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CNSC Exam 2021 > Chapter 11: EN Formulations > Flashcards

Chapter 11: EN Formulations Flashcards

1
Q

**What are EN practice recommendations from ASPEN, include what statements regarding enteral formulation selection? (3)

A
  • *1. The accuracy of adult enteral formula labeling and product claims is dependent on formula vendors
    1. Nutrition support clinicians and consumers are responsible for determining the accuracy of information about adult enteral formulas.
    2. 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.

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2
Q

Explain carbohydrate composition for EN formulations, in general

A

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.

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3
Q

Explain fiber composition for EN formulations, in general

A

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

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4
Q

**What are the ASPEN/SCCM recommendations related to use of fiber in EN formulations?

A

**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.

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5
Q

Why may the prebiotic fibers (in fiber-containing EN formulas) provide benefits to some patients?

A

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

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6
Q

Explain fat composition for EN formulations, in general

A

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

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7
Q

What are structured lipids?

A

“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

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8
Q

Define hydolyzed protein

A

small peptides (more than 3 AA residues)

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9
Q

Define Semi-elemental or Elemental formulas

A

aka dipeptides, tri-peptides, and free AA

Any peptide greater than 3 AAs require further hydrolyzation prior to absorption

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10
Q

Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in what volumes/day?

A

1000 - 1500 mL/day

Supplementation should be considered for patients when the enteral formula does not meet their v/m needs

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11
Q

(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.

A

TRUE

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12
Q

How much (% range) do enteral formulas contain by volume?

A

70 - 85%

Most patients receiving EN require an additional source of water to meet their fluid needs (IVF, additional water flushes)

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13
Q

Define osmolality, when referring to EN formula.

A

“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.

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14
Q

Define hypertonic enteral formulations

A

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.

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15
Q

What is EN formula tolerance or diarrhea, most often related to? (4)

A
  • Severity of illness
  • Co-morbid conditions
  • Enteric pathogens
  • Concomitant use of meds administered through the enteral access device
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16
Q

Describe diabetes-specific EN formulas.

A

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

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17
Q

What does the ADA (American Diabetes Association) recommend for DM management?

A

“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

18
Q

**What do North American nutrition support guidelines say for diabetic patients in the ICU?

A

**Does not recommend the use of diabetes-specific formulas based on the evidence available.

19
Q

(T/F) Switching to a diabetes-specific EN formula is the first step in management of hyperglycemia?

A

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

20
Q

**What does ESPEN/ASPEN recommend for elemental EN formula use with patients with GI issues?

A

**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.

21
Q

What does the research show for hepatic encephalopathy EN formulas?

A

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

22
Q

Define immune-modulating formulations (IMFs).

A

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

23
Q

Explain how/why the effects of arginine differs from surgical vs. non-surgical patients.

A

It relates to metabolism

Surgical: in patients undergoing surgery for head/neck cancers, arginine-containing formulas were associated with reduction in fistula and LOS

24
Q

**What are SCCM/ASPEN guidelines for IMFs in critically ill patients?

A
  • *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.
25
Q

Define respiratory quotient (RQ).

A

“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.

26
Q

Explain EN formulas specified for respiratory disease.

A

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.

27
Q

What does the research show regarding critically ill patients with ARDS/ALI, receiving specialized EN formulas?

A

Inconsistent

28
Q

**What does SCCM/ASPEN recommend for specialized formulas for ARDS/ALI?

A

**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

29
Q

**What does SCCM/ASPEN recommend for EN formulas for patients (in ICU) with AKI?

A

**They recommend the use of standard, high-protein EN formulas for AKI.

Patients with hyperkalemia or hyperphosphatemia may require a renal-specific formula.

30
Q

**What does SCCM/ASPEN recommend for EN formulas for patients with acute respiratory failure?

A

**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.

31
Q

Define beta-hydroxy beta-methylbutyrate (HMB)? What does it do metabolically?

A

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

32
Q

Pharmacological dosing of what nutrients is linked to improved wound healing? (6)

A
  • Glutamine
  • Arginine
  • Omega-3 FAs
  • Zinc
  • Selenium
  • Vitamin A
  • Vitamin C
33
Q

**What are the SCCM/ASPEN recommendations for critically ill obese patients?

A

**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.

34
Q

**What are the equations for estimating energy needs in obese ICU patients, when IC is not available?

A

** For BMI 30 - 50: Use 11-14 kcal/kg ACTUAL weight

For BMI greater than 50: Use 22 - 25 kcal/kg IBW

35
Q

**What is the protein recommendation for critically ill obese patients?

A

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

36
Q

What is NPC:N?

A

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

37
Q

Define modular products?

A

Typically, a single nutrient product and are available for use in addition to the selected enteral formulations.; protein powders are the most popular

38
Q

Define PDCAAS.

A

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.

39
Q

Why do you need to be cautious of liquid modulars?

A

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

40
Q

What are the considerations for healthcare facilities when developing an enteral formulary? (5)

A
  1. Patient acuity
  2. Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
  3. Formulation components that may be contraindicated
  4. Need for fluid restriction
  5. 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

41
Q

What is the hang time for ‘open system’ EN?

A

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

42
Q

What is the hang time for ‘ready-to-hang/closed system’ EN?

A

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

CNSC Exam 2021 (50 decks)

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