Complications of Enteral Nutrition Flashcards
What is the most common cause of nausea/vomiting in EN? What conditions can occur as a result of vomiting?
- Delayed gastric emptying.
2. Vomiting especially in minimally responsive pts, increase the risk of pulmonary aspiration, PNA, and sepsis.
What conditions contribute to slowed gastric emptying?
Hypotension, sepsis, stress, anesthesia and surgery, infiltration gastric neoplasms, surgical vagotomy, opiate analgesic meds (morphine SO4, codeine, fentanyl), anticholinergics, excessive rapid infusion of formula, infusion of a very cold solution or one containing a large amount of fat, various autoimmune diseases, pancreaticoduodenectomy.
If delayed gastric emptying is suspected, what interventions are indicated?
- Reduced or discontinuing all narcotic medications.
- Switching to low-fat and/or isotonic formula
- Reducing the rate of infusion by 20 to 25 ml/hr or providing the small volume feeding (50 -100ml/feeding).
- Administering a prokinetic agent (e.g. reglan, erythromycin)
NB: Once tolerance is achieved, increase rate or volume every 8 to 24 hrs as tol until goals are met.
If a patient has abdominal distention with nausea while on EN, what measures should be done to indicate causes or prevent n/v?
- Gastric residual volume and abdominal status should be monitored closely-before the next bolus feeding or every 4 hrs for continuous feeding. While elevated GRVs alone do not always correlate with intolerance, the combination of an abnormal abdominal exam and an elevated GRV may be significant.
If low and nausea persists, antiemetics may resolved the problem. - Monitor stool frequency. Obstipation and impaction may lead to distention and nausea especially in institutionalized or chronically ill pt.
- Distention and vomiting may also occur as a result of diarrheal illness such as C.difficile colitis.
- Monitor abdominal status closely
What are the symptoms and causes of abdominal distention?
- Symptoms/ associated symptoms are bloating and cramping.
- Causes include GI ileus, obstruction, obstipation, ascites, and diarrheal illness (c-diff).
- Excessively rapid formula infusion, initial use of fiber supplemented formula or infusion of very cold formula.
- List some causes of Maldigestion/Malabsorption?
2. List some clinical manifestations of above conditions?
- Gluten-sensitive enteropathy, Crohn’s disease, diverticular disease, radiation enteritis, enteric fistulas, HIV, pancreatic insufficiency, short gut syndrome.
- Unexplained wt loss, steatorrhea, diarrhea, bloating, abdominal distention and anemia.
List some diagnostic malabsorption studies.
- Screening: Gross and microscopic examination of stool, determination of fat, pro content of random stool collection (qualitative) etc.
- Intake-output balance: stool collections for quantitative fecal fat studies.
- Maldigestion/malabsorption of specific nutrients: lactose intolerance test, schilling test for abnormal absorption of Vit B12 etc
- Endoscopic small bowel biopsy: for mucosal disorders like celiac disease, tropical sprue, and whipple’s disease.
What is the difference between Malabsorption and maldigestion?
Maldigestion is an impaired breakdown of nutrients into absorbable forms such as lactose intolerance, whereas malabsorption refers to defective mucosal uptake and transport of nutrients from the small intestines.
What is the clinical definition of Diarrhea?
Abnormal volume or consistency of stool. Normal stool water content is 250 to 500ml/d. Diarrhea is >500ml stool output every 24 hrs or more than 3 stools/day for at least 2 consecutive days.
What are common causes of diarrhea in patients receiving EN?
- Medications (liquid meds in a sorbital base, antibiotics etc.)
- Infection (c-diff and nonclostridial bacteria).
- Formula intolerance (osmolarity, fat content).
- Specific components in the formula (lactose).
Normal formula hang times is 48hrs. However, for vulnerable hosts like neonates, critically ill and immuned-suppressed pt, and loss of the gastric acid microbial barrier may predispose some to greater risk of morbidity related to formula contamination. In this case, what shld be hang-times for formulas at room temp?
8 to 12 hrs.
What is steatorrhea? What causes it? How could be improve tolerance to fat or reduce symptoms of steatorrhea?
- Is the malabsorption of fat, and it is confirmed by a fecal fat analysis (quantitative or qualitive)
- Steatorrhea is usually seen in pt with absorptive problems (short gut, pancreatic insufficiencies etc).
- A lower fat enteral formula or a formula with higher %age of fat as MCT, which may improve absorption of calories.
- Add pancreatic enzymes if pancreatic dysfunction is present.
Why can defining constipation in an EN pt be difficult at times?
Normal defecation may range from 4 stools each day to one stool every 4 or 5 days. On EN, this variation can be increased because if the Pt is on a predigested, low residue formula, there may be nearly 100% absorption, which may result in stool frequency of less than once/wk.
- Define constipation. 2. Define impaction
3. What is the most effective method for diagnosing constipation?
- Clinically, constipation is the accumulation of excess waste in the colon, often to the transverse colon or even in the cecum.
- Impaction is a variation of constipation. It is a firm collection of stool in the distal colon (sigmoid colon or rectum).
- Rectal examination and plain Abdominal x-ray. This method can differentiate constipation from SBO or ileus.
- What are common causes of constipation?
Dehydration and either inadequate or excessive fiber intake. Inadequate physical activity can also contribute to constipation. So patients should ambulate whenever possible.
If fiber is added to the enteral regimen, what is the minimal fluid requirements?
1ml of fluid / kcal to prevent solidification of waste in the colon and constipation.
What is secretory diarrhea?
Diarrhea in which there is a large volume of fecal output caused by abnormalities of the movement of fluid and electrolytes into the intestinal lumen.
Why there is an increased risk of aspiration PNA in critically ill Pts?
In critically ill Pts, there’s an increased risk of pulmonary aspiration because of prolonged supine position, endotracheal intubation, delayed gastric emptying and decreased level of consciousness.
What diseases or syndromes are associated with secretory diarrhea?
Primary diseases of the intestines, including inflammatory bowel disease , short gut syndrome, gluten sensitive enteropathy, and acquired immunodeficiency syndrome may result in malabsorption or secretory diarrhea. Here are various diseases associated w/ secretory diarrhea.
- Infection w/ enterotoxic organisms e.g. c-diff
- Abuse of stimulant laxatives
- Intestinal resection
- Inflammatory bowel disease
- Bile acid malabsorption
- Chronic infections
- Celiac sprue
- Small intestine lymphoma
- Villous adenoma of the rectum
- Zollinger-Ellison syndrome
- Collagen vascular disease
- Malignant carcinoid syndrome.
- Define aspiration?
- What factors contribute to increased aspiration risks?
- What are some of the clinical symptoms that can occur aspiration?
- Aspiration is defined as the inhalation of material into the airway.
- Regurgitation, vomiting, h/o aspiration, h/o neuromuscular disease, and malpositioned feeding tube.
- Dyspnea, wheezing, frothy or purulent sputum, fever, tachycardia, tachypnea etc.
What factors increased risks of aspiration pna?
Age, immune status and comorbidities influences the tendency towards aspiration pna. When the quantity and acidity of the formula overwhelms the pt’s natural defense mechanism or the pulmonary defense mechanisms, pna is more likely to happen.
What are some strategies to prevent pulmonary aspiration?
- Elevating HOB >45degrees, which has been associated with decreased esophageal and pharyngeal reflux of gastric contents and lwr incidence of asp pna.
- Gastric residual volume checks (volume ranges from 100ml to 500ml) but decision to hold EN shld be based on trends not a single elevated GRV.
What condition(s) increased the risk for refeeding syndrome?
Refeeding syndrome should be anticipated in all malnourished pts, especially those w/ large electrolytes losses such as in diarrhea, high output fistulae, or vomiting.
What are the basic characteristics of refeeding syndrome?
Hypokalemia, hypophosphatemia, increased intravascular volume, hypomagnesemia, and less commonly Wernicke’s encephalitis.