Complications of Enteral Nutrition Flashcards

1
Q

Vomiting, especially in minimally responsive patients, is believed to increase the risk of:

A

Pulmonary aspiration, pneumonia, and sepsis

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2
Q

What is the most commonly identified problem for nausea and vomiting with EN?

A

Delayed gastric emptying

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3
Q

Name potential causes of slowed gastric emptying:

A

Diabetic gastropathy
Hypotension
Sepsis
Stress
Anesthesia and surgery
Infiltrative gastric neoplasms
Various autoimmune diseases
Surgical vagotomy
Pancreaticoduodenectomy
Opiate analgesic medications (morphine sulfate, codeine, fentanyl)
Anticholinergics (chlordiazepoxide hydrochloride and clidinium bromide)
Excessively rapid infusion of formula
Infusion of a very cold solution or one containing a large amount of fat or fiber

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4
Q

What interventions are recommended if delayed gastric emptying is suspected?

A

Reducing or discontinuing all narcotic medications
Switching to a low-fiber, low-fat, and/or isotonic formula
Administering the feeding solution at room temperature
Temporarily reducing the rate of infusion by 20-25 ml/hr
Changing the infusion method from bolus to continuous
Administering a prokinetic agent such as metoclopramide or erythromycin

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5
Q

What is the next step to alleviate complications of slow gastric emptying if all efforts to increase EN to goal rate have failed?

A

Small bowel access (nasojejunal tube or transgastric jejunostomy tube) should be considered

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6
Q

Nausea with EN not related to slow gastric emptying may be related to:

A

Low stool frequency. Obstipation or fecal impaction may lead to distention and nausea, particularly in institutionalized patients or those with critical illness

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7
Q

Name some causes of abdominal distention?

A

GI ileus
Obstruction
Obstipation
Ascites
Diarrheal illness
Excessively rapid formula administration or very cold formula
Use of fiber-containing formulas (fiber ferments and produces gas in the gut vs fiber’s role in slowing gastric emptying)

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8
Q

What is a simple method in patients with feeding tubes to assess abdominal distention?

A

Inject a small amount of contrast material through the feeding tube and observe intestinal anatomy and motility on a follow-up, single x-ray or under fluoroscopy. May be used when position of feeding tube is in question.

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9
Q

Define maldigestion and its clinical manifestations

A

Impaired breakdown of nutrients into absorbable forms. Manifestations include bloating, abdominal distention, diarrhea

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10
Q

Define malabsorption and its clinical manifestations

A

Resulting from maldigestion. A defective mucosal uptake and transport of nutrients (fat, carbs, protein, vitamins, electrolytes, minerals, or water) from the small intestine. Manifestations include unexplained weight loss; steatorrhea; diarrhea; and signs of vitamin, mineral, or essential macronutrient deficiency, such as anemia, tetany, bone pain, pathologic fractures, bleeding, dermatitis, neuropathy, and glossitis

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11
Q

List methods used to screen for malabsorption (in order of complexity)

A

Gross and microscopic examination of the stool
Qualitative determination of fat and protein content of a random stool collection
Measurement of serum carotene concentration
Measurement of serum citrulline levels
Measurement of d-oxylose absorption
Radiological examination of intestinal transit time and motility

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12
Q

When laboratory data, history, and/or radiologic examination suggest maldigestion or malabsorption, diagnosis can involve the following:

A

Intake-output balance (stool collections for quantitative fecal fat assessment)
Tests for malabsorption/maldigestion of specific nutrients (lactose tolerance, Schilling test for vitamin B12, EFA profile for lipid malabsorption, and various radioisotopic tests to identify iron, calcium, amino acid, folic acid, pyridoxine, and vitamin D malabsorption)
Endoscopic small bowel biopsy (helpful in diagnosing mucosal disorders such as celiac, tropical sprue, and Whipple disease)

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13
Q

Name causes of maldigestion/malabsorption

A

Gluten-sensitive enteropathy
Crohn’s disease
Diverticular disease
Radiation enteritis
Enteric fistulas
HIV
Pancreatic insufficiency
Short-gut syndrome
Small intestinal bacterial overgrowth (SIBO)
Numerous other syndromes

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14
Q

What is the most commonly reported side effect in patients receiving EN?

A

Diarrhea

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15
Q

How can stool volume be measured?

A

Placing a collection device in the toilet or by using a bedpan. In incontinent patients, it can be measured via fecal management system or by placing a pad under the patient and weighing it after each stool (1gm = 1 ml stool)

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16
Q

What are common causes of diarrhea in patients receiving EN?

A

Primary GI disease
Medications
Bacterial infection

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17
Q

What amount of sorbitol in medications can start to cause GI symptoms?

A

10-20 gm

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18
Q

List medications containing sorbitol (higher to lower amount)

A

Hydroxyzine
Amantadine/Symmetrel
Doxycycline
Isoniazid
Nortriptyline
Pseudoephedrine and tripolidine
Cimetidine
Metoclopramide
Acetaminophen elixir
Furosemide
Guaifenesin and codeine/Robitussin
Indomethacin

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19
Q

List medications with increased incidence of diarrhea

A

Ampicillin
Bisacodyl
Caffeine
Clindamycin
Colchicine
Digoxin
Erythromycin
Hydralazine
Lactulose
Magnesium-containing preparations
Metoclopramide
Methotrexate
Neomycin
Penicillamine
Procainamide
Quinidine
Theophylline

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20
Q

Types of drugs with direct effects on the gut that can also cause diarrhea?

A

Proton pump inhibitors
Prokinetic medications

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21
Q

What property of some medications may make diarrhea inevitible?

A

The osmotic load (hypertonicity)

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22
Q

What should be done for any drug in a liquid vehicle given via small bowel tube?

A

Should be diluted to avoid a hypertonic-induced, dumping-like syndrome. Most drugs and electrolytes (eg potassium) should be mixed with a minimum of 30-60 ml water per 10 mEq dose to avoid direct irritation of the gut

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23
Q

Name conditions associated with secretory diarrhea

A

Infection with enterotoxic organisms (C diff)
Abuse of stimulant laxatives
Intestinal resection
Inflammatory bowel disease
Bile acid malabsorption
Fatty acid malabsorption
Chronic infections
Celiac sprue
Small intestinal lymphoma
Villous adenoma of the rectum
Zollinger-Ellison syndrome
Collagen vascular diseases
Congenital defects
Malignant carcinoid syndrome

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24
Q

What should and shouldn’t a clinician do if it is suspected that the hyperosmolality of an enteral formula is causing diarrhea?

A

Could change to an isotonic formula
Not recommended to dilute the formula with water as it may result in suboptimal nutrient provision, has not been shown to improve tolerance, and contaminated formula

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25
True or false: Hyperosmolar EN products usually cause clinically significant diarrhea
False. Rarely cause diarrhea unless they are infused at a very high rate or administered by bolus into the small bowel
26
What is the highest osmolality of a tube feed? Compare to the osmolality of electrolyte supplements
Highest osmolality is around 750 mOsm/L (2.5x greater than NS) Electrolyte supplements have osmolalities in the range of 5000-7000 mOsm/L so they are far more likely to cause osmotic diarrhea
27
If clinically significant diarrhea develops during EN, clinicians should consider the following options
Rule out infectious or inflammatory causes, fecal impaction, diarrheagenic medications, etc Use of an antidiarrheal agent (loperamide, diphenoxylate, paregoric, octreotide) once C diff has been ruled out or is being treated Changing formula type (intact protein to peptide-based) Addition of soluble fiber or insoluble fiber to the medication regimen and/or changing to an EN formula with added fiber, except in unstable critically ill patients Continuation of EN as tolerated and initiation of PN to complete delivery of macro- and micronutrients if tolerance or malabsorption is severe and prolonged
28
In a randomized pilot trial comparing a peptide-based formula with polymeric formula in critically ill patients, the number of days of adverse GI events was significant reduced with which formula?
Peptide-based
29
How does a nutrition support clinician select an enteral formula for a tube-fed patient who experiences diarrhea? Scenario: 78 y/o M initiated on NG feeding of isotonic, fiber-free formula following surgical intervention for perforated duodenal ulcer for which pt was receiving PPI. Post-op course complicated by hospital-acquired pneumonia requiring ventilator support and use of antibiotic. EN initiated and advanced over 72 hours. Initially exhibited good tolerance with EN with slightly distended abdomen, hypoactive bowel sounds, 1-2 semiloose stools per day. After day 5, develops 4-5 watery stools per day and a fecal management system was required
Assess medications for any hypertonic or sorbitol-based, evaluate whether prokinetic agent in use. Obtain stool culture to r/o C diff. Could add fiber to EN regimen by using a fiber modular supplement or changing to a fiber-containing enteral formula (fiber containing formula is preferred bc fiber modulars can clog tubes). If C diff results are negative and any offending medications cannot be stopped, initiation of antidiarrheal is appropriate. Changing to peptide-based formula may be an option if other interventions are ineffective (these formulas can be more costly though) The addition of fiber to the EN regimen or changing the formulation should never be the primary intervention or the end of the evaluation or intervention for diarrhea
30
Volume definition for diarrhea?
>500 ml stool output every 24 hours or more than 3 stools per day for at least 2 consecutive days
31
What intervention is recommended in EN patient with diarrhea and distended, tympanic, or painful abdomen?
Discontinue EN. MD to review
32
What intervention is recommended in EN patient with diarrhea and medical/surgical history consistent with diarrhea (IBD, terminal ileal resection, chemo, short bowel, pancreatic insufficiency)?
Medical intervention as indicated
33
What intervention is recommended in EN patient with diarrhea and risk of stool impaction (chronic constipation, absent BM x5 days, regular narcotic use, limited fluid intake)?
Rectal check; manual disimpaction if positive. Obtain abdominal x-ray to rule out more proximal impaction as indicated
34
What intervention is recommended in EN patient with diarrhea receiving cathartic agents (Citromag, milk of magnesia, cascara, enema, PEG, hypertonic or sorbitol-containing liquid medications, oral electrolyte solutions, lactulose, kayexalate)?
Change all oral liquid medications to tablet or parenteral alternative; change oral electrolyte solutions to parenteral route; discontinue all known cathartics if possible. Pharmacist to review to rule out other potential drug-related cause of diarrhea
35
What intervention is recommended in EN patient with diarrhea that does not have distended, tympanic, or painful abdomen; medical/surgical history is not consistent with diarrhea; no risk of stool impaction; not receiving cathartic agents?
Rule out C diff associated diarrhea, bowel ischemia, other. If all investigations negative, consider adding fiber-containing formula
36
What intervention is recommended in EN patient with diarrhea for which all investigative efforts are negative and/or fiber is added to regimen and diarrhea does not resolve?
Initiate antidiarrheal agent and reassess need/dose daily
37
Bacterial overgrowth in the GI tract can cause:
Severe enteritis with marked diarrhea Abdominal cramps and pain Hypoalbuminemia Protein catabolism Cachexia Fever Sepsis
38
SIBO is increasingly being seen in which patient population?
After Roux-en-Y gastric bypass surgery
39
When should the enteral delivery system be considered a potential cause of the problem?
Whenever enterally fed patients have diarrhea, abdominal upset, or fever
40
What populations are at a greater risk for morbidity and mortality related to EN formula contamination?
Neonates Critically ill Immune-suppressed patients Those with compromised gastric acid microbial barrier
41
What symptoms can contamination of enteral formula lead to?
Diarrhea Abdominal distention Pneumonia Infectious enterocolitis Bacteremia Septicemia Death
42
What is the hang-time for formulas poured into feeding bags directly from cans, screw-top plastic bottles, and tetrapacks?
4-12 hours
43
What is the hang time for reconstituted powdered formulas or formulas with added modular components delivered by gravity drip or pump?
Should hang no more than 4 hours at room temperature
44
What kind of water should be used to reconstitute powdered formulas?
Sterile water
45
Why are powdered formulas more prone to contamination vs liquid?
Formulas in liquid form undergo heat sterilization, whereas powdered formulas are not required to be sterile and may contain contaminants
46
What should be done if formula is leftover after the intended volume is poured into the feeding system?
The excess should be refrigerated immediately and stored according to manufacturer's recommendations, typically a maximum of 24-48 hours
47
Example scenario for formula hang-time: What is the maximum volume of formula that should be poured into the feeding bag if the formula rate is 25 ml/hr and the hang time is 8 hours?
Max 200 ml formula. Any leftover formula in original container should be immediately refrigerated for future use
48
How often should the feeding bag be changed?
24 hours
49
Tubing used with closed delivery systems should be replaced how often?
24 hours
50
What are Lopez valves?
3-way stopcocks that are frequently attached to enteral feeding tubes that do not contain a clamp (such as NG, balloon gastrostomy, balloon gastrojejunostomy, and jejunostomy tubes). They swivel to block or allow fluid passage. Increases contamination risk
51
What are common causes of constipation?
Dehydration Inadequate or excessive fiber in the diet
52
Underlying factors possibly associated with nonocclusive bowel necrosis?
Use of jejunal feedings Hyperosmolar formulas Feeding in the presence of hypotension Disordered peristalsis
53
Precautionary measures to prevent the development of nonocclusive bowel necrosis?
Delaying EN until patient is fluid-resuscitated Initial use of an isotonic and fiber-free enteral formula Ongoing monitoring of EN (monitor for development of abdominal distention, abdominal pain, acute change in NG output)
54
What can cause chemical pneumonitis and/or pneumonia?
Pulmonary aspiration of significant volumes of enteral formula; however, aspiration of very small amounts of fluid alone is likely insufficient to cause pneumonia
55
Acute symptoms of clinically significant aspiration?
Dyspnea Wheezing Frothy or purulent sputum Hypoxia Cyanosis Anxiety Agitation Fever Tachycardia Tachypnea Rhonchi and rales Leukocytosis Leukopenia New or progressing infiltrates on chest film
56
What risk factors were identified when pepsin-positive secretions were used to identify aspiration of gastric contents?
Low HOB elevation Vomiting Gastric feedings (as opposed to small bowel) Low Glasgow coma score GI reflux disease
57
Name possible causes of hypertonic dehydration with EN and the prevention methods or therapy
Possible causes: excessive fluid loss, inadequate fluid intake, concentrated (energy, protein) formula administered to a patient who cannot express thirst Prevention/Therapy: monitor daily fluid I/O; monitor body weight daily; estimate fluid losses; monitor serum electrolytes, urine-specific gravity, BUN, and Cr daily; provide enteral or IV fluid as indicated
58
Name possible causes of overhydration with EN and the prevention methods or therapy
Possible causes: excessive fluid intake; rapid refeeding; catabolism of lean body mass with potassium loss; refeeding syndrome; renal, hepatic, or cardiac insufficiency Prevention/Therapy: Monitor I/O daily, assess fluid status daily, monitor body weight daily, check aldosterone levels (will be elevated w/ sodium retention), consider use of less-concentrated formula, diuretic therapy
59
Name possible causes of hypokalemia with EN and the prevention methods or therapy
Possible causes: refeeding syndrome, catabolic stress, depleted body cell mass, effect of ADH and aldosterone, diuretic therapy, excessive losses (diarrhea, NGT), metabolic alkalosis, insulin therapy, dilution Prevention/Therapy: supplement potassium to normal before initiation of TF, monitor serum potassium daily until stable w/ pt at goa TF rate, supplement potassium and chloride, consider supplementation protocol
60
Name possible causes of hyperkalemia with EN and the prevention methods or therapy
Possible causes: Metabolic acidosis; poor perfusion (CHF); renal failure; excessive potassium intake from TF, IV fluid, oral diet Prevention/Therapy: correct acidosis if possible, recheck serum potassium; correct serum potassium before initiation of TF if possible; monitor serum potassium daily; treat cause of poor perfusion; potassium-binding resin, glucose, and/or insulin therapy; eliminate potassium from IV fluids, reduce potassium in TF and oral diet
61
Name possible causes of hyponatremia with EN and the prevention methods or therapy
Possible causes: dilution, from elevated ADH levels; hepatic, cardiac, or renal insufficiency; reduced sodium intake relative to output; depletion of total body sodium, extracellular mass, ECF, SIADH Prevention/Therapy: consider addition of table salt to TF, monitor sodium level daily, assess fluid status, diuretic therapy if indicated, fluid and/or sodium restriction
62
Name possible causes of hypernatremia with EN and the prevention methods or therapy
Possible causes: inadequate fluid intake with increased fluid losses (sweating ,osmotic diuresis), increased sodium intake (IV fluid) Prevention/Therapy: monitor daily I/O, monitor electrolytes and BUN:Cr daily, monitor body weight daily, estimate fluid loss, replace fluid loss via enteral or parenteral route to replace ECF
63
Name possible causes of hypophosphatemia with EN and the prevention methods or therapy
Possible causes: Refeeding syndrome, excessive energy intake, binding by epinephrine, sucralfate/antacids, insulin therapy Prevention/Therapy: supplement phosphorus to achieve normal levels before initiation of TF; monitor serum phosphorus daily and replete as necessary as clinical course changes; supplement phosphorus as sodium or potassium form, as clinically indicated, via enteral or parenteral route
64
Name possible causes of hyperphosphatemia with EN and the prevention methods or therapy
Possible causes: renal insufficiency Prevention/Therapy: phosphate-binder therapy
65
Name possible causes of hypozincemia with EN and the prevention methods or therapy
Possible causes: excessive losses (NGT, protein-losing enteropathy, ostomy, wound) Prevention/Therapy: supplement zinc via enteral or parenteral route
66
Name possible causes of vitamin K deficiency with EN and the prevention methods or therapy
Possible causes: inadequate vitamin K intake; prolonged use of low fat or low vitamin K formula; antibiotic use, cirrhosis, malabsorption, pancreatic insufficiency Prevention/Therapy: supplement vitamin K, consider probiotic agents, measure PT and PTT or INR daily until stable
67
Name possible causes of thiamin deficiency with EN and the prevention methods or therapy
Possible causes: chronic alcoholism, advanced age, long-term malnutrition, malabsorption, antacid therapy, dialysis Prevention/Therapy: supplement thiamin 3-7 days, consider addition of folate and multivitamin in cases of alcoholism or chronic disease
68
Name possible causes of essential fatty acid deficiency with EN and the prevention methods or therapy
Possible causes: inadequate linoleic acid intake Prevention/Therapy: provide >/=4% of energy needs as linoleic acid, add modular fat component to TF if needed, provide 5ml of safflower oil per day via enteral route
69
Name possible causes of hyperglycemia with EN and the prevention methods or therapy
Possible causes: refeeding syndrome; DM, sepsis, catabolism, trauma, or other disease states or conditions; insulin resistance; glucocorticoids; excessive carbohydrate Prevention/Therapy: correct serum glucose levels before initiation of TF if possible; monitor serum glucose q 6 hr or per protocol; treat underlying disease; maintain appropriate intravascular volume and hydration; provide OHA or insulin therapy as needed to maintain serum glucose as low as possible; consider providing 30-50% of total energy as fat; consider use of a product with fiber
70
Name possible causes of hypoglycemia with EN and the prevention methods or therapy
Possible causes: abrupt cessation of EN in a patient receiving OHA or insulin Prevention/Therapy: monitor serum glucose q 6 hr or per protocol, treat w/ glucose (IV or via tube) to increase serum level to >100 mg/dL, taper TF gradually
71
Associated risks with dehydration
Falls, pressure injuries, constipation, UTI, respiratory infections, and medication toxicities
72
Persistent dehydration can lead to:
Delirium, renal failure, coma, death
73
Risk factors for dehydration
Patients who are tube fed Older adults (have lower water reserves bc of the decrease in LBM that occurs w/ aging) Age-related changes: altered sense of thirst, diminished cognition, dysphagia, dysgeusia, hyposmia, reduced kidney function, impairment of hormonal modulators of sodium and water balance, limitations in function Younger TF patients with characteristics similar to those with older adults Chronic disease At risk for adverse drug reactions
74
Useful signs of intravascular volume depletion in acutely ill patients?
Increased heart rate Decreased or more concentrated urine Increase in oxygen extraction (an increase in the difference between arterial and venous oxygen concentration)
75
How much should fluid intake be increased if a patient has a fever?
Increase fluid intake by 12% per degree Celsius above 37.8
76
Name some clinical conditions during which fluid intake should be increased?
Fever Emesis Diarrhea High fistula and ostomy outputs Hyperglycemia