Chapter 12: Nutrition Support Flashcards
Prevalence of malnutrition in the oncology population has a wide range, ____ - _____%
30-85%
EN is most appropriate for those who are ___________ or unexpected to be able to ingest/absorb adequate nutrients for more than ____ - _____ days
7-14
T/F: According to ASPEN patients undergoing major cancer operations do not benefit from routine use of EN
True
Perioperative nutrition may be beneficial in those malnourished if administered _____ - ____ days preoperatively, but this must be weighed against potential risks of delayed surgical intervention
7-14
EN uses first-pass metabolism in the __________, which can promote more efficient nutrient utilization and reduces the risk of bacterial translocation when compared with PN
liver
T/F: GI obstructions, GI bleeds, bowel ischemia, and active peritonitis are contraindications for EN
True
The ligament of Trietz is the landmark area of separation between ____ & _______
Duodenum & jejunum
PEG-J - benefits and how do you feed into it?
Feed into the jejunum only, must use a continuous pump. The g tube is used to reduce stomach contents. This can decrease risk for aspiration of gastric contents.
Short-term enteral access (NG & NJ) are intended for how long?
~4-6 weeks
These 2 feeding tubes must be placed surgically
j tube (not PEJ) & low-profile button
Low profile button (MIC-KEY) feeding tubes are less obtrusive but require ___________ for administration
Extension sets
Standard formulas AKA _______________ formulas are appropriate for the majority of cancer patients
Polymeric
All tubes into the intestine decrease the risk for….
Aspiration of gastric contents
Most EN formulas provide _______ - ______% of the body’s required free water
70-85%
Provide a minimum flushes of ______ mL at least every _____ hours during continuous feeds for patency
30 mL q 4 hours
Blenderized tube feeding requirements:
-Hang time:
-Type of tube:
-Side of tube
-Method of administration
Hang time: 2 hours
Type of tube: G
Size of tube: at least 14 French
Method: must be able to tolerate bolus
4 primary methods of EN administration
- Bolus
- Intermittent (gravity)
- Cyclic
- Continuous
Semi-elemental formulas are AKA
Peptide-based
Standard EN formulas provide ~15-25% kcal from protein while renal formulas provide….
7-18% kcal from protein
Renal formulas are more concentrated (lower in water), and have reduced amounts of these 4 minerals
Sodium, potassium, phosphorus, calcium
Pulmonary formulas are lower in ______ but higher in _____
lower in CHO, higher in fat
moderate protein (16-18%)
Immune-modulating formulas are often higher in _______
Protein
The 2 most commonly use modular components are
Protein & fiber
Refeeding syndrome can occur when malnourished patients are initially fed full-energy feeds or high ______ diets
carbohydrate
Hallmark signs of refeeding
– _____ retention
- ______ dysfunction
- _______ failure
Fluid retention, cardiac dysfunction, respiratory failure
Taking NPO for > _____ days increases risk for refeeding
7
_____ is an important cofactor in CHO metabolism, thus supplementation of ______ mg for ____ - ____ days can help prevent refeeding syndrome
Thiamine
100
5-7 days
ASPEN recommends not routinely monitoring for residual volumes. Do not hold if GRV is < _____ mL in the absence of other symptoms
500 mL
Recommended initiation rate for bolus or intermittent feeds
60-120 mL
Initiation rate for cyclic or continuous feeds
10-40 mL/hour
Advancement schedule for bolus/intermittent feeds
Increase by 60-120 mL every 8-12 hours (or every 1-2 feeds)
Advancement schedule for cyclic/continuous feeds
Increase by 10-20 mL/hour every 8-12 hours or 4-24 hours (respectively)
If dehydrated, you may wish to switch to a less _____ formula
concentrated (thus higher in free water)
Hypernatremia is caused by one of 2 causes:
- Inadequate free water
- Excessive diuresis
SIADH causes low _______
2 ways to correct _________
Sodium
Restrict free water & diuresis`
Supplement w/ sodium if the cause of hyponatremia is ________
GI losses
Metabolic acidosis _______ concentration of potassium in the blood
increases
T/F: Insulin raises phosphorus & potassium in the blood
False, lowers and could cause hyponatremia/hypophosphatemia
Tumor lysis syndrome is characterized by (high/low) levels of potassium & phos
High
To prevent aspiration, the HOB should be
30-45 degrees
Small bore tubes may increase risk for clogs but decrease risk for
Aspiration
_______ agents are beneficial for aspiration, GERD, and nausea
Prokinetics
If bacterial contamination is the cause of diarrhea….
Educate on hang times, change tubing frequently, switch to a closed system
Is prune juice appropriate for constipation with EN?
Yes
Suspend EN for constipation when _______ is supected
Obstruction or illeus
Small diameters tubes are considered
8-10 French and increase risk for clogs
The most common G-tube complication is….
Peristomal infection (leakage is also common but underreported)
5 strategies for managing a clogged EAD
- Warm water instillation for up to 15 minutes
- Push pull method with syringe
- Pancrealipase + sodium bicarb mixture (baking soda)
- Commercial unclogging device (mechanical)
- Commercial unclogging solution (i.e TubeClear or Clog Zapper) - use under medical supervision
Hyperosmolar meds (>1000 mg/kg) through tube
dilute with 10-30 mL water to reduce GI effectd
Instead of cholestyramine through feeding tube for anti-diarrhea, use hydrolyzed _______ ____
Guar gum to thicken the stool)
These 2 anti-emetics can not be put through the feeding tube
Aprepitant and orally disintegrating Ondansetron
Put ondansetron in mouth to dissolve or use alternatives
These antibiotics cannot but put through feeding tube and there’s no alternatives
Fluoroquinololones (Cirpofloxacin, Levofloxacin)
This appetite stimulant cannot be put through the feeding tube
Dronabinol
This solid form of opiod cannot be put through feeding tube
Oxycodone (switch to liquid)
Should you put psyllium or methylcellulose through feeding tube?
NO nor should you put bisacodyl tables (consider suppository or liquid forms)
Avoid these tablet forms of PPIs through feeding tube
Pantoprazole & Rabeprazole (Lansoprazole & Esomperazole OK)
This H2 agaonist may bind to protein left in feeding tube and create clogs
Sucralfate
Those who would die from __________ before tumor progression could be considered for EN
Malnutriiton
Is central parenteral nutrition or peripheral parenteral nutrition preferred?
Central
Lower infectious rate, better for long term. Usually already have central access via port but would benefit from a separate line. PICC = peripherally inserted central catheter
5 Reasons for PN
- Illeus (possibly post-op)
- Malignant bowel obstruction
- High output distal GI fistula (>200 mL/day)
- Inability to tolerate EN for > 7-14 days
- Refractory diarrhea, large volume
_______ is the primary source of energy source with PN and a minimum of _________ g/day is needed to prevent ketosis
Dextrose
50 g
(but ideally no less than 100-150 g/day is recommended)
SMOFlipid was approved in 2016 as an alternative to soy-based only lipid emulsions. This contains
Soybean, MCT oil, Olive oil, Fish oil
Higher in vitamin e but not excessive
Omegaven was approved in 2018 and contains 100% ______ oil, which has shown to improve PN liver disease in the pediatric population
fish oil
ASPEN recommends providing at least ______% energy from linoleic acid & ______% energy from linolenic acid to prevent deficiency
1-2%
0.5%
PN products are often deficient in vitamin ________
D
_____ is not routinely added to PN d/t concern for adverse reactions and incompatibility issues
Iron, thus periodic iron infusions mahy be needed
It’s acceptable to mix some medications into PN including
Regular human insulin, famotidine, and heparin
2 in 1 vs 3 in 1 PN mixtures
2 in 1 is dextrose + AAs, then “piggyback” of fats
-lipids are less stable (12 hour hang time)
3 in 1 is “total nutrient mixture” (fat, cho, amino acids) - longer hang time but next to mix the lipids in right before
kcal/kg recommendation for PN with refeeding syndrome risk
15 kcal/kg (20-30 kcal/kg if stable)
To prevent hyperglycemia, EN should be provided with _____ - _____ g dextrose or ______ for those with already poor glycemic control
150-200
100
When PN has started, begin with 24 hour infusion. Then can consider a cyclic regimen of ______ - ____ hours/day
12-16
Long-term PN complications
Mirconutrient toxicities or deficiencies, organ dysfunction, metabolic bone disease
Short-term PN complications
uncontrolled BG, hypertriglyceridemia, fluid/electrolyte imbalances
(more common w/ PN than EN)
Once the patient is meeting ______% needs via enteral or oral route, the PN can be safely discontinued
60%
Daily monitors w/ new PN
weight, i/os, BMP + phos & mg, glucose (q6 hours until stable)
Weekly labs w/ new PN
CBC, LFTs
If unable to tolerate fats in PN, consider these alternative modes of administration
Topical & oral ingestion
Define Azotemia
Excessive BUN & protein components in blood
(may be d/t dehydration or excess amino acids)
Soy-based fat emulsions may cause liver disease & ________
Immunosuppression (increased infectious risk)
*avoid lipids with critically ill during week 1
If experiencing hyperglycemia, limit CHO to ____-_____ mg/body wt or ___ - _____ kcal/kg
4-5 mg/kg
20-25 kcal/kg
Hypertrigylceridemia w/ PN may be d/t ________ or ________
excess dextrose OR rapid infusion of lipids
Rise of these enzymes within the first 2 weeks of PN is normal and should be monitored
Liver (ALT & AST)
minimum requirement for lipids
250 ml of 20% IVFE twice per week
