Complications of Enteral Nutrition Flashcards
Vomiting, especially in minimally responsive patients, is believed to increase the risk of:
Pulmonary aspiration, pneumonia, and sepsis
What is the most commonly identified problem for nausea and vomiting with EN?
Delayed gastric emptying
Name potential causes of slowed gastric emptying:
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
What interventions are recommended if delayed gastric emptying is suspected?
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
What is the next step to alleviate complications of slow gastric emptying if all efforts to increase EN to goal rate have failed?
Small bowel access (nasojejunal tube or transgastric jejunostomy tube) should be considered
Nausea with EN not related to slow gastric emptying may be related to:
Low stool frequency. Obstipation or fecal impaction may lead to distention and nausea, particularly in institutionalized patients or those with critical illness
Name some causes of abdominal distention?
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)
What is a simple method in patients with feeding tubes to assess abdominal distention?
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.
Define maldigestion and its clinical manifestations
Impaired breakdown of nutrients into absorbable forms. Manifestations include bloating, abdominal distention, diarrhea
Define malabsorption and its clinical manifestations
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
List methods used to screen for malabsorption (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 concentration
Measurement of serum citrulline levels
Measurement of d-oxylose absorption
Radiological examination of intestinal transit time and motility
When laboratory data, history, and/or radiologic examination suggest maldigestion or malabsorption, diagnosis can involve the following:
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)
Name causes of maldigestion/malabsorption
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
What is the most commonly reported side effect in patients receiving EN?
Diarrhea
How can stool volume be measured?
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)
What are common causes of diarrhea in patients receiving EN?
Primary GI disease
Medications
Bacterial infection
What amount of sorbitol in medications can start to cause GI symptoms?
10-20 gm
List medications containing sorbitol (higher to lower amount)
Hydroxyzine
Amantadine/Symmetrel
Doxycycline
Isoniazid
Nortriptyline
Pseudoephedrine and tripolidine
Cimetidine
Metoclopramide
Acetaminophen elixir
Furosemide
Guaifenesin and codeine/Robitussin
Indomethacin
List medications with increased incidence of diarrhea
Ampicillin
Bisacodyl
Caffeine
Clindamycin
Colchicine
Digoxin
Erythromycin
Hydralazine
Lactulose
Magnesium-containing preparations
Metoclopramide
Methotrexate
Neomycin
Penicillamine
Procainamide
Quinidine
Theophylline
Types of drugs with direct effects on the gut that can also cause diarrhea?
Proton pump inhibitors
Prokinetic medications
What property of some medications may make diarrhea inevitible?
The osmotic load (hypertonicity)
What should be done for any drug in a liquid vehicle given via small bowel tube?
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
Name conditions associated with secretory diarrhea
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
What should and shouldn’t a clinician do if it is suspected that the hyperosmolality of an enteral formula is causing diarrhea?
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
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
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
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
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
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
Volume definition for diarrhea?
> 500 ml stool output every 24 hours or more than 3 stools per day for at least 2 consecutive days
