site
distal to the fistula
before placing a PEG tube, is testing of coagulation parameters and platelets still recommended. When at all should they be tested.
- No not recommended routinely
- If a patient has a concern for abnormal coagulation d/t anticoagulant meds, history of excessive bleeding or recent ANTIBIOTIC USE
what is the most reliable method to placing nasojenunal tubes
endoscopy
fluoroscopy
If a patient has recently been on antibiotics what should be checked/tested fore PEG or PEJ placement
- INR, coagulation parameters
Patients on coumadin, have a high risk of bleeding or are recently on antibiotics are at high risk of PEG/PEJ placement according to
The American Society of Gastrointestinal Endoscopy Guidelines
clopidrel/thienopyridines (inhibits platelet aggregation) should be held ___ to ___ days before PEG/PEJ placement. If not what should be given to promote vasoconstriction in patients with high thromboembolic risk
5-7 days
epinephrine
how long should warfarin be held before PEG placement
5 days
patients who normally take warfarin at high risk for bleeding should be bridged with short acting _______ before PEG placement
heparin
_____ are given prophylactically when PEG tubes are placed to decrease peristomal infection when using endoscopy
antibiotics
the most common method for PEG placement is
Ponsky/Pull method
what is the soonest a percutaneous tube can be removed after placement
1-2 weeks after the stoma has matured
most clinicians wait until ___to___ weeks to remove a percutaneous tube, especially for patients with immunosuppression, steroid use, obesity or poor wound healing
4-6 weeks
what happens when a percutaneous tube is removed too early
the stomach/bowel can fall away from the abdominal wall and bowel contents can leak into the peritoneum
a percutaneous tube should be replaced
endoscopically, interventional radiology or surgery
a standard profile or low profile percutaneous tube can be exchanged _______ unless it is a direct gastrojejunostomy or jejunostomy
at the bedside
if a patient suddenly develops pain, gastric leakage and reddened/ulcerated skin soon after percutaneous tube feeding placement what should be done
- verify the placement of the tube to make sure there is no peritoneal leakage
- Replace tube and confirm correct location with fluoroscopy or endoscopy after replacement
if a percutaneous feeding tube is mispositioned over time it can lead to ____ if not treated
necrotizing fasciitis
what is one of the best ways to prevent aspiration PNA in patients with PEG tubes/NPO
good oral hygeine
what is the best method to clean a percutaneous tube around the skin
warm water
mild soap
rinse and dry
is routine use of antibiotic ointments or hydrogen peroxide recommended to prevent infection around a stoma
No; should not be preventative
what are methods to prevent feeding tube clogging
- adequate flushing with meds/feedings
- don’t over check GRV’s
- avoid high protein/high fiber formulas or use larger bore tubes
in order to reduce the chance of a feeding tube to clog what is essential
flushing protocol compliance
each patient should be evaluated in conjunction with a ___ to determine the best way to deliver a medication to a tube fed patient
Pharmacist
meds should be given ____ to decrease risk of clogs and be ___ before and after each administration
separately
flushed
what can be used to prevent tube dislodgement
a bridle
cracking, breaking or kinking of a feeding tube is consider a
tube malfunction
obstruction of physiological sinus drainage by a naso-enteric tube is a complication of what
sinusitis
vomiting in minimally responsive patients may increase the risk of
aspiration PNA
to gastric residual volumes correlate with tube feeding tolerance
no
ileus, obstruction, obstipation, ascites , diarrheal illness, rapid formula admin or infusion of very cold formulas can can all cause
bloating/abd distention
impaired breakdown of nutrients into the absorbable forms are called
maldigestion
how is maldigestion tested for
fecal fat assessment
lactose tolerance test
schilling test for B12 absorption
small bowel biopsy
Celiac disease, Chron’s disease, diverticulosis, radiation enteritis, enteric fistula, short gut and SIBO are all possible causes for
maldigestion
if providing a high sorbitol medication in an enteral feeding what can be provided to reduce irritation of the gut
give with at least 30-60mL of water
is intact protein recommended for starting patients on tube feedings
yes
____ might be the most tolerable form of protein in EN formulas on the critically ill patient
polypeptides
a patient can become ____ intolerant after illness, especially when transitioning to an oral diet because most EN formulas are ____ free. Try a ___ restricted diet to reduce diarrhea.
lactose intolerant, lactose free, lactose restricted
what are the first steps in managing diarrhea in an enterally tube fed patient
- rule out infection/inflammatory causes
- rule out fecal impaction/obstipation
- Identify sorbitol containing medications
if diarrhea continues in an enterally fed patient what medication can be given to slow down the diarrhea
anti-diarrheal agent (loperamide, octreotide)
if a patient’s abdomen (who is getting tube fed) becomes distended, tympanic or painful what should be done
- stop the tube feed and contact the MD to evaluate
if diarrhea is not related to a medical or surgical reason, and has not had a BM in 5 days assess for
- regular narcotic use, stool impaction, fluid provision
if a patient is not on cathartic medications, doesn’t have a surgical reason and not on sorbitol medications what should be assessed with diarrhea
C Difficile
a patient develops 4-5 water stools a day. what should the RD evaluate.
- is the patient getting high sorbitol or hypertonic solutions
- are they on a pro-kinetic, antibiotic
To manage diarrhea in a tube fed patient (not due to medications) ____ fiber can be used in a modular or specific formula. However this can clog tubes.
soluble fiber
if a patient has been on prolonged antibiotics and having diarrhea, what should be tested
C Difficile
what is the primary EN intervention when a patient has diarrhea (not due to meds, infection, sorbitol)
use a fiber containing formula
what is the last resort type of formula when a patient has diarrhea (not due to meds, infection, sorbitol)
peptide based formulas
accumulation of excess waste in the colon is known as
constipation
if constipation is suspected, what should be the following steps
- check for SBO, obstruction or ileus
prolonged use of ____ can cause tachyphylaxis and should not be used for constipation
sennakot
firm collection of stool in the distal colon where liquid stool will seep around an impaction
impaction
who are at risk for fecal impaction
older adults, bed bound
who are at risk for intestinal ischemia
neonates
critically ill
immunosuppressed
what precautions are used to prevent intestinal ischemia in enteral nutrition
- delay EN until fluid resuscitated
- avoid EN during profound hypotension/hypovolemia
- use isotonic, fiber free EN formula
- ongoing monitoring of abdomen, MAPs
what is the most invasive method of NGT placement
endoscopic, requires placement of a large instrument along with the feeding tube
what is used for pharmacologic stimulation of tube feeding placement
pro-kinetic to stimulate gastric peristalsis
the external bumper used in the placement of PEG/PEJ to hold the stomach or small bowel in place against the abdominal wall
T-fastener
how long are t-fasteners kept in place to allow formation of a stoma tract
10-14 days
air insufflation, auscultation and pH aspirates to check TF placement are not recommended as
lead to false positives and can lead to tube placement into the tracheobronchial tree
to decrease the risk of the feeding tube being placed into the airway during NG placement is to have the patient
bend their head forward and tuck their chin to their chest
the most successful way to place a trans pyloric feeding tube is
fluoroscopy
a 75 year old female with dementia and history of aspiration would best benefit from this tube
PEJ; decreased risk of aspiration and long term
contraindications to PEJ placement
end jejunostomy, short bowel syndrome if only the jejunum remains
What is the maximum hang time for closed-system enteral formulas?
48 hours
What are the fluid needs for an adult over the age of 65?
30 mL/day with a minimum of 1500 mL
What percent water are standard enteral formulas?
~84%
What are the benefits of early enteral feeding in critically ill patients?
- Decreases translocation of gut bacteria
- Reduces atrophy of intestinal villae
- Reduces risk for infectious complications.
It does not increase intestinal permeability.
What are the 2 most important factors in assessing the adequacy and efficacy of enteral feedings in pregnancy?
- Maternal weight gain
2. Fetal growth
(TRUE/FALSE)
There is a strong correlation between infant birth weight and maternal weight.
TRUE
Why is serum albumin not recommended for assessing the adequacy and efficacy of EN during pregnancy?
Serum albumin is not recommended due to diluational effects associated with normal plasma expansion and alterations in plasma protein production.
Lactose is a common ingredient in which type of enteral formula?
Standard infant formula
Lactose is used to mimic the carbohydrate found in human milk.
What EN formula is appropriate for patients with chyle leaks? Why?
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
What are 3 important parameters for predicting tolerance of EN in patients with pancreatitis?
- APACHE II score (disease severity; most important)
- Duration of NPO (Greater than 6 days have shown poor tolerance)
- Increasing abdominal pain
(TRUE/FALSE)
Triglyceride level is an appropriate parameter for EN tolerance in patients with pancreatitis.
FALSE.
Serum TG levels are used to measure tolerance of PN, not EN
When should EN be initiated?
How long should it last?
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.
(TRUE/FALSE)
It is safe to provide EN in patients with open abdomen.
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.
Why would placement of a jejunostomy feeding tube NOT be beneficial for patient’s with short bowel syndrome?
What is recommended instead?
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.
What is the best intervention to assist with the appropriate placement of an NG tube in an alert patient?
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.
(TRUE/FALSE)
Bedside electromagnetic imaging systems have shown greater than 90% success with placement.
TRUE.
Weighted tube tips are the LEAST likely to facilitate transpyloric placement of an NG tube.
What is the primary advantage of a direct PEJ (percutaneous endoscopic placed jejunal tube) VERSUS PEG-J (percutaneous endoscopic transgastric-placed jejunal tube)?
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.
What characteristic of enteral formulas is the MOST likely to increase splanchnic blood flow in a critically ill patient?
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.
What two interventions reduce the risk of aspiration with EN?
- Elevate HOB to 30-45 degrees
- Oral hygiene
No benefit to holding the TF during brief periods of supine positioning or elevated gastric residuals.
What is the effect of alpha-2 adrenergic agonist meds in EN?
Alpha-2 adrenergic agonists, such as clonidine, have been shown to have significant antimotility effects and often prolong instead of reducing intestinal transit time.
(TRUE/FALSE)
Metoprolol administration requires changing TF schedules.
FALSE, does NOT.
(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.
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.
(TRUE/FALSE)
An acidic juice such as OJ can reduce the risk of microencapsulated beads/pellets sticking to the tube.
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.
What is the hang time for blenderized formulas?
2 to 8 hours depending on if it’s homemade or commercial
What is the hang time for reconstituted enteral formulas?
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
What is the hang time for closed system EN?
24 to 48 hours, depending on the connection set.
What is the best method to assess protein requirement and adequacy?
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
(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.
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.
Immune-modulating EN formulas should be reserved for which patients?
Trauma, TBI and, surgical ICU patients.
(TRUE/FALSE)
Immune-modulating EN formulas are contraindicated in septic patients.
TRUE.
Due to adverse effects are seen with arginine supplementation in these individuals.
(TRUE/FALSE)
Immune-modulating EN formulas are recommended for routine use in the medical ICU.
FALSE, are NOT recommended
Which of the following are modular products?
Safflower oil Protein Glucose Selenium MCT oil Fiber Glutamine Cholecalciferol
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.
(TRUE/FALSE)
There is believed to be an increased ratio of AAA (aromatic AA) to BCAAs in patients experiencing hepatic encephalopathy.
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)
Why may EN be contraindicated in the early post-transplant period with hematopoietic cell transplants?
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.
Which type of medications can be crushed for administration via EN tube?
Only immediate-release tablets
(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.
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.
what are major risk factors for aspiration in critically ill patients
- decreased levels of consciousness
- previous history of aspiration
- vomiting
- tracheal intubation
- neuromuscular disease
- persistent high gastric residual volume
- prolonged supine positioning
- large diameter feeding tube
what is the most appropriate management of hyperagranulation around a PEG tube site
cauterize with silver nitrate
_______ forms within the tract of a PEG tube and may grow on the surface of the skin. It is a source of moisture underneath the bolster causing breakdown of the skin
granulation tissue
A tube feeding schedule where formula is provided as 240mL administered over 45 mins 5x/day is known as a __________
intermittent schedule
Tube feeding provided in a volume between 240-480mL given over 45minutes several times a day with or without a pump is called _____ feeding
intermittent feeding
What is the benefit of using an electromagnetic replacement device for NGT placement?
it provides a 3 dimensional localization, displayed in real life. A receiver is placed on the patient at the xiphoid process, therefore the magnet follows the tip placement relative to the LES, not the pylorus.
In a patient with a newly placed gastrostomy or jejunostomy tube, observation of which conditions at the tube exit site would signal a possible peristomal infection?
foul smelling drainage
The most common complication soon after PEG or PEJ placement is a
peristomal infection
what type of feeding schedule would be the most appropriate for a critically ill patient with poorly controlled blood glucose
continuous (consistency stabilizes blood sugars)
Continuous tube feeding is most appropriate in the critically ill and poorly controlled diabetic TF patient as intermittent schedules may cause fluctuations in blood glucose concentrations, placing patients at risk for ______ or ______ complications
hypo or hyperglycemia
A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue the enteral feeding because
- EN feeding and hydration don’t always ensure comfort
- During starvation the body produces ketones which are euphoric
- The most common symptom when nutrition/hydration are withheld is dry mouth, which is alleviated with good oral mouth care
- IV hydration in the terminally ill patient can raise the risk of patient discomfort and respiratory distress
The most common symptom when withholding hydration or nutrition from a terminally ill patient would be _____ and can be alleviated by ________
dry mouth
good oral mouth care
One method of minimizing the complications associated with refeeding syndrome is to initiate an electrolyte replacement protocol before nutrition therapy begins. This should also be done on patients that
are not considered to be at risk to also be added on the protocol
when refeeding, electrolytes should be replete via which route
IV, oral or feeding tube depending on appropriateness
when a patient is at risk for refeeding syndrome, feedings should ________ be delayed but instead __________
don’t delay nutrition feedings
initiate slowly, advance slowly per electrolyte levels and clinical response
Bacterial contamination during enteral feeding can originate from the patients throat, stomach, lungs, feeding equipment, and retrograde contamination from the patient’s own
secretions
the longer an enteral product is hung the _______ the chance of bacterial contamination
higher
A male patient suffered from a stroke 2 wks ago and has significant dysphagia. An isotonic EN formula has been infusing continuously at a goal rate for 2 days, along with an ordered 30mL water flush per hour. The pt begins to complain of bloating and his abd becomes mildly distended to 4 cm from baseline. He denies nausea, bad cramping or abd pain. His last 2 gastric residual volumes were measured at 100mL. What is the best strategy to reduce his symptoms?
check when his last bowel movement was and if the patient is found to be constipated, initiate a bowel regimen
abdominal distention from enteral feeding can be caused by _______ administration from bolus schedules, _________ solutions, pain medications that slow ______, tube migration from the stomach to the _________, cold temperature formula inadequate fluid causing constipation, and fat/fiber/lactose intolerance.
- rapid administration
- hyper-osmolar solutions
- peristalsis
Only hold a tube feeding if a patient’s abdominal girth has extended beyond ____ to ___ cm
8-10
Patients who are alert and cooperative are at the ____ risk of pulmonary injury from small bore feeding tube misplacement
lowest risk
Oral or nasogastric feeding tubes used for EN should only be indicated for use less than ____ weeks
4 weeks
Placement of feeding tubes is complicated in uncooperative patients with anatomic abnormalities and critically ill patients in which ______ is inhibited
swallowing
a patient with oral cancer who has gained 10 lbs since starting home bolus EN feedings via gastrostomy tube complains of pain and pressure on the “inside of his stomach.” but no redness or drainage at the exterior gastrostomy site. What is the most appropriate response for the clinician?
refer the patient to the gastroenterologist or enterostomal nurse
a new occurrence of pain at or near the tube feeding site of a patient should be promptly evaluated by
the patient’s GI doctor or enterostomal nurse
Constipation in the enterally fed patient may be associated with
obstruction lack of adequate hydration prolonged best rest / lack of activity long term fiber free feedings narcotics
what is most likely the cause of watery diarrhea and bloating in the enterally fed adult
sorbitol content of liquid medications
An enterally fed patient reports nausea and vomiting. If delayed gastric emptying is the suspected cause, what can be done to improve the patient’s symptoms
decrease or discontinue narcotic meds
use low fat. low fiber formulas
administer TF at room temp
decrease the rate or volume of the feeding
the initiation of enteral tube feeding should be delayed in the ICU when the patient is _________, and not ______ to decrease the risk of intestinal ischemia
hemodynamically unstable
fully volume resuscitated
evidence of bowel sounds is _______ required prior to the initiation of EN
NOT required
Patients at risk for refeeding syndrome should _____ delay EN
NOT delay
how should EN feeding be initiated and advanced in the hospitalized patient
use a full strength formula, start at 10-40mL/hr and advance to goal rate within 1-2 days
while a patient is receiving SLP therapy, oral foods are provided during daytime hours. To meet the patient’s nutrition requirements, polymeric tube feeding is required during the night at a rate of 75mL/hr over 10 hours. This night feeding is an example of
cyclic feeding
Patients who are on TF via pump and are initiated on oral foods during the day would likely benefit from ______ feedings schedules
overnight cycle feedings
what type of insulin should be used when initiating EN in a hospitalized diabetic patient?
regular insulin
An 82 year old female s/p CVA with dysphagia and subsequent PEG placement weighing 45 kg is initiated on tube feeds which provide 1500 kcal, 63 g of protein/L. The team added a modular protein supplement providing 15 grams additional protein a day. She is discharging home and will be taken care of by family. During the tube feeding education what is important to discuss with the family to prevent tube feeding syndrome
the importance of providing adequate free water daily
What is tube feeding syndrome
the use of high protein tube feeding without adequate fluids. The kidneys are inefficiently able to excrete the solute load and can cause azotemia, hypernatremia and dehydration.
most enteral formulas designed for oral consumption are made up primarily of
carbohydrates (40-60% total kcals from carbs)
______ in enteral formulas designed for oral consumption provide palatability
sucrose
blue dye is ______________ recommended for the detection of aspiration of enteral formula 2/2 low sensitivity, several cases of system toxicity and is removed by the FDA
NOT
which enteral feeding method provides 240mL of formula via a syringe over as few as 4-10 minutes, 3-6 times a day
bolus
bolus feedings mimic
normal feeding schedules
what type of feeding delivery method is most appropriate for patients with a jejunostomy
continuous pump
_______ feedings via pump minimize diarrhea and abdominal bloating
continuous
which type of enteral nutrition delivery is preferred for critically ill patients
continuous
why is continuous enteral tube feeding the most appropriate for critically ill patients
controls the rate and volume
better EN tolerance
decreased aspiration risk
which of the following is a best practice recommendation in EN formula safety
change the EN feeding administration set every 24 hours with open systems
EN that is mixed, reconstituted or diluted should be done in _________ to decrease the risk of contamination
a sterile, centralized location
Only ___ to ___ hours of formula should be poured into an open set
8-12 hours
canned, ready-to-use formula hang times should be a maximum of
12 hours
closed EN formula can be safely used for ______ hours after opening
24-48 hours
__________ formulas should be immediately refrigerated after preparation, discarded within 24 hours of not being used and should not be held at room temperature for longer than 4 hours
powdered
use of purified water vs tap water does what
decreases risk of bacterial contamination
what are the benefits of closed enteral feeding systems
decreased risk of microbial contamination
minimal manipulation needed
long hang times of 24-48 hours
requires less nursing time
when transitioning from enteral to oral feeding, tube feeding may be discontinued when adequacy of oral intake meets at least _________ needs
66% of estimated needs (2/3 to 3/4)
what information should always appear on the label of an enteral feeding product given to a hospitalized patient
patient identification product name administration method route of delivery access device date and time the formula was prepared/hung/expires
when administering multiple medications via enteral feeding tubes, medications should be
administered separately and flushed with 15-30mL of water before and after administration
enteric-coated, controlled release and sustained release medications should not be ______ and given via feeding tube
crushed
what type of feeding tube requires immediate replacement if it becomes dislodged as the tract can close very quickly
jejunostomy
replacement of a jejunostomy tube requires
radiographic verification with contrast medium
the first replacement of a gastrostomy or PEG tube should be done
by the physician who inserted the tube, after that it is appropriate for trained nurses to replace them
Nasogastric or nasoduodenal tubes can be replaced by who
doctors, physicians assistances, nurse practitioner’s or appropriately trained healthcare providers
what type of formulas are most likely to occlude a feeding tube
calorie dense
high fiber
what can be done to assist with maintaining feeding tube patency in the adult patient
flush the feeding tube with 30mL of water every 4 hours during continuous feeding, and also flush after measuring GRVs
change short term feeding tubes (NG,NJ,ND)every ____ to ___ weeks
4-6 weeks
which of the following is not a research based method to restore patency to clogged feeding tubes
cranberry juice
what 3 methods are used to restore patency to clogged feeding tubes?
water flush
mechanical de-clogging devices
pancreatic enzymes mixed with NaBicarb
you get a consult for a patient on EN with abdominal distention, nausea and vomiting. Monitoring of GRV’s have been ordered. What intervention can be utilized to prevent feeding tube occlusion associated with GRV assessment in an adult patient
flush the feeding tube with 30mL of water after GRV assessment
The Society of Critical Care Medicine and ASPEN 2016 guidelines suggest that ________ should not be used as part of routine care to monitor EN tolerance
gastric residual volumes
what methods have been proven effective in decreasing the risk of aspiration associated with enteral tube feeding in adult patients
good oral care BID
motility agents when TF intolerance
post pyloric tube when the patient is at high risk
what is most likely to improve tolerance of enteral feeding in a patient who is post op and documented with high gastric residual volumes, receiving bolus tube feedings
switch to continuous tube feedings
recovery of gastric emptying may be slower than the return of _____ motility in the post op patient
small bowel
continuous feedings is the preferred method in the _______
small bowel
`what is the primary cause of oozing stools in a tube fed patient
fecal impaction
______ can be manifested by symptoms of diarrhea with constipation
impaction
a home enteral nutrition patient recently treated for pneumonia is noted to have new onset diarrhea. What should be the first intervention be?
obtain a CDiff culture especially if the patient was recently on abx
A patient with short bowel and end-jejunostomy requires the use of an oral rehydration solution to help prevent dehydration. What best describes the preferred composition of the ORS?
an iso-osmolar solution such as juice diluted with 50% water, should be made up of glucose to promote salt and water absorption and 90-120mEq/L of sodium
Glucose in oral rehydration solutions serves what function
to promote salt and water absorption
why are commercial sports drinks not good oral rehydration solutions
they contain much more glucose and not enough sodium
what is the optimal concentration of an oral rehydration solution for patients with short bowel syndrome to promote jejunal absorption
90-120mEq/L
in critically ill patients getting early EN, which is the most likely to increase success in achieving goal feeding rates?
volume based EN feeding protocols
what is the maximum hang time for human breast milk
4 hours
Your patient is showing outward signs of tube feeding intolerance including nausea and abdominal distention. The nurse checks gastric residuals and the last 3 measurements are 265mL, 250mL and 330mL. What is the most appropriate recommendation
consider adding promotility agent
the largest payer of home enteral and PN is
Medicare
education materials for home EN/PN should be at a ____ level
6-8th grade level
what should be evaluated on a home care provider performance improvement plan
hospital re admit rate (also, mortality rate, customer satisfaction, complications, problem reporting/resolution)
benefits of a home nutrition support team
earlier transition to PO or EN, avoids multiple lab draws, improved coordination of care, more psychosocial support, earlier identification of potential problems and deficiencies
a non-profit organization for education and support that is free to all home PN or EN patients
Oley Foundation
what are the benefits of a nutrition support support group
increased quality of life, decreased depression, decreased incidence of catheter related sepsis
how often should electrolytes be monitored in nutrition support
Initially: weekly until clinically stable
What makes a patient a good candidate for home EN
physical & emotional well being, willingness to go home, adequate storage pace, electricity, running water, phone in the home, patient support/support network, back up battery for powered infusion pump
Medicare: in order to be covered for a tube feeding pump at home you must have
nausea/vomiting, GERD, gastroparesis, dumping syndrome
in order to be covered for home enteral feeding ____ must not be possible
PO intake
according to medicare, permanence of EN or PN is defined as > ____ days
90 days
when an anatomic or motility disorder will interfere with oral intake for > 90 days, EN will be covered. True or False
True
for an enterally fed home patient, a pump will be covered if
intolerance to bolus or gravity feeding is demonstrated
Third Party insurance payers are the ____ likely to pay for EN formulas because they equate to the cost of a grocery bill
third party
the 3 most important monitoring for HEN patients who are stable are
weight, I/O and bowel function
if a PEG tube dislodges after the tract matures (>6 weeks) a replacement tube can be
reinserted and surgery is not required
if a PEG tube dislodges that has an immature tract, within ___ hours a dilator can be used to open the tract IN THE HOSPITAL NOT AT HOME
12
what is the best way to ensure the patient is performing proper tube feeding technique
return demonstration
To ensure the best adherence to feeding and improved psychosocial health of a tube fed patient their tube feeding schedule should be
integrated into the patient/family’s way of living and should simulate normal meal times
in a stable home EN patient, it would be most appropriate to routinely monitor
weight, intake/output, bowel fx
enteral feeding should be incorporated into the patient’s/families
lifestyle, mimic normal meal times
what is encouraged of family members of an enterally fed patient at home
participation, dinner table socializing
a home tube fed patient’s administration schedule should mimic
normal meal times
patient education materials should be at the ___ to ____ grade level
5th to 6th grade level
the best way to to know the patient/family’s understanding of EN delivery is
return demonstration/ teach back
an active process where the patient can demonstrate themselves and verbalize the process is called
teach back/ return demonstration
Teach Back/Return demonstration helps the patient/family get accurate _______, verify ______ and reinforce new home care ________
information
understanding
skills
the maximum hang time for an open enteral system IN THE HOME SETTING is
12 hours
the maximum hang time for a closed system in the HOME setting is
24-48 hours
the best way to care for the skin around a feeding tube is
mild soap and water, rinse and keep dry thoroughly, clean under the external bolster
when are dressings recommended for PEG tubes
only if there is drainage
the home care improvement plan for an enterally fed tube feeding patient measures ________ in the home tube feeding setting
outcomes
what NEEDS to be included in the home care improvement plan for home enterally fed patients
- hospital re admits
- complications
- patient/family satisfaction
- problem reporting/resolution
Under the Centers for Medicare and Medicaid Prosthetic Device Act, hone enteral nutrition patients (HEN) are only covered if they meet the criteria for permanent disease of the structures that ________________ or disease of the small bowel that impairs. WITH these 3 documented indicators
- permit the food to reach the small bowel
- digestion/absorption of a PO diet
- test of performance documented by MD
- statement of permanence (90 days)
- statement of needing to maintain weight/strength not possible by taking in oral nutrition supplements
- serum albumin <3.4 g/dL , fecal fat test
- weight loss >10% >/= 3 months
In enteral nutrition discharge instructions the following needs to be documented. Name of the _______, total ______, route of _______, care of the ________, product hang time, stability at room temp, inspection of the product, expiration dates , _____ prevention, what to do when you _______, phone number for the home care company and proper_____
- name of the formula
- total daily volume needed
- route of administration
- care of the enteral access device
- infection prevention
- run out of supplies
- storage
the most common complication associated with PEG tube placement is ____ which can occur within days to months
peristomal infection
examples of Medicare coverage part B conditions
obstruction 2/2 head/neck cancer
motility disorders
severe dysphagia
which conditions are not covered by medicare for home EN
anorexia, malnutrition, nausea
Medicare reimbursement for nutrition education by an RD is only covered for
diabetes
renal disease (pre dialysis)
kidney transplant
managed care / private insurance companies usually use ______ criteria for HPN coverage
medicare criteria
managed care/private insurance companies usually require _________ and medical _____ and sole source of ______ in order to cover EN
pre authorization
medical necessity
sole source of nutrition
how often initially should electrolytes, glucose, BUN, Cr, Mag, Phos be monitored
weekly for 4 weeks or until clinically stable
what type of venous access devices are indicated for home PN use
PICC lines (Hickman)
Implanted Ports
Tunneled CVCs
a permanent ____ must be placed before discharging home with HPN
venous access device (central)
upon initiation of home PN, initial lab data should be obtained when
prior to starting home PN
the patient/training policies for home PN should address
education
training
evaluation of the patient/caregiver competency
home infusion companies are responsible for the delivery of
- nutrition products
- supplies
- nursing care
- formula delivery
- equipment delivery
assessing of micronutrient status in HPN patients requires thorough ______
symptom observation
copper deficiency masks _____deficiency making it difficult to assess home PN patients
B12
Hypermagnesemia results from ______ in HPN patients
commercial trace element preparation
manganese is almost fully excreted by the ________
hepatobiliary system (bile)
try to decrease the dose of manganese in patients on HPN with
hepatobiliary disease or liver disease
who are at risk for a manganese toxicity
long term PN over 30 days with obstruction of the biliary duct
when there is a toxicity of manganese with inability to excrete it through the bile, it can deposit in the ______ especially with IV manganese
brain
what is the BEST way to detect manganese levels
whole blood manganese
what is the best indicator for chromium deficiency
there is NO known reliable indicator of chromium status
what are the roles of chromium
- potentiates the action of insulin
2. plays a role in glucose, protein and lipid metabolism
which populations are at risk for chromium deficiency
- pregnancy
2. Type 2 DM
if a patient is hyperglycemic, give ______ supplementation and see if the blood glucose resolves
chromium
what are some causes of zinc deficiency
inadequate intake, decreased absorption, increased losses, increased demand
primary symptoms of zinc deficiency
loss of taste, altered smell, rash, alopecia, gonadal hypofunction, night blindness
every HPN patient should get ____ daily unless there is a toxicity / potential for toxicity or national shortage
micronutrients
whenever a patient has a nutrient omitted what should be done
monitor for deficiency or toxicity that can develop over time
are lab values always the best indicators for normal micronutrient status
NO
normal lab values of micronutrients can give a false ______
sense of security
failure to monitor which long term micronutrient can result in toxicities of these micronutrients in PN: zinc, manganese, folate or molybdenum
manganese
hypermanganesemia can occur in all ____ patients regardless of liver function
long term PN patients
PN contains these potential toxic elements from an ASPEN 2009 review
manganese, copper, chromium
in the 2012 ASPEN recommendations, there was a recommended decrease of these trace elements
manganese and copper
symptoms of manganese toxicity
headache, Parkinson’s like abnormalities
Case: A malnourished patient with metastatic ovarian cancer is diagnosed with inoperable, partial SBO. She is taking in small amounts of a full liquid diet by mouth but is unable to take enough nutrition to maintain her weight. She has lost 12% of her body weight in the past 2 months. According to current Medicare guidelines the patient’s HPN will be covered under which of the following circumstances
- the medical record must document failure of EN feeding tube or explain why it is not an option
- it is critical to document a non functional GI tract
diagnosis of a SBO alone is _____ qualifying for HPN
Not
Large volume, small volume, pharmacy bulk PN components must be labeled with the amount of ______ anticipated to be in the product when the product _________
aluminum, expires
the amount of aluminum on PN labels are about ____________ than what is actually in the PN bag of an individual patient
10 times more
pharmacies are not require to list _____ content of each individual patient’s PN bag
aluminum
symptoms of aluminum toxicity
neurological, hepatic, hematologic, skeletal muscle
Sx are non specific, non sensitive, can include some metabolic bone disease but is not the primary symptom
the most practical way to manage micronutrients in long term PN patients is to
perform micronutrient assessment every 6 months including nutrient intake assessment, assessment for potential losses, medications/surgical history and a nutrition focused physical exam
what are the causes of nausea and vomiting in long term EN patients
rapid EN infusion, gastric outlet obstruction from tube migration, excessive feeding volume, gastroparesis
how is nausea and vomiting prevented in home EN patients
- decrease TF rate/volume of an EN infusion of N/V occurs
many third party payors (insurance companies) equate the cost of EN formulas to the cost of _____ and DON’T cover the expense
groceries
if a patient cannot afford their formula, what are their options
- work with an RD to find an alternative
2. there are non profit/indigent care programs to help
EN formula may be covered under Medicare Part _____ and is usually only covered to about ____%. Patients with supplemental ______ may have the rest of the 20% covered.
Medicare Part B
20%
Supplemental insurance
Home blenderized EN formulations should be discarded after _____ hours at home. Their hang time should be ____ hours.
Discard after 24 hours
hang time 4 hours
which non profit organization is a great resource for home PN/EN patients
Association of GI motility Disorders
a 69 year old male on a continuous, high-protein, high fiber tube feeding is running at 65mL/hr via a PEG. The TF was selected to assist with wound healing and diarrhea. The tube feeding is stopped every 6 hours , residuals are checked and the tube is flushed with 30mL of water. The patient is provided liquid medication via the PEG tube 2 times a day. The tube now seems occluded, why?
inadequate flushing
the agency that regulates medical foods
the Food and Drug Administration (FDA)
when should blue dye/blue food coloring be used in enteral tubes
NEVER
what is not a nursing responsibility for monitoring jejunal tube feeding
measurement of residuals
how can clogging of a feeding tube be prevented when checking residuals
flush the tube with 20-30 mL of water before checking a GRV to prevent clogging
which patients are at risk for formula related contamination
neonates, critically ill, immunosuppressed, compromised gastric acid microbial barrier
what are the 3 chances of contamination in EN formulas
storage
preparation
administration
which type of Enteral Feeding has the lowest chances of contamination
sterile/closed system feedings
which type of EN formula has the highest risk of contamination
mixing, dilution, reconstitution (powder)
hang time for open systems
4-12 hours
hang time for reconstituted formulas
4 hours, room temperature
powdered enteral formulas are ____ sterilized
NOT
___ water should be used to reconstitute powdered formula
sterile
closed enteral systems can hang for ____ hours
24-48 hours
formulas should be used ____ after opening which reconstitution with ____ water
immediately, sterile
what should be referenced for recommended room temperature and hang time of specific formulas
manufacturer recommendations
should a blender be used to mix powders
no, high risk of contamination
clean the lids of enteral feeding products with ____ and dry
isopropyl alcohol
how often should feeding bags be changed
every 24 hours
when material from the lungs, stomach, and throat back up into the feeding tube, where they can proliferate and be re-infused in greater numbers is considered _____ contamination
retrograde
most gravity drips have a ____ that decreases the risk of retrograde contamination
drip chamber
checking ____ can also lead to contamination of enteral feeding by pulling back gastric contents and infecting the tube feed hub
gastric residuals
what is one example of prevention policy for enteral feeding to reduce chance of contamination
enteral quality control programs/institutional protocols
what is another example of prevention of EN contamination
define the process for receiving, distributing, storing, preparing, handling and administering EN
To ensure safety during EN feedings, visually inspect each TF bottle for ___ and ___
damage
expiration date
use proper _____ before feeding administration, and formula handling
hand washing/clean gloves
flip top enteral feeding cans should be wiped with _______
isopropyl alcohol
visually inspect EN formulas for
separation, thickening, clumping or curdling
inhalation of material into the airway is known as
aspiration
aspiration PNA can be caused when _____are in the wrong place or inhaled ____ contents
feeding tubes , gastric contents
asymptomatic aspiration of saliva is called
silent aspiration
dyspnea, wheezing, frothy/purulent sputum, cyanosis, anxiety, fever, tachycardia, rhonchi/rales, leukocytosis, leukopenia or a new / progressing infiltrate are symptoms of
aspiration pneumonia
when aspiration occurs from a ventilator it is known as
ventilator associated PNA
_____ is one of the most feared complications of EN and can lead to acute pulmonary pathology
aspiration PNA
patients with dysphagia may aspirate saliva regardless of enteral feedings, true or false
true
what are the steps to reduce aspiration risk during enteral feeding
- elevated HOB 30-45 degrees
- sit patient upright or reverse Trendelenburg position
- good oral care BID with chlorhexidine
- continuous tube feeding,
- minimal sedation, suction prior to lying down,
to decrease risk of aspiration check GRV’s every ___ hours if they are part of your hospital protocol. Start _____ in setting of elevated GRV’s in the critically ill and use ___ trees for actions depending on the GRV
4 hours
pro-kinetic
decision
per ASPEN, GRV’s should ____ be used routinely to monitor ICU patients with enteral nutrition
NOT
if your ICU still uses GRVs, avoid holding EN for GRVs < ____mL in the absence of other signs of feeding intolerance
500mL
what methods should be used to check TF placement to decrease the risk of aspiration PNA and tube feeding
- check visible tube length
2. routinely check CXR especially if migration is suspected
to avoid hypertonic dehydration in EN what should be monitored
daily fluid I/O daily body weight serum electrolytes urine specific gravity BUN/Cr raio enteral/IV fluid provision
excessive fluid intake, rapid feeding, catabolism of LBM tissue with potassium loss, cardiac insufficiencyy/renal/hepatic insufficiency/refeeding syndrome are all causes of
overhydration
if a patient is experiencing overhydration during enteral feeding , what can be done/monitored
I/O
body weight/fluid status
check aldosterone (increases Na retention)
diuretic therapy
refeeding syndrome, catabolic stress, high ADH/aldosterone, diuretics, diarrhea/NGT loss, metabolic alkalosis, insulin and dilution can all cause _____
hypokalemia
if hypercapnia from overfeeding is suspected during enteral feeding what can be done
- lower phosphorous
- measure EEN with IC
provide balance of CHO, fat and protein
if a patient on EN develops low levels of serum zinc what can be done
supplement zinc in EN
per ASPEN when EN is being provided in a patient suspected to be at risk for refeeding syndrome provide ____% of energy goal on Day 1 with attention to energy contribution from ____then cautiously advance toward energy goal within ____ to ___ days pending clinical status/electrolyte levels.
25% on day 1
dextrose from IV
3-5 days
hyperglycemia is more common in EN Or PN
PN
when a patient on Enteral Nutrition experiences hyperglycemia what can be done
- use EN formula high in fat/fiber
- manage with insulin
- advance TF slowly toward goal
a BUN/Cr ration over > can indicate dehydration
20:1
a patient with renal failure/malnutrition with a BUN of 100 and Cr of 1 with a ratio of 100:1 may still be _____
adequately hydrated
typical urine output range
0.5-2 mL/kg/hour
1 liter of fluid = ___ kg of weight
1
Describe the overall benefits of using enteral nutrition
Helps maintain the functional integrity of the gut
Promotes efficient nutrient utilization
Reduces the risk of cholecystitis by ensuring release of cholecystokinin with the presence of nutrients in the small bowel
Luminal nutrients provide GI structural support and help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
Reduces infectious complications associated with pneumonia, sepsis, IV line sepsis, and intra-abdominal abscess
Less expensive than PN
List contraindications for enteral nutrition
Severe short bowel syndrome (<100-150 cm remaining small bowel w/o colon or 50-70 cm small bowel w/ colon)
Other severe malabsorptive conditions
Severe GI bleed
Distal high-output GI fistula
Paralytic ileus
Intractable vomiting and/or diarrhea that does not improve with medical management
Inoperable mechanical obstruction
When the GI tract cannot be accessed (when upper GI obstructions prevent feeding tube placement)
What factors should be included when choosing a feeding tube?
Expected duration of therapy
Desired feeding location (stomach or small bowel)
Administration mode (continuous vs bolus)
Expertise of clinicians available for feeding tube placement
What methods can be used for placement of long-term feeding tube?
Percutaneous endoscopy methods
Radiological methods using fluoroscopy, ultrasound, or CT
Open or laparoscopic
List the various potential signs and symptoms of refeeding
Electrolyte abnormalities (hypophosphatemia, hypokalemia, hypomagnesemia, hypocalcemia, hyponatremia)
Cardiovascular conditions (arrhythmias, hypotension, heart failure, cardiac arrest)
Thiamin deficiency
Fluid retention
Hyperglycemia
Neurologic conditions (weakness, numbness, paresthesia, myalgia, vertigo)
Respiratory conditions (shortness of breath, pulmonary edema, respiratory failure)
List risk factors for aspiration
Inability to protect the airway related to: reduced level of consciousness, neurologic deficit
Delayed gastric emptying related to: gastroparesis, medications (opioids), hyperglycemia, electrolyte abnormalities
Presence of naso- or oroenteric feeding tube
GERD
Supine position
Vomiting
Bolus enteral feeding
Mechanical ventilation
Age >70 years
Transport outside the ICU
Inadequate nurse-to-patient ratio
Poor oral care
Define early EN initiation in the critically ill population
EN that is initiated with 24-48 hours of the initial insult (surgery, mechanical ventilation, neurological injury)
Burn patients may benefit from early EN initiation, within __ to __ hours of injury
4-6 hours
When are pump-assisted continuous drip infusions the preferred method for feeding patients?
Critical illness, mechanically vented using an oro-tracheal method, at risk for refeeding syndrome, poor glycemic control, fed via jejunostomy, demonstrated intolerance to intermittent gravity drip or bolus feed
Should initiation of EN be delayed in the absence of bowel sounds or movements?
No; delayed EN will increase the risk of compromising the GI mucosal barrier and immune function
How soon should EN be advanced to goal rate in stable noncritically ill patients?
Generally tolerate initially at the goal rate, should be advanced within 24-48 hours
Standard initiation and advancement protocols for noncritically ill patients?
Start full strength at 50 ml/hr and advance by 15 ml q 4 hours to goal rate
Standard initiation and advancement protocols for critically ill patients?
Start at 10-40 ml/hr and advance by 10-20 ml q 8 or 12 hours. However, many critically ill patients can tolerate rapid advancement of EN to goal rate within 24-48 hours, which results in smaller energy and protein deficits
What are 2 EN volume-based protocols that have been shown to significantly improve nutrient delivery?
FEED ME (Feed Early Enteral Diet Adequately for Maximum Effect)
PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol)
When should EN initiation be delayed in the critically ill population?
When considered hemodynamically unstable (those with MAP <50 mmHg or starting vasopressor medication/require increasing doses to maintain BP). Rare complication of ischemic bowel
Factors that increase the risk for clogging a feeding tube?
Not flushing the tube with water, fiber-containing formulas, use of small-diameter tubes, use of silicone rather than polyurethane tubes, checking gastric residual volumes, and improper medication administration via the tube
2009 ASPEN EN practice guidelines for water flushes in feeding tubes?
Recommend flushing feeding tubes with at least 30 ml of water every 4 hours during continuous feeding or before and after intermittent or bolus feeding in adult patients. Should also be flushed with 30 ml of water after gastric residual checks.
What is the purpose of providing water flushes through feeding tubes?
Maintain tube patency, provided to meet hydration needs especially if patient is not receiving IV hydration of drinking fluids
Tips regarding the form of a medication when given through enteral feeding tube
Use liquid or suspension forms when possible (liquid meds may contain sorbitol or be hyperosmotic, which can lead to diarrhea; if diarrhea occurs, an alternate medication regimen may be needed)
If tablet form must be used, consult with pharmacist to ensure it can be safely crushed and dispersed in water prior to administration.
Enteric-coated, sublingual, or sustained release tablets generally should NOT be crushed
Confirm appropriate medication delivery route with pharmacist. Medications that depend on gastric acid for breakdown or absorption may need to be substituted or given by alternate method if feeding tube is in duodenum or jejunum
Tips regarding medication administration via the enteral feeding tube
Stop EN prior to the administration of meds; restart ASAP, only delay restarting EN when it is necessary to avoid altered drug bioavailability
Flush tube w/ at least 30 ml water before and after giving meds through tube
Give each med separately and flush tube w/ 5 ml warm water btwn meds
Do not mix meds or dosage forms, can affect drug stability and efficacy
If tube is smaller than 12 Fr, avoid using it to give crushed meds, if possible
Do not add meds to EN formula. This could increase incidence of tube occlusions, interfere with medication and nutrient bioavailability, affect GI function, and increase risk of microbial contamination
Which EN delivery system is least likely to contribute to infection through bacterial contamination?
Closed system. Involves less manipulation and human/environmental contact with the EN formula and feeding sets
How can contamination of an EN formula occur?
During preparation if additional modular components must be added to the formula
When feeding is transferred to the administration container
During assembly of the feeding system
During administration to the patient
Improper hand washing
Name some factors that can compromise the accuracy of gastric residual volume (GRV) checks
Feeding tube type, diameter, and position
Viscosity of the GRVs
Technique, including size of the syringe and time and effort spent
Position of the patient
What other methods, aside from checking GRVs, should be used to assess GI function
Passage of flatus
Stool frequency and consistency
Physical examination to assess bowel sounds and abdominal girth
Abdominal radiographs
Describe conditions in which patients are at a high risk for dehydration
Those with increased fluid losses, high GI volume output
Diarrhea, colostomies, ileostomies, fistulas
High fever, burns, extensive wounds
Highly osmolar enteral nutrition (osmotic diuresis related to an increased renal solute load)
Causes of hyperglycemia in hospitalized patients that aren’t related to diabetes
Multifactorial, including increased release of counterregulatory hormones that stimulate gluconeogenesis , proinflammatory cytokines that result in insulin resistance, provision of steroid and adrenergic medications, and excess dextrose administration via IV fluid solutions and medications.
Target blood sugar range per SCCM/ASPEN guidelines for hospitalized patients?
140-180 mg/dL
What are potential causes of slowed/delayed gastric emptying? (~13 total)
- diabetic gastropathy
- hypotension
- sepsis
- stress
- anesthesia and surgery
- infiltrative gastric neoplasms
- various autoimmune diseases
- surgical vagotomy
- pancreaticoduodenectomy
- opiate analgesic meds (morphine sulfate, codeine, fentanyl)
- anticholinergics (chlordiazepoxide hydrochloride and clidinium bromide)
- excessively rapid infusion of formula
- infusion of very cold solution or one containing a large amount of fat or fiber
What are appropriate interventions for delayed gastric emptying?
-reducing/discontinuing all narcotic meds
-switching to a low-fiber, low-fat, and/or isotonic formula
-administering the TF formula at room temp
-temporarily reducing the rate of infusion by 20 - 25 mL/hr
-changing the infusion method from bolus to continuous
AND/OR
-administering prokinetic agent (metoclopramide or erythromycin).
What if the patient has N/V as the TF rate is advancing to goal?
The rate or volume should be reduced to the greatest tolerated amount, with an attempt to increase the rate again after symptoms abate.
If this fails, small bowel access should be considered
(T/F) Elevated GRVs correlate with TF intolerance.
FALSE. They DO NOT
**What does SCCM/ASPEN recommend for GRVs in critically ill patients?
**SCCM/ASPEN does not recommend routine checks of GRVs in critically ill patients.
What should the clinician monitor, and potentially recommend for patients with nausea, but low GRVs?
Patient may benefit from antiemetic medications. Clinicians should monitor stool frequency.
What are potential causes of abdominal distention?
- GI ileus
- Obstruction
- Obstipation
- Ascites
- Diarrheal illness
- Excessively rapid formula administration or infusion of very cold formula
- Use of fiber-containing formulas
How is abdominal distention diagnosed?
By visual inspection and palpation, and patient reports.
Clinical evaluation remains the most practical means of assessment.
How is distention defined?
No objective definition, suggestion is “an increase in abdominal girth of more than 8 to 10 cm”
What is the appropriate screening method for ileus or obstruction?
Plain radiology; sometimes cross-sectional imaging (computed tomography) may be needed to confirm the dx.
If a patient has a feeding tube and distention is suspected and/or the location of the feeding tube, what method can be used?
A small amount of contrast material injected through the feeding tube, and the intestinal anatomy and motility is observed on a follow-up, single x-ray or under fluoroscopy.
If motility is poor and the bowel is markedly dilated, or the patient’s discomfort is too severe, the feedings may need to be discontinued.
Define maldigestion.
refers to impaired breakdown of nutrients into absorbable forms (ie: lactose intolerance); may result in significant malabsorption
What are the clinical manifestations of maldigestion?
- Bloating
- Abdominal distention
- Diarrhea
Define malabsorption
Defective mucosal uptake and transport of nutrients (fat, carbs, protein, vitamins, electrolytes, minerals, or water) from the small intestine.
What are the clinical manifestations of malabsorption?
- Unexplained weight loss
- Steatorrhea
- Diarrhea
- Signs of vitamin, mineral, or essential macronutrient deficiency (anemia, tetany, bone pain, bleeding, neuropathy, glossitis)
What are the methods used to screen for malabsorption?
(Listed in order of complexity)
- Gross and microscopic examination of the stool
- Qualitative determination of fat and protein content of a random stool collection
- Measurement of [serum carotene]
- Measurement of [serum citrulline]
- Measurement of d-xylose absorption
- Radiologic exam of intestinal transit time and motility
What methods can be used to diagnose malabsorption?
- Intake/output balance (stool collections for quantitative fecal fat assessment)
- Tests for maldigestion/malabsorption for specific nutrients, ie: lactose tolerance test; Schilling test to screen for abnormal absorption of vitamin B12, etc.
- Endoscopic small bowel biopsy, which is helpful in dx mucosal disorders (Celiac, tropical sprue, Whipple disease)
What are some diseases that cause maldigestion/malabsorption?
- Gluten-sensitive enteropathy
- Crohn’s disease
- Diverticular disease
- Radiation enteritis
- Enteric fistulas
- HIV
- Pancreatic insufficiency
- Short-gut syndrome
- SIBO (small intestinal bacterial overgrowth)
- ETC
(T/F) It is recommended to use predigested enteral formula when malabsorption is suspected.
INBETWEEN. It is common practice to use predigested enteral formulas; but only weak data supports their use to prevent intolerance.
Selected patients with severe malabsorption that is unresponsive to medical therapy or supplementation may require PN.
How is diarrhea defined?
“any abnormal volume or consistency of stool”
Greater than 500 mL stool output every 24 hours or more than 3 stools per day for at least 2 consecutive days.
How much sorbitol can cause diarrhea?
10 - 20 grams
**How should medications that contain sorbitol be administered?
Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome.
**Most drugs and electrolytes (ie: potassium), should be mixed with a minimum of 30 to 60 mL water per 10 mEq dose to avoid direct irritation of the gut.
If clinically significant diarrhea develops during EN, clinicians should consider what options? (5)
- Medical assessment to rule out infectious or inflammatory causes, fecal impaction, diarrheagenic meds, etc.
- Use of antidiarrheal agent
(T/F) SIBO is being increasingly seen in patients s/p Roux-en-Y gastric bypass surgery.
TRUE
(T/F) When EN fed patients develop diarrhea, abdominal upset or fever, the contamination of enteral formula and the enteral delivery system should be considered as a potential cause of the problem.
TRUE
How often should feeding bags be changed?
Every 24 hours.
Feeding bags do not need to be rinsed with water before additional formula is added, but formula should not be added until the previous formula has infused.
How often should ‘closed’ EN delivery system, such as spike sets, be change?
Every 24 hours to reduce the incidence of diarrhea
How should disconnections within the enteral delivery system be handled?
They should be minimized. When they are necessary, the distal end of the delivery system should be covered with a clean cap and long periods of formula stagnation should be avoided.
Define constipation.
Difficult to define given normal defecation patterns range from 4 stools/day to 1 stool every 4 to 5 days.
The best clinical definition is the accumulation of excess waste in the colon, often up to the transverse colon or even the cecum
What is the best method for diagnosis of constipation?
Plan abdominal x-ray, and can differentiate from SBO or ileus
What are the two main causes of constipation?
- Dehydration
- Inadequate or excessive dietary fiber intake
If a patient has constipation, but excessive fluid is a concerned, what you recommend?
Addition of a stool softener: docusate sodium or docusate calcium; Addition of a laxative or cleansing enema may be needed.
Note: Chronic use of stimulants (ie: senna) often results in tachyphylaxis (rapidly diminishing responsive to successive doses of a drug) and is not indicated.
If fiber is added to the enteral regimen, what equation should you use to calculate fluid needs.
1 mL/kcal/day; may help prevent solidification of waste in the colon and constipation.
Define impaction.
A firm collection of stool in the distant colon (sigmoid colon or rectum). Liquid stool will seep around an impaction, occasionally at high volume.
When should impaction be considered in patients? And which patients?
When stool volumes have been small and then become liquid. Specifically, in older adults and patients who are bedbound.
What is used to treat impaction?
Enemas, cartharics (sorbitol, lactulose), and even endoscopy in severe cases.
What is NOBN? Who is at higher risk?
Nonocclusive bowel necrosis
Neonates, critically-ill and immune-suppressed patients, and patients with a compromised gastric acid microbial barrier
What are underlying factors for NOBN?
- Use of jejunal feedings
- Hyperosmolar formulas
- Feeding in the presence of hypotension and disordered peristalsis
What are the clinical manifestations of NOBN? What is the treatment?
Abdominal distention, N/V
Precautionary measures are used, most importantly, delaying EN until the patient is fluid-resuscitated
How can aspiration be detected in patients?
By detecting either pepsin (major enzyme found in gastric fluid) OR yellow microscopic beads (added to the TF)
What is the most reliable method for detecting pulmonary aspiration of TF formula?
There is none. Radiographic findings are generally non-specific and insensitive.
(T/F) Glucose assay strips are available for routine clinical use to detect high glucose level in tracheal aspirates, to possibly detect that aspirates contain TF formula
FALSE; These assays are not available for routine use
(T/F) Elevated GRVs can predict vomiting or reflux.
TRUE; clinicians have used GRV to determine the risk for aspiration as well
(T/F) Other methods for detecting gastric emptying delays during EN include: scintigraphy, paracetamol absorption test, carbon-isotope breath test, refractometry, ultrasound, gastric impedance.
FALSE. These are all experimental or of unproven value; also time-consuming, difficult to perform at bedside and require standardization and validation in critically ill patients
What angle should the HOB be positioned at to decrease reflux and aspiration PNA?
30 - 45 degrees
If that is contraindicated, use the reverse Trendelenburg position
**What are the SCCM/ASPEN guidelines for GRVs in ICU patients?
**GRVs should not be used as part of the routine care to monitor ICU patients receiving EN.
**If ICUs still use GRVs, it is recommended that clinicians avoid holding EN for GRVs less than 500 mL, in the absence of other signs of feeding intolerance (quality of evidence: low).
*What are the guidelines for tube-fed patients for preventing TF intolerance?
- Assessed for signs of tube-feed intolerance (distention, fullness feeling, discomfort, N/V) Q 4 hours
- HOB elevation 30 - 45 degrees, or position in chair or reverse Trendelenburg position
- Good oral care BID (with chlorhexidine in critically ill patients)
- Continuous tube feeding schedules
- Use of minimal sedation techniques
- Appropriate and timely oropharyngeal suctioning (ie: prior to lowering the bed, deflating the cuff of endotracheal tubes or extubation)
- Tube placement should be checked by noting any change in the visible tube length or marking at stoma Q 4 hours
- Unless the patient is vomiting, GRVs up to 250 mL should be re-instilled to replace fluid, electrolytes and feeding formula.
- Prokinetic agents and small bowel feedings should be considered for patients determined to be at high aspiration risk
**What are the SCCM/ASPEN guidelines for EN in patients at risk for refeeding syndrome?
**Should provide only 25% of the energy goal on Day 1, with attention to the energy contribution from IV fluids, and then cautiously advanced toward the energy goal over the next 3 to 5 days, as dictated by clinical status and/or stable electrolyte levels.
Define dehydration.
An excessive fluid volume deficit, which may be accompanied by sodium imbalance.
What causes dehydration? What is it associated with?
Caused by insufficient fluid intake, and/or excessive fluid losses, such as from fever, D, V, significant blood volume loss, chronic illness (diabetes, kidney disease), overuse of diuretics, drainage tube or paracentesis losses, wound seepage, or high nasogastric, fistula or ostomy outputs.
Dehydration is associated with an increased risk of falls, pressure ulcers, constipation, UTIs, respiratory infections, and medication toxicities.
What are early signs of dehydration?
- Dry mouth and eyes
- Thirst
- Lightheadedness
- Headache
- Fatigue
- Loss of appetite
- Flushed skin
- Heat intolerance
- Dark urine with a strong odor
Tongue dryness can be a simple, quick, reliable, cost-effective way to identify dehydration in older adults
What are signs of progressive dehydration?
- Dysphagia
- Clumsiness
- Poor skin turgor (sternum: more than 2 seconds)
- Sunken eyes with dim vision
- Painful urination
- Muscle cramps
- Delirium
What laboratory values are seen in dehydrated patients?
Elevation in BUN, plasma osmolality, and hematocrit, whereas [sodium] can be elevated, low, or normal depending on the etiology of dehydration.
Usually the BUN rises out of proportion to the usual BUN-to-creatinine ratio of 20:1.
What is the minimum urine output required to remove waste?
30 mL/hr or about 700 mL/day
*An output of at least 1 mL/kg/h is useful as a guidelines for adequate urine output
When should fluid intakes be increased?
if a patient develops a fever, emesis, diarrhea, high fistula and ostomy outputs or hyperglycemia
For patients with fever, how much should their fluid intakes be increased?
Increase by 12% per degree Celsius above 37.8.
**What are EN practice recommendations from ASPEN, include what statements regarding enteral formulation selection? (3)
- *1. The accuracy of adult enteral formula labeling and product claims is dependent on formula vendors
- Nutrition support clinicians and consumers are responsible for determining the accuracy of information about adult enteral formulas.
- Interpret enteral formulations content/labeling and health claims with caution until such time as more specific regulations are in place.
EN formulas are not FDA-approved, so their claims are not regulated.
Explain carbohydrate composition for EN formulations, in general
40 - 70% of their energy as carbs; primary macronutrient
Polymeric formulas use mostly corn syrup solids as carb source
Hydrolyzed formulas use maltodextrin or hydrolyzed cornstarch as the carb. source
Most formulas do not contain lactose.
Explain fiber composition for EN formulations, in general
Guar gum and soy fiber are the common fiber sources
Soluble fiber may help control diarrhea due to its ability to increase sodium and water absorption via its fermentation byproducts, SCFAs
Insoluble fiber may help to decrease transit time by increasing fecal weight
**What are the ASPEN/SCCM recommendations related to use of fiber in EN formulations?
**They suggest that clinicians consider fiber-containing formulas if patients have persistent diarrhea.
Also, both insoluble and insoluble fiber be avoided if the patients are at a high risk for bowel ischemia and have severe dysmotility.
Why may the prebiotic fibers (in fiber-containing EN formulas) provide benefits to some patients?
Some EN formulas contain FOS (fructooligosaccharides), aka prebiotics that help promote growth of beneficial bacteria, in the distal bowel and are fermented to produce SCFAs
Explain fat composition for EN formulations, in general
Concentrated energy source, and provides essential FAs
Usually contain a mixture of LCTs and MCTs (MCTs do not provide EFAs and are also not stored, LCTs are also added)
Corn and soybean oil are the most common sources used; safflower, canola and fish oils are also used
What are structured lipids?
“are a chemical re-esterification of LCTs and MCTs on the same glycerol backbone, offering advantages of MCTs, while including enough LCTs to meet EFA needs”
Some EN formulas contain these lipids
Define hydolyzed protein
small peptides (more than 3 AA residues)
Define Semi-elemental or Elemental formulas
aka dipeptides, tri-peptides, and free AA
Any peptide greater than 3 AAs require further hydrolyzation prior to absorption
Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in what volumes/day?
1000 - 1500 mL/day
Supplementation should be considered for patients when the enteral formula does not meet their v/m needs
(T/F) Standard enteral formulas contain modest amounts of electrolytes, typically enough to meet daily needs in most patients when the formula is provided in adequate amounts to meet DRIs.
TRUE
How much (% range) do enteral formulas contain by volume?
70 - 85%
Most patients receiving EN require an additional source of water to meet their fluid needs (IVF, additional water flushes)
Define osmolality, when referring to EN formula.
“is the concentration of free particles, molecules, or ions in a given solution, and is expresed as milliosmoles per kg of water (mOsm/kg).”
Osmolality of EN formula ranges from: 280 - 875 mOsm/kg.
As the content of free particles, ions or molecules increases in the product, so does the osmolality.
For example, formulas containing sucrose have a higher osmolality than those with cornstarch or maltodextrin.
Formulas with single AAs or high amounts of di- or tri-peptides, also have higher osmolality than those with intact proteins.
Define hypertonic enteral formulations
Osmolality greater than 320 mOsm/kg.
Are frequently blamed for formula intolerance, like diarrhea, etc. Which can result when these formulas (especially ones with sucrose) are delivered directly to the SI, causing dumping syndrome. This problem is unlikely to occur when peptide or single AAs are provided in the same manner
*Other than simple sugar-related hyperosmolality, the osmolality of an enteral formula has little to do with formula tolerance.
What is EN formula tolerance or diarrhea, most often related to? (4)
- Severity of illness
- Co-morbid conditions
- Enteric pathogens
- Concomitant use of meds administered through the enteral access device
Describe diabetes-specific EN formulas.
Lower in carbs (33 - 40%), higher in monounsaturated fat and total fat (42 - 54%) and provide more fiber (14 - 16 g/L) than standard polymeric formulas.
Rationale: Fiber will slow gastric emptying, leading to better glycemic control
What does the ADA (American Diabetes Association) recommend for DM management?
“Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals”
“Ideal quantity of carbs intakes as well as insulin therapy should be individualized for each patients”
Note fiber is not usually appropriate to use in critically-ill patients
**What do North American nutrition support guidelines say for diabetic patients in the ICU?
**Does not recommend the use of diabetes-specific formulas based on the evidence available.
(T/F) Switching to a diabetes-specific EN formula is the first step in management of hyperglycemia?
FALSE: Blood glucose control should be optimized by appropriate energy provision and insulin therapy, usually insulin gtt in the ICU setting.
Providing SSI “as needed” is not effective in controlling BG within the recommended range of 140 - 180 mg/dL
**What does ESPEN/ASPEN recommend for elemental EN formula use with patients with GI issues?
**ESPEN does not recommend the routine use of elemental formulas with Crohn’s disease, ulcerative colitis, or short-bowel syndrome.
**ASPEN also recommends that routine elemental and disease-specific EN formulas be avoided in critically ill patients because no clear benefit to patient outcomes has been shown in the literature.
What does the research show for hepatic encephalopathy EN formulas?
No evidence that the use of high-BCAAs formulations alter patient outcomes compared to standard formulas.
Hepatic encephalopathy is a complication of liver failure and elevated blood ammonia, so the rationale is a formula with lower protein, increased amounts of BCAAs, and decreased amounts of AAAs were developed for this patient population.
BCAA supplementation has been associated with an increased risk of nausea and vomiting, as well
Define immune-modulating formulations (IMFs).
EN formulas that contain arginine, glutamine, omega-3 FAs, nucleotides, and antioxidants
These specific nutrients are thought to have potential to modulate the metabolic response to surgery/stress
Explain how/why the effects of arginine differs from surgical vs. non-surgical patients.
It relates to metabolism
Surgical: in patients undergoing surgery for head/neck cancers, arginine-containing formulas were associated with reduction in fistula and LOS
**What are SCCM/ASPEN guidelines for IMFs in critically ill patients?
- *1. Do not recommend the routine use of IMFs with severe sepsis.
2. Recommend IMF use be reserved for the postoperative patients in the surgical ICU.
Define respiratory quotient (RQ).
“a value that describes CO2 production in relation to oxygen consumption, varies for carbs (1.0), protein (0.8), and lipid (0.7)”
Research has showed that total energy provision or overfeeding was more important than composition of formula in respiratory status of vented patients.
Explain EN formulas specified for respiratory disease.
Energy dense, in order to accommodate for fluid restrictions and/or elevated energy requirements and altered respiratory function
Formulations are low in carb (27%), high in lipid (55%), with moderate amounts of protein
Ambulatory patients: formulas will have corn and safflower oils
ARDS/ALI patients: will contain fish oil and borage oil
*High doses of omega-6 FAs are not recommended because of their potential to exacerbate the inflammatory state already present.
What does the research show regarding critically ill patients with ARDS/ALI, receiving specialized EN formulas?
Inconsistent
**What does SCCM/ASPEN recommend for specialized formulas for ARDS/ALI?
**Does not recommend for ARDS/ALI
Also, does not recommend the use of high-fat, low-carb formulas containing high levels of omega-6 FAs
**What does SCCM/ASPEN recommend for EN formulas for patients (in ICU) with AKI?
**They recommend the use of standard, high-protein EN formulas for AKI.
Patients with hyperkalemia or hyperphosphatemia may require a renal-specific formula.
**What does SCCM/ASPEN recommend for EN formulas for patients with acute respiratory failure?
**They recommend the use of concentrated formulas, because of the presence of concomitant fluid overload, pulmonary edema, and renal failure. These formulas may also be used in other disease states and conditions, such as liver and heart failure, that result in fluid overload, hypervolemic hyponatremia, decreased urine output, early satiety, and elevated nutrition needs.
Define beta-hydroxy beta-methylbutyrate (HMB)? What does it do metabolically?
a metabolite of BCAA leucine; a dietary supplement that results in positive patient outcomes (THINK ENSURE).
HMB promotes anabolism by increasing protein synthesis and inhibiting the ubiquitin-proteasome pathway controlling protein degradation, so conserving and even promoting accretion of LBM.
It helps preserve LBM in patients w/ sarcopenia, cancer cachexia, and AIDS
Research is limiting to support routine use and effectiveness of these supplements in patients with wasting syndrome
Pharmacological dosing of what nutrients is linked to improved wound healing? (6)
- Glutamine
- Arginine
- Omega-3 FAs
- Zinc
- Selenium
- Vitamin A
- Vitamin C
**What are the SCCM/ASPEN recommendations for critically ill obese patients?
**They recommend these patients should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores
The energy goal should not exceed 65 - 70% of energy requirements as calculated.
**What are the equations for estimating energy needs in obese ICU patients, when IC is not available?
** For BMI 30 - 50: Use 11-14 kcal/kg ACTUAL weight
For BMI greater than 50: Use 22 - 25 kcal/kg IBW
**What is the protein recommendation for critically ill obese patients?
More than 2.0 g/kg/day protein is adequate to maintain nitrogen balance with hypocaloric feedings, preserve LBM, and allow for adequate wound healing
What is NPC:N?
Nonprotein calorie-to-nitrogen ratio
Most EN formulations have a high NPC:N; therefore, protein modulars are usually needed to meet the protein needs of the obese patient
Define modular products?
Typically, a single nutrient product and are available for use in addition to the selected enteral formulations.; protein powders are the most popular
Define PDCAAS.
Protein digestibility corrected amino acid score; it assesses the bioavailability of essential AAs as a protein module; used by manufacturers of modulars for product competition.
Why do you need to be cautious of liquid modulars?
They are often hyperosmolar and caution should be taken before administering into the feeding tube
Powder and liquid modulars can be mixed in with beverages and oral supplements. If patient is NPO w/ TF, modular should be flushed like a med down feeding tube, never mixed with EN formula
What are the considerations for healthcare facilities when developing an enteral formulary? (5)
- Patient acuity
- Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
- Formulation components that may be contraindicated
- Need for fluid restriction
- Need for added formulation components
Enteral formulary contracts should ALWAYS include a clause that allows the facility to purchase a noncompeting product if it better meets the nutrition needs of patients.
Always complete a cost-benefit analysis when developing a formulary to choose appropriate products and limit expenditure
What is the hang time for ‘open system’ EN?
8 to 12 hours
Any non-sterile formula, such as powder formula, that needs to be reconstituted with sterile water, should not hang FOR MORE THAN 4 HOURS. It can be mixed ahead and refrigerated for no more than 24 hours after preparation
What is the hang time for ‘ready-to-hang/closed system’ EN?
24 to 48 hours, depending on manufacturer instructions
Biggest drawback is high amount of waste, if switching formulas etc, and misconnection errors, now being solved by the ENfit connector
EN practice recommendations from ASPEN regarding enteral formula selection
The veracity (accuracy, credibility) of adult enteral formula labeling and product claims is dependent on vendors
Nutrition support clinicians and consumers are responsible for determining the veracity of information about adult enteral formulations
Interpret enteral formulation content/labeling and health claims with caution until such time as more specific regulations are in place
Define standard/polymeric enteral nutrition formula?
Formula containing macronutrients as nonhydrolyzed protein, fat, carbs
Define elemental and semi-elemental enteral nutrition formulas?
Contains partially or completely hydrolyzed nutrients (protein) and altered fats to maximize absorption
Define blenderized enteral nutrition formula?
Formulated with a mixture of blenderized whole foods, with or without the addition of standard formula; best suited for patients with a healed feeding site and for those who adhere to safe food practices and tube maintenance
Define disease-specific enteral nutrition formulas?
Targeted for organ dysfunction or specific metabolic conditions
Define a modular
Used for supplementation to create a formula or enhance nutrient content of a formula or diet
Name carbohydrate sources of polymeric enteral formulas?
Main: corn syrup solids
Other: hydrolyzed corn starch, maltodextrin, sucrose, fructose, sugar alcohols
Name carbohydrate sources of elemental formulas?
Cornstarch, hydrolyzed cornstarch, maltodextrin, fructose
Name fat sources of polymeric formulas?
Borage oil, canola oil, corn oil, fish oil, high-oleic sunflower oil, MCT, menhaden oil, mono- and diglycerides, palm kernel oil, safflower oil, soybean oil, soy lecithin
Name fat sources in elemental formulas?
Fatty acid esters, fish oil, MCT, safflower oil, sardine oil, soybean oil, soy lecithin, structured lipids
Why might palm kernel and coconut oil be added to an enteral formula?
As a source of MCTs
Describe some advantages of using MCTs in enteral formulations? Disadvantage?
Absorbed directly into the portal circulation and do not require chylomicron formation for absorption.
Do not require pancreatic enzymes or bile salts for digestion and absorption.
Cleared from the blood stream rapidly and cross the mitochondrial membrane without the need for carnitine, where they are oxidized to CO2 and water and therefore are not stored.
Disadvantage: MCTs do not provide EFAs, so most enteral formulations contain a mixture of LCTs and MCTs
What are structured lipids?
Chemical re-esterification of LCTs and MCTs on the same glycerol backbone. They offer advantages of MCTs while including enough LCTs to meet EFA needs
Describe the health benefits of omega-3 fatty acids?
Omega-3 fatty acid end products are metabolized to prostaglandins of the 3 series and leukotrienes of the 5 series, which are associated with anti-inflammatory effects, slowing of platelet aggregation, immune enhancement, and antiarrhythmic properties
What are the most commonly used sources of intact protein in enteral formulations?
Casein and soy protein
Elemental or semi-elemental enteral formulas contain protein in what forms?
Hydrolyzed protein, small peptides (more than 3 amino acid residues), dipeptides and tripeptides, and free amino acids
What populations are elemental and semi-elemental enteral formulas intended for?
GI dysfunction such as short bowel syndrome, malabsorption, or pancreatic exocrine insufficiency
Name common fiber sources in enteral formulas?
Guar gum and soy fiber
What is the purpose to soluble fiber in an enteral formula?
It is fermented by the gut microbiota in the distal intestine to produce short-chain fatty acids (SCFAs)- which are a source of energy for colonocytes and help increase intestinal mucosal growth and promote water and sodium absorption. May help control diarrhea due to its ability to increase sodium and water absorption. Some formulas supplemented with soluble fiber have been shown to reduce incidence of diarrhea
SCCM guidelines on fiber-containing enteral formulas?
Suggest that clinicians consider their use if patients have persistent diarrhea, and suggest both insoluble and soluble fiber be avoided if patients are at a high risk for bowel ischemia and have severe dysmotility
Describe the relationship of fiber-containing formulas with the frequency of bowel movements according to a systematic review
Fiber-containing formulas reduced bowel frequency when baseline bowel frequency was high and increased bowel frequency when baseline bowel frequency was low.
Benefits of fiber in an enteral formula?
May speed up transit time, increase fecal bulk, reduce constipation, and improve gut barrier function through the stimulation of colonic bacteria
True or false: Research suggests nitrogen absorption is greater with enteral formulations containing only free amino acids
False. Suggests absorption may be greater with peptide-based formulations
Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in volumes of ___ to ___ mL/day
1000-1500 mL/day
Define the osmolality of an enteral formula and typical ranges
The concentration of free particles, molecules, or ions in a given solution, expressed as milliosmoles per kilogram of water (mOsm/kg).
Ranges from 280-875 mOsm/kg
Does the osmolality increase or decrease as the content of free particles, ions, or molecules increases?
Increases
Describe some contents of formulas that would have a higher osmolality than others
Formulas with sucrose rather than cornstarch or maltodextrin have higher osmolality
Formulas with single amino acids or high amounts of di- and tripeptides rather than intact protein have higher osmolality
When is a formula considered hypertonic?
When the osmolality is >320 mOsm/kg
Under what circumstance would it be reasonable to relate a patient’s diarrhea to the osmolality of the enteral formula used?
When hyperosmolar formulas containing sucrose are delivered directly into the small intestine, dumping syndrome can occur. But this problem is unlikely to occur when peptide or single amino acids are provided in a similar manner
Describe considerations when evaluating research or specialized enteral formulas
In vitro (animal) versus in vivo (human) study
Quality of study design (prospective randomized controlled trial, retrospective review, case reports)
Similarity of patient population studied to patients being cared for (demographic factors, clinical status, clinical environment, etc)
Generalizability of results
Describe the general macronutrient distribution of diabetes-specific formulas and the reasoning?
Lower in carbs (33-40% of total energy)
Higher in monounsaturated fat and total fat (42-54% of total energy)
Provide more fiber (14-16 gm/L) than standard polymeric formulas
Rationale is that this mixture of low carb, high fat and fiber will slow gastric emptying and lead to better glycemia control
ADA macronutrient distribution recommendation for patients with diabetes?
There is not an ideal percentage of calories from carbs, protein, and fat for all patients with diabetes. Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. The ideal quantity of carb intake as well as insulin therapy should be individualized for each patient.
What is the best approach to enteral nutrition management in a post-op patient with T2DM?
Scenario: 56 y/o M PMH of T2DM and HTN admit to STICU s/p aortic valve replacement. Intubated and sedated post-op day 1 getting IV fluids @ 100 ml/hr using 5% dextrose with half-normal saline. 5’10” and 80 kg (5kg less than 2 months prior). All lab values insignificant except BG which were consistently >180 mg/dL. Treated with subcutaneous insulin q 4 hr following standard glucose monitoring schedule. Energy requirements estimated 2000 kcal/day, protein 96-120 gm/day (1.2-1.5 g/kg/day). EN started ICU day 1 using diabetes-specific formula at 30 ml/hr and insulin management unchanged. After initiation of EN, BG levels continued to be higher than 180 mg/dL
Diabetes- specific formula is not necessary in ICU patients with diabetes and hyperglycemia. Pt was experiencing hyperglycemia prior to initiation of EN due to T2DM, postsurgical stress, and IV fluids (were providing 400kcal from dextrose). Intervention: change to standard 1.0 kcal/ml polymeric formula, decrease IV fluids and change to 1/2 NS, start continuous IV insulin infusion
Name some prebiotics
Fructooligosaccharides (FOS) and inulin
ASPEN recommendation regarding routine use of elemental formulas in critical illness?
Recommend that routine use of elemental and disease-specific formulas be avoided in critically ill patients because no clear benefit has been shown in the literature.
Why have the branched chain amino acids (BCAAs) leucine, valine, and isoleucine been promoted for use in hepatic encephalopathy?
Because they clear ammonia in the skeletal muscles, decreasing cerebral ammonia levels and reducing the uptake of aromatic amino acids (AAAs) across the blood-brain barrier
Is protein restriction recommended in liver failure?
No; leads to a further decline in nutrition status and lean body mass and may result in higher ammonia levels
Define immune-modulating formulations (IMFs)
Enteral formulas that contain arginine, glutamine, omega-3 polyunsaturated fatty acids, nucleotides, and antioxidants. These specific nutrients are thought to have the potential to modulate the metabolic response to surgery or stress
SCCM/ASPEN guidelines regarding the use of IMFs in critical illness?
Guidelines do not recommend the routine use to IMFs with severe sepsis; IMF use should be reserved for the post-op patient in the surgical ICU
What is the respiratory quotient (RQ) for each macronutrient?
RQ is a value that describes CO2 production in relation to oxygen consumption
Carb: 1.0
Protein: 0.8
Lipid: 0.7
Describe the role of HMB (beta-hydroxy beta-methylbutyrate) in wasting conditions?
HMB is a metabolite of leucine. Promotes anabolism by increasing protein synthesis and inhibiting the ubiquitin-proteasome pathway controlling protein degradation, thereby conserving and even promoting accretion of LBM. Helps preserve LBM in patients with sarcopenia, cancer cachexia, and AIDS
Name nutrients beyond energy and protein that are linked with improving patient outcomes in regard to wounds
Glutamine, arginine, omega-3 fatty acids, zinc, selenium, and vitamins A, C, and E
SCCM/ASPEN guidelines regarding nutrient provision in critically ill obese population?
The critically ill obese patient should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores
How might weight loss positively influence outcomes in the critically ill obese patient?
Weight loss may increase insulin sensitivity, facilitate nursing care, and reduce the risk of comorbidities
Enteral formulas that provide 1 kcal/ml have a higher or lower NPC:N (nonprotein calorie-to-nitrogen) ratio?
Lower
What makes 1 kcal/ml enteral formulas a good choice for critically ill obese patients?
Lower NPC:N ration, less need for protein modular, additional fluid
What factors should be considered when developing an enteral formulary?
Patient acuity
Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
Formulation components that may be contraindicated
Need for fluid restriction
Need for added formulation components
How often should administration sets for open system enteral feedings be changed?
At least every 24 hours
Recommended hang time for powdered, reconstituted formula and EN formula with additives?
4 hours
Recommended hang time for closed-system EN formulas?
24-48 hours
Recommended hang time for sterile, decanted formula?
8 hours
What is the maximum hang time for closed-system enteral formulas
48 hours (or based on manufacturer’s guidelines)
A 74 year old male with history of Alzheimer’s dementia and dysphagia requires enteral nutrition as his sole source of nutrition. He presents to the hospital with a fever, hypotension, poor skin turgor an dry mucous membranes. He is 5 feet 9 inches tall and 67 kg. He is currently getting 1200mL of free water daily from the EN + 400 mL from free water flushes. His estimated calorie needs are 1800 kcals/day. How should his fluid needs be estimated?
30mL per kg of body weight as using mL /kcal is NOT appropriate and can lead to overhydration
what are three methods for estimating fluid needs in enterally fed patients
1mL per kcal of enteral feeding (<65 years old)
Weight based (25-35kcal/kg) for adults > 65 years old
Holliday-Segar Method (1500mL for the first 20 kg and 15mL/kg for each kg remaining over 20kg)
how is the Holliday-Segar Method calculated in adults
1500mL of fluid for the first 20 kg
add an additional 15ml/kg over 20 kg
weight based fluid calculations are not recommended for
patients with cardiac/kidney failure issues as can lead to fluid overload
A 56 year old female with dysphagia who is afebrile weighs 60kg, is on a standard 1kcal/mL enteral formula at 180mL/hr for 10 hours nightly. What volume of water flushes would best meet her daily estimated fluid requirements
1mL/kcal = 1800 mL of total water needed (same as 30mL x 60 kg of water = 1800mL)
Tube Feed Volume + 180mL/hr x 10 hours = 1800 mL, a 1mL/kcal formula contains 84% water, so 1800 x0.840 is approx 1500mL so 1800mL - 1500 mL from tube feed leaves over 300 mL of water for free water flushes
Adult, afebrile patients who are enterally fed can have their fluid needs calculated by
1mL or 30-40mL/kg
Standard enteral formulas that are 1mL/kcal contain ____% water
84%
what are the benefits of starting early, appropriate enteral feedings
decreased bacterial translocation in the gut
preserves gut mucosal lining to decrease infection risk
decreases atrophy of the intestinal villi
lack of feeding via the gut during critical illness may lead to ____ of the intestinal villi, predisposing a patient to _____, increased gut ___ and potentially increased ____ risk
atrophy
bacterial translocation of the gut
increased gut permeability
increased infection risk
A patient is receiving EN during her 2nd trimester of pregnancy. Nutrition assessment data reflects an average maternal weight gain of 0.42 pounds a week, normal fetal growth, an albumin of 0.2 g/dL and a nitrogen balance of +2 grams a day. based on the data provided, which parameters are useful in assessing efficacy of enteral nutrition in pregnancy. Which ones are not?
Good indicators: maternal weight gain, fetal growth
Poor indicators: albumin, protein
what are the most important factors in assessing adequacy and efficacy of enteral nutrition in pregnancy?
fetal growth & maternal weight gain
there is a strong correlation between infant birth weight and ______ weight
maternal
a positive nitrogen balance indicates adequate
protien provision
A diabetic patient with early satiety, bloating, occasional vomiting & extensive weight loss. After a thorough GI workup, the patient is diagnosed with gastroparesis. What type of EN formula is most efficacious?
concentrated (if sensitive to volume)
standard/polymeric (esp. if given jejunum)
low in fat and fiber to avoid delayed gastric emptying
elemental formulas are reserved for patients with
malabsorption and pancreatic insufficiency
high protein enteral formulas are reserved for patients with
wound healing and critical care nutrition
Lactose is a common ingredient in which type of EN formula?
standard infant formula as it mimics the carbohydrate content found in human milk
Most adult medical nutrition products are _____ free because many adults are lactose intolerant, and lactase efficacy is decreased during illness
lactose
Patients with chyle leaks will have trouble tolerating polymeric EN formulas becuase
they cannot absorb long chain fatty acids well
Elemental EN formulas contain individual _____ and 2-3% of calories from these types of fats ______
amino acids
long chain fatty acids
Patients with chyle leaks need to decrease the quantity and duration of chyle loss using ___ formulas and a ______ diet
elemental
low fat
patients with Chron’s or Celiac Disease usually do well with intact macronutrients true or false
true
patients with gastroparesis can usually tolerate polymeric enteral formulas especially wehn
they are provided in the jejunum
In patients with pancreatitis, which parameters are important in predicting tolerance of enteral feedings?
APACHE II Score
Duration of NPO
Abdominal pain
What is the most influential factor to determine tolerance of enteral nutrition in pancreatitis
disease severity as measured by APACHE II Score
A duration of NPO > _____ days has indicated poor tolerance to EN in studies for pancreatitis
6 days
Increased ______ is a clinical indication of enteral feeding intolerance in patients with pancreatitis
abdominal pain
what is the rationale for starting EN
it may be started in patients who cannot or will not eat adequately
Prior to starting EN, what should be considered
ethics patient & family wishes quality of life risks & benefits clinical status prognosis
EN should be started when patients are expected to or have not had adequate oral intake for ______ days
7-14 days
EN should not be initiated if the expected duration is less than ____ days in the malnourished patient or less than ____ days in an adequately nourished pateint
5-7 days (malnourished)
7-10 days (adequately nourished)
EN should only be started when the patient is
fully resuscitated or stable
What is the preferred method of nutrition for open abdomen
enteral
when should PN be started in open abdomen when
EN isn’t tolerated for greater than 7 days
PN is indicated in high output mid-jejunal fistula, intractable obstipation & vomiting and short bowel syndrome with < _______ cm and without a ______
<50 cm w/ out a colon
what are common indications to place a gastro-jejunostomy tube?
diabetic gastroparesis as it bypasses the stomach to prevent nausea, vomiting during feeding
Skin level or low profile enteral access devices have what desire features?
more comfortable
more cosmetically pleasing
can be capped when not in use
what are cons of low profile enteral access devices
they require an access connector to provide meds or feedings & requires manual dexterity
what is the gold standard for determining proper position of a feeding tube placed at the bedside?
radiographic confirmation
do auscultation, pH testing, aspiration still require cxr
yes
placement of a jejunostomy feeding tube would NOT be beneficial in _____ as it would increase stool output , decreased absorption
short bowel syndrome
what are uses for jejunostomy
gastroparesis, pancreaticduodenectomy (whipple), chronic pancreatitis
for patients with short bowel syndrome what type of enteral feeding is recommended
slow, continuous infusion in the stomach to maximize absorption and intestinal transit time
compared to gastric feeding, small bowel feeding is associated with which of the following outcomes in critically ill patients
increased nutrient delivery, reduced GRV and reflux, shorter time to get to target goal
what intervention may assist with the appropriate placement of a nasogastric feeding tube in an alert patient?
elevated the HOB
have the patient in a sitting position
take small sips of water
what is most likely to facilitate transpyloric placement of a nasoenteric feeding tube
fluoroscopy & endoscopy or bedside electromagnetic imaging system
what are contraindications for the placement of a PEG in a patient with liver disease
ascites (it may prevent the gastric and abdominal wall from being in close proximity so the trocar won’t be able to pass through the stomach wall with a poor seal possibly leading to peritonitis
what are POSSIBLE contraindications to PEG tube placement when risk vs. benefit should be evaluated
esophageal & gastric varices coagulopathy hepatic encephalopathy fulminant hepatic failure portal HTN
What is an advantage of a gastrostomy feeding tube compared to an NG tube
gastrostomy tubes can be used in long term needs
When EN is needed for over 4 weeks what type of feeding tube is preferred
gastrostomy
do gastrostomy tubes decrease the risk of aspiration
no, but the due have an increased risk of gastric perforation
Ascites is considered a relative contraindication to PEG tube as it increases the risk of
peritonitis
A patient with a traumatic brain injury will require enteral nutrition for three weeks. What is the preferred method of feeding tube placement
naso-enteric
what are the risks of an open feeding tube, laparoscopic feeding tube and endoscopic feeding tube placement
bleeding, anesthesia, bowel perforation , infection
What is the primary advantage of a direct percutaneous endoscopic transgastric placed jejunal (PEG-J) tube vs a a PEJ
the PEG-J has a decreased risk of migration into the stomach
placement of a percutaneous endoscopic _____ tube increases the risk of developing a gastric outlet obstruction
PEJ tube
What characteristic of EN formulas is MOST likely to increase splanchnic blood flow in a critically ill patient?
high fat enteral formulas
high fat enteral nutrition helps promote what in a critically ill patient
blood flow to the bowel is maxamized
what type of enteral nutrition formula is ideal for patients at high risk for intestinal ischemia, as adequate bowel perfusion is needed for tolerance of high fiber, high osmolarity
isotonic, fiber free
Hospital prepared enteral nutrition formulas should be stored at approximately what temperature
4 degrees C to 39 degrees F
what is considered the danger zone for food contamination
5-57 decrees C
A 60 year old female is admitted with a stroke and fails a swallowing evaluation. An NG tube is placed and the MD requests an isotonic formula. What calorie density of EN formulas is isotonic
1 kcal/mL which is about 300 mOsm/kg
what is the range of osmolarity for 1kcal/mL EN formulas
300-350 mOsm/kg
what is the range of osmolarity for 1.2 kcal/mL EN formulas
400-450 mOsm/kg
what is the range of osmolarity for 1.5 kcal/mL EN formulas
500-650 mOsm/kg
what is the range of osmolarity for 2 kcal/mL EN formulas
700-800 mOsm/kg
what is the best initial enteral feeding regimen for a critically ill adult
full strength started at a low rate and slowly advance to goal
why is it not encouraged to dilute enteral formulas
it can cause microbial growth and inadequate nutrition provision
What is the most important intervention to decrease the risk of pulmonary aspiration during gastric tube feedings
elevated the HOB 30-45 degrees
drugs that cause diarrhea are due to their
hypertonicity, laxative action from sorbitol or magnesium containing products
what are drugs/medications that are known to cause diarrhea
medications containing sorbitol, magnesium citrate, antibiotics that cause enteritis, high TF osmolarity/bolus (sometimes)
tube feeding is often held 2 hours before and after enteral administration of these types of meds
warfarin ciprofloxacin phenytoin carbamazepine fluoroquinolones
what strategies can be employed to reduce the risk of feeding tube occlusion
flush with water before and after each medication
drugs that are microencapsulated with beads or pellets are most effectively administrated through large bore feeding tubes when mixed with _______ due to the acidity to reduce the beads/pellets from sticking to the tube. The tube should also be flushed with water before and after the OJ and separately from the EN formula. Don’t use warm water.
orange juice
what type of enteral formulas are least likely to be contaminated with microorganisms
ready to hang
what is the hang time of formula made from reconstituted powder
4 hours
what is the hang time of home made blenderized enteral formulas
2 hours
what is the hang time of commercially made blenderiezed enteral formulas
4-8 hours
A 45 year old male is admitted with stage 4 pressure wounds, sepsis and acute respiratory failure who requires mechanical ventilation. BUN is stable, no additional excessive GI losses are noted. A polymeric high protein EN formula was started on day 1 of admit. On day 7, the primary care team requested an eval of the protein dose provided by EN. The EN formula gives 136 grams of protein (1.5g/kg/day). What is the best method to assess protein adequacy
nitrogen balance study
_____ is the gold standard for assessing the adequacy of protein intake in the acute hospital setting
nitrogen balance
Nitrogen balance is the difference of
nitrogen intake -nitrogen output
nitrogen output as part of a nitrogen balance study is measured from
urine urea nitrogen from a 24 hour urine collection
nitrogen intake as part of a nitrogen balance study is measured from
EN or PN intake
what are limitations to using a nitrogen balance study
renal dysfunction, errors estimating output and intake
Use of a semi-elemental or elemental formula in place of a polymeric formula should be considered with
intolerance to polymeric formula
Use of immune modulating formula may be beneficial in
elective surgery, TBI, abdominal and torso injury from a MVA crash
immune modulating formulas contain
arginine, glutamine, nucleotides, omega 3 fatty acids
the use of immune modulating formulas is not recommended for routine use
use is controversial, there are inconsistent outcomes and contraindicated in septic patients 2/2 adverse effects with arginine
what would be the most appropriate TF formula for a patient with extensive second degree burns
high protein
high protein EN formulas are needed in severe burns because
burns cause a breakdown of lean muscle for energy and loss from wounds
What are types of modular products for EN
MCT Oil
Glucose
Fiber
Protein
what are EN modulars used for
to fortify EN regimens or meals
EN modulars should not be added directly to
enteral formula
Early initiation of EN has been a suggested benefit LICU patients by reduction infectious complications, length of stay and possibly decreased mortality. Which group of patient’s might be at significant risk from early EN.
patients with increased vasopressor support which may increase the risk of intestinal ischemia from decreased blood perfusion
a patient with ARDS getting EN will benefit most from
avoidance of overfeeding
this disease is associated with inflammation causing alveolar damage and lung capillary endothelial injury
ARDS
Formulas with omega 3’s are thought to be used for ARDS because
the omega 3 fatty acids, arginine, and glutamine may down regulate the inflammatory response induced by ARDS
immune modulating formulas with omega 3 fatty acids are not recommended for routine use in ARDS because
research remains inconclusive
The use of EN formulas enriched with branched-chain amino acids may benefit with
refractory encephalopathy
Theory: liver failure is thought to increase the ratio of aromatic amino acids (AAA) to branched chain amino acids (BCAAs). BCAAs also decrease from muscle breakdown. Increased AAAs develop “fake neurotransmitters” causing encephalopathy. Only use formulas with increased BCAAs if a patient is still encephalopathic despite medicine
encephalopathy
unresponsive to standard medical therapy
EN may be contraindicated in early post transplant period with hematopoietic cell transplants because of
potential mucosal toxicities r/t conditioning regimen that causes to GI toxicities that cause, nausea, vomiting, delayed gastric emptying, diarrhea within the first 2-3 weeks of post stem cell transplant may provide EN
in patients with early post transplant period with hematopoietic cell transplants what form of artificial nutrition is recommended
there is insufficient data to establish the benefits of enteral nutrition over parenteral nutrition for hematopoietic cell transplants
which medication would be appropriate to crush and deliver via enteral nutrition tube
immediate release
____ medications should not be crushed to be put through a feeding tube as can cause medication toxicity
slow release typical abbreviations (XL, XR,SR,CD)
which describes an optimal method of preparing and administering meds via enteral tube
flush the tube with water before and after each medication
in patients with severe acute pancreatitis, EN has been documented to provide the following benefits over parenteral nutrition
EN will decrease infection rate, decrease length of stay and decrease mortality
In a pt with fat malabsorption of an enteral products containing which of the following concentrated source of energy
MCT’s; they are absorbed directly into the blood stream into the portal circulation by passing need for pancreatic enzymes, bile carnitine dependent transport into the mitochondria
