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CNSC Exam 2021 > Chapter 13: Complications of EN > Flashcards

Chapter 13: Complications of EN Flashcards

1
Q

What are potential causes of slowed/delayed gastric emptying? (~13 total)

A
  • 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
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2
Q

What are appropriate interventions for delayed gastric emptying?

A

-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).

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3
Q

What if the patient has N/V as the TF rate is advancing to goal?

A

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

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4
Q

(T/F) Elevated GRVs correlate with TF intolerance.

A

FALSE. They DO NOT

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5
Q

**What does SCCM/ASPEN recommend for GRVs in critically ill patients?

A

**SCCM/ASPEN does not recommend routine checks of GRVs in critically ill patients.

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6
Q

What should the clinician monitor, and potentially recommend for patients with nausea, but low GRVs?

A

Patient may benefit from antiemetic medications. Clinicians should monitor stool frequency.

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7
Q

What are potential causes of abdominal distention?

A
  • GI ileus
  • Obstruction
  • Obstipation
  • Ascites
  • Diarrheal illness
  • Excessively rapid formula administration or infusion of very cold formula
  • Use of fiber-containing formulas
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8
Q

How is abdominal distention diagnosed?

A

By visual inspection and palpation, and patient reports.

Clinical evaluation remains the most practical means of assessment.

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9
Q

How is distention defined?

A

No objective definition, suggestion is “an increase in abdominal girth of more than 8 to 10 cm”

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10
Q

What is the appropriate screening method for ileus or obstruction?

A

Plain radiology; sometimes cross-sectional imaging (computed tomography) may be needed to confirm the dx.

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11
Q

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

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.

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12
Q

Define maldigestion.

A

refers to impaired breakdown of nutrients into absorbable forms (ie: lactose intolerance); may result in significant malabsorption

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13
Q

What are the clinical manifestations of maldigestion?

A
  • Bloating
  • Abdominal distention
  • Diarrhea
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14
Q

Define malabsorption

A

Defective mucosal uptake and transport of nutrients (fat, carbs, protein, vitamins, electrolytes, minerals, or water) from the small intestine.

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15
Q

What are the clinical manifestations of malabsorption?

A
  • Unexplained weight loss
  • Steatorrhea
  • Diarrhea
  • Signs of vitamin, mineral, or essential macronutrient deficiency (anemia, tetany, bone pain, bleeding, neuropathy, glossitis)
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16
Q

What are the methods used to screen for malabsorption?

A

(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
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17
Q

What methods can be used to diagnose malabsorption?

A
  • 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)
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18
Q

What are some diseases that cause maldigestion/malabsorption?

A
  • Gluten-sensitive enteropathy
  • Crohn’s disease
  • Diverticular disease
  • Radiation enteritis
  • Enteric fistulas
  • HIV
  • Pancreatic insufficiency
  • Short-gut syndrome
  • SIBO (small intestinal bacterial overgrowth)
  • ETC
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19
Q

(T/F) It is recommended to use predigested enteral formula when malabsorption is suspected.

A

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.

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20
Q

How is diarrhea defined?

A

“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.

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21
Q

How much sorbitol can cause diarrhea?

A

10 - 20 grams

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22
Q

**How should medications that contain sorbitol be administered?

A

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.

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23
Q

If clinically significant diarrhea develops during EN, clinicians should consider what options? (5)

A
  • Medical assessment to rule out infectious or inflammatory causes, fecal impaction, diarrheagenic meds, etc.
  • Use of antidiarrheal agent
24
Q

(T/F) SIBO is being increasingly seen in patients s/p Roux-en-Y gastric bypass surgery.

A

TRUE

25
Q

(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.

A

TRUE

26
Q

How often should feeding bags be changed?

A

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.

27
Q

How often should ‘closed’ EN delivery system, such as spike sets, be change?

A

Every 24 hours to reduce the incidence of diarrhea

28
Q

How should disconnections within the enteral delivery system be handled?

A

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.

29
Q

Define constipation.

A

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

30
Q

What is the best method for diagnosis of constipation?

A

Plan abdominal x-ray, and can differentiate from SBO or ileus

31
Q

What are the two main causes of constipation?

A
  • Dehydration

- Inadequate or excessive dietary fiber intake

32
Q

If a patient has constipation, but excessive fluid is a concerned, what you recommend?

A

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.

33
Q

If fiber is added to the enteral regimen, what equation should you use to calculate fluid needs.

A

1 mL/kcal/day; may help prevent solidification of waste in the colon and constipation.

34
Q

Define impaction.

A

A firm collection of stool in the distant colon (sigmoid colon or rectum). Liquid stool will seep around an impaction, occasionally at high volume.

35
Q

When should impaction be considered in patients? And which patients?

A

When stool volumes have been small and then become liquid. Specifically, in older adults and patients who are bedbound.

36
Q

What is used to treat impaction?

A

Enemas, cartharics (sorbitol, lactulose), and even endoscopy in severe cases.

37
Q

What is NOBN? Who is at higher risk?

A

Nonocclusive bowel necrosis

Neonates, critically-ill and immune-suppressed patients, and patients with a compromised gastric acid microbial barrier

38
Q

What are underlying factors for NOBN?

A
  • Use of jejunal feedings
  • Hyperosmolar formulas
  • Feeding in the presence of hypotension and disordered peristalsis
39
Q

What are the clinical manifestations of NOBN? What is the treatment?

A

Abdominal distention, N/V

Precautionary measures are used, most importantly, delaying EN until the patient is fluid-resuscitated

40
Q

How can aspiration be detected in patients?

A

By detecting either pepsin (major enzyme found in gastric fluid) OR yellow microscopic beads (added to the TF)

41
Q

What is the most reliable method for detecting pulmonary aspiration of TF formula?

A

There is none. Radiographic findings are generally non-specific and insensitive.

42
Q

(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

A

FALSE; These assays are not available for routine use

43
Q

(T/F) Elevated GRVs can predict vomiting or reflux.

A

TRUE; clinicians have used GRV to determine the risk for aspiration as well

44
Q

(T/F) Other methods for detecting gastric emptying delays during EN include: scintigraphy, paracetamol absorption test, carbon-isotope breath test, refractometry, ultrasound, gastric impedance.

A

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

45
Q

What angle should the HOB be positioned at to decrease reflux and aspiration PNA?

A

30 - 45 degrees

If that is contraindicated, use the reverse Trendelenburg position

46
Q

**What are the SCCM/ASPEN guidelines for GRVs in ICU patients?

A

**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).

47
Q

*What are the guidelines for tube-fed patients for preventing TF intolerance?

A
  • 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
48
Q

**What are the SCCM/ASPEN guidelines for EN in patients at risk for refeeding syndrome?

A

**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.

49
Q

Define dehydration.

A

An excessive fluid volume deficit, which may be accompanied by sodium imbalance.

50
Q

What causes dehydration? What is it associated with?

A

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.

51
Q

What are early signs of dehydration?

A
  • 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

52
Q

What are signs of progressive dehydration?

A
  • Dysphagia
  • Clumsiness
  • Poor skin turgor (sternum: more than 2 seconds)
  • Sunken eyes with dim vision
  • Painful urination
  • Muscle cramps
  • Delirium
53
Q

What laboratory values are seen in dehydrated patients?

A

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.

54
Q

What is the minimum urine output required to remove waste?

A

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

55
Q

When should fluid intakes be increased?

A

if a patient develops a fever, emesis, diarrhea, high fistula and ostomy outputs or hyperglycemia

56
Q

For patients with fever, how much should their fluid intakes be increased?

A

Increase by 12% per degree Celsius above 37.8.

CNSC Exam 2021 (50 decks)

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