Chapter 13: Complications of EN Flashcards
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.