Complications of Enteral Nutrition Flashcards

1
Q

What is the most common cause of nausea/vomiting in EN? What conditions can occur as a result of vomiting?

A
  1. Delayed gastric emptying.

2. Vomiting especially in minimally responsive pts, increase the risk of pulmonary aspiration, PNA, and sepsis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What conditions contribute to slowed gastric emptying?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

If delayed gastric emptying is suspected, what interventions are indicated?

A
  1. Reduced or discontinuing all narcotic medications.
  2. Switching to low-fat and/or isotonic formula
  3. Reducing the rate of infusion by 20 to 25 ml/hr or providing the small volume feeding (50 -100ml/feeding).
  4. 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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

If a patient has abdominal distention with nausea while on EN, what measures should be done to indicate causes or prevent n/v?

A
  1. 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.
  2. Monitor stool frequency. Obstipation and impaction may lead to distention and nausea especially in institutionalized or chronically ill pt.
  3. Distention and vomiting may also occur as a result of diarrheal illness such as C.difficile colitis.
  4. Monitor abdominal status closely
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the symptoms and causes of abdominal distention?

A
  1. Symptoms/ associated symptoms are bloating and cramping.
  2. Causes include GI ileus, obstruction, obstipation, ascites, and diarrheal illness (c-diff).
  3. Excessively rapid formula infusion, initial use of fiber supplemented formula or infusion of very cold formula.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q
  1. List some causes of Maldigestion/Malabsorption?

2. List some clinical manifestations of above conditions?

A
  1. Gluten-sensitive enteropathy, Crohn’s disease, diverticular disease, radiation enteritis, enteric fistulas, HIV, pancreatic insufficiency, short gut syndrome.
  2. Unexplained wt loss, steatorrhea, diarrhea, bloating, abdominal distention and anemia.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

List some diagnostic malabsorption studies.

A
  1. Screening: Gross and microscopic examination of stool, determination of fat, pro content of random stool collection (qualitative) etc.
  2. Intake-output balance: stool collections for quantitative fecal fat studies.
  3. Maldigestion/malabsorption of specific nutrients: lactose intolerance test, schilling test for abnormal absorption of Vit B12 etc
  4. Endoscopic small bowel biopsy: for mucosal disorders like celiac disease, tropical sprue, and whipple’s disease.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the difference between Malabsorption and maldigestion?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the clinical definition of Diarrhea?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are common causes of diarrhea in patients receiving EN?

A
  1. Medications (liquid meds in a sorbital base, antibiotics etc.)
  2. Infection (c-diff and nonclostridial bacteria).
  3. Formula intolerance (osmolarity, fat content).
  4. Specific components in the formula (lactose).
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

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?

A

8 to 12 hrs.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is steatorrhea? What causes it? How could be improve tolerance to fat or reduce symptoms of steatorrhea?

A
  1. Is the malabsorption of fat, and it is confirmed by a fecal fat analysis (quantitative or qualitive)
  2. Steatorrhea is usually seen in pt with absorptive problems (short gut, pancreatic insufficiencies etc).
  3. A lower fat enteral formula or a formula with higher %age of fat as MCT, which may improve absorption of calories.
  4. Add pancreatic enzymes if pancreatic dysfunction is present.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why can defining constipation in an EN pt be difficult at times?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q
  1. Define constipation. 2. Define impaction

3. What is the most effective method for diagnosing constipation?

A
  1. Clinically, constipation is the accumulation of excess waste in the colon, often to the transverse colon or even in the cecum.
  2. Impaction is a variation of constipation. It is a firm collection of stool in the distal colon (sigmoid colon or rectum).
  3. Rectal examination and plain Abdominal x-ray. This method can differentiate constipation from SBO or ileus.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q
  1. What are common causes of constipation?
A

Dehydration and either inadequate or excessive fiber intake. Inadequate physical activity can also contribute to constipation. So patients should ambulate whenever possible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

If fiber is added to the enteral regimen, what is the minimal fluid requirements?

A

1ml of fluid / kcal to prevent solidification of waste in the colon and constipation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is secretory diarrhea?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Why there is an increased risk of aspiration PNA in critically ill Pts?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What diseases or syndromes are associated with secretory diarrhea?

A

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.

  1. Infection w/ enterotoxic organisms e.g. c-diff
  2. Abuse of stimulant laxatives
  3. Intestinal resection
  4. Inflammatory bowel disease
  5. Bile acid malabsorption
  6. Chronic infections
  7. Celiac sprue
  8. Small intestine lymphoma
  9. Villous adenoma of the rectum
  10. Zollinger-Ellison syndrome
  11. Collagen vascular disease
  12. Malignant carcinoid syndrome.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q
  1. Define aspiration?
  2. What factors contribute to increased aspiration risks?
  3. What are some of the clinical symptoms that can occur aspiration?
A
  1. Aspiration is defined as the inhalation of material into the airway.
  2. Regurgitation, vomiting, h/o aspiration, h/o neuromuscular disease, and malpositioned feeding tube.
  3. Dyspnea, wheezing, frothy or purulent sputum, fever, tachycardia, tachypnea etc.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What factors increased risks of aspiration pna?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are some strategies to prevent pulmonary aspiration?

A
  1. Elevating HOB >45degrees, which has been associated with decreased esophageal and pharyngeal reflux of gastric contents and lwr incidence of asp pna.
  2. 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.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What condition(s) increased the risk for refeeding syndrome?

A

Refeeding syndrome should be anticipated in all malnourished pts, especially those w/ large electrolytes losses such as in diarrhea, high output fistulae, or vomiting.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the basic characteristics of refeeding syndrome?

A

Hypokalemia, hypophosphatemia, increased intravascular volume, hypomagnesemia, and less commonly Wernicke’s encephalitis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What conditions can be the resulted of refeeding syndromes

A

Arrhythmias, respiratory and cardiac failure, aspiration, and death.

26
Q

What methods/strategies are used to prevent refeeding syndrome?

A
  1. Examine the chart for previous episodes of hypokalemia and hypophosphatemia bcuz they may suggest multiple unrecognized electrolytes def.
  2. Review pt’s history for prolonged starvation and chronic electrolytes-losing disease states like diarrhea, or liquid stool from ileostomy.
  3. Feeding should be advance slowly and not exceeding 15-20kcal/kg in pt at high risk until electrolytes are stable or not dangerously low.
  4. Monitor electrolytes for 1st few days of feeding until stable.
27
Q

In advanced renal disease and/or critical ill patients, what is the recommended % of H20 indicated in feeding products?
In renal insufficiency or failure, what electrolytes should be monitor for excess?

A
  1. 70 to 75%
  2. potassium and phosphorus, and water, which would indicate an electrolyte and water restricted formula in the longer term.
28
Q

Enteral formulas developed to reduce hyperglycemia are high in fat and fiber content, why this is not indicated in acutely ill patents with antropyloric dysfunction (poor gastric emptying, gastroparesis)?

A

Formulas with high fat and/or fiber content both slow gastric emptying.

29
Q

What are some causes hypertonic dehydration in EN?

A
  1. Excessive fluid loss
  2. Inadequate fluid intake
  3. Concentrated (energy, protein) formula administered to a pt who cannot express thirst.
30
Q

What are some prevent or therapies for hypertonic dehydration?

A
  1. Monitor daily fluid intake and output
  2. Monitor body wt daily
  3. Wt changes >.2kg/d (.44lbs/d) reflects changes in ECF.
  4. Monitor serum electrolytes, urine specify gravity, BUN and Cr daily. BUN:Cr is usually 10:1 in state of normal hydration.
  5. Provide enteral or IVF as indicated.
31
Q

List some causes of overhydration in EN?

A
  1. Excessive fluid intake.
  2. Rapid refeeding
  3. Refeeding syndrome
  4. Catabolism of lean body mass w/ loss of potassium.
  5. Renal, hepatic, or cardiac insufficiency
32
Q

What are prevention or therapies for overhydration?

A
  1. Monitor I/O daily.
  2. Monitor wts daily.
  3. Wt changes >.2kg/d reflects change in ECF volume.
  4. Consider use of concentrated formula
  5. Diuretic formula
  6. Elevated aldosterone levels with Na retention.
33
Q

List some causes of Hypokalemia in EN?

A
  1. Refeeding syndrome.
  2. Catabolic stress
  3. Depleted body cell mass
  4. Effect of ADH and aldosterone (↑Urinary K excretion). Conditions that ↑ aldosterone (e.g. volume depletion or post surgical stress) may cause excess K loss.
  5. Diuretic therapy
  6. Excessive losses (diarrhea, NGT suctioning)
  7. Metabolic alkalosis (induce or result -K shift into cell while H+ out)
  8. Insulin therapy (↑ Insulin cause an intracellular shift of K)
  9. Dilution
34
Q

List some preventive/therapies for hypokalemia?

A
  1. Supplement K to normal before initiation of T.F.
  2. Monitor serum K daily until stable w/ pt at goal TF rate.
  3. Supplement K and Cl
35
Q

List some causes of Hyperkalemia in EN.

A
  1. Metabolic acidosis (K shift out of cell while H+ shift in)
  2. Renal failure
  3. Poor perfusion e.g. CHF (The rate of urine flow affects K excretion. ↑urine prod = ↑K excretion)
  4. Excessive K intake from TF, IVF, oral diet.
36
Q

List some prevention/ therapies for Hyperkalemia in EN?

A
  1. Correct acidosis, if possible; recheck serum k.
  2. Correct serum K before initiation of TF, if possible.
  3. Monitor serum K daily
  4. K binding resin, glucose, and/or insulin
  5. Eliminate K from IVF; reduce K in TF and oral diet.
37
Q

List causes of Hyponatremia and Hypernatremia.

A
  1. Dilution, from elevated ADH levels
    b) Hepatic, cardia, or renal insufficiency
    c) Reduced Na intake relative to output
  2. Inadequate fluid intake w/ increased fluid loss (sweating, osmotic diuresis)
    b) Increased Na intake (IVF)
38
Q

List prevention/ therapies for hyponatremia

A
  1. Consider addition of table salt to TF only in cases of true Na depletion
  2. Monitor Na levels daily
  3. Assess fluid status
  4. Diuretic therapy, if indicated
  5. Fluid and/or Na restriction
39
Q

List prevention/therapies for hypernatremia.

A
  1. Monitor daily I/O
  2. Monitor electrolytes, BUN:Cr daily
  3. Monitor body wt daily; wt changes >.2kg/d reflects changes in ECF volume
  4. Estimate fluid loss; Replace fluid loss via enteral or parenteral route to replete ECF.
40
Q

List causes for hypophosphatemia and hyperphosphatemia.

A
  1. Refeeding syndrome
    b. Excessive calories
    c. Binding by epinephrine
    d. Sucralfate, antacids
    e. Insulin therapy (Cause a temporary intracellular shift of P).
  2. Renal insufficiency
    b) Extracellular shift esp from respiratory acidosis
41
Q

List prevention/therapies for hypophosphatemia and hyperphosphatemia.

A
  1. Supplement P to normal before initiation of TF.
    b. Monitor serum P daily and replete as necessary.
    c. Supplement P as Na or K form, as clinically indicated, via enteral or parenteral route.
  2. Phosphate binder therapy
    b. Choose TF formula w/ lower P content.
42
Q

List some causes of Hypozincemia.

A

Excessive loss (NGT suction, protein-losing, enteropathy, via ostomy, wound)

43
Q

List prevention/therapies for hypozincemia

A

Supplement zinc via EN or PN

44
Q

In what situation can enteral feeding be continue when abdominal distention is present?

A

If intestinal appearance and function are normal (from x-ray, fluoroscopy etc), EN may be continued, despite the distention. The discontinuation of feedings may be necessary, however, if motility is poor or if the bowel is markedly dilated.

45
Q

Drugs may cause diarhhea because of hypertonicity (such as those that contain mg or sorbitol) or direct laxative action (such as occurs due to proton pump inhibitors or prokinetic meds).List drugs that contain significant amt of sorbitol (at least 10 - 20 g)

A

Drugs that contain significant amt of sorbitol are:
Tylenol (Acetaminophen elixir), Lasix (Furosemide), Reglan (Metoclopramide), symmetrel (amantadine), tagamet (cimetidine), vibramycin (doxycycline), robitussin ac (guafenesin/codeine), vistaril (hydroxyzine), indocin (indomethacin), generic (isoniazid), aventyl (nortriptyline), actifed (pseudoephedrine/triprolidine)

46
Q

What are some medications that increased incidence of diarrhea?

A

Medications that increased incidence of diarrhea is ampicillin, bisacodyl, caffeine, clindamycin, colchicine, digoxin, erythromycin, hydralazine, lactulose, magnesium-containing preparations, reglan, methotrexate, penicillamine, procainamide, neomycin, quinidine, theophylline.

47
Q

Is it usual for hypertonic enteral feeding to cause clinically diarrhea? If so, what could be done to prevent diarrhea?

A

No. unless hypertonic enteral feeding products are infused at a very high rate, or by bolus into the small intestine, they rarely cause clinically diarrhea. If the hypertonicity is thought to be the cause of diarrhea, changing to an isotonic formula may be beneficial.

48
Q

If clinical significant diarrhea develops during EN, what options should clinicians consider?

A
  • Medical assessment of the patient to rule out infections of inflammatory causes, fecal impaction, diarrheagenic meds etc.
  • Change of the formula type
  • Addition of soluble fiber or insoluble fiber to the med regimen, and/or changing to an enteral formula w/ added fiber excepting in critically ill patients.
  • Use of antidiarrheal agent once C.diff has been ruled out or is being treated (loperamide, diphenoxylate, paregoric, or octreotide)
  • Continuation of EN as tolerated and initiation of PN to complete delivery of macro and micronutrients if intolerance or malabsorption is prolonged.
    See fig 13-1.
49
Q

Bacterial overgrowth in the GI tract can cause severe enteritis w/ marked diarrhea, abdominal cramp pain, hypoalbuminemia and catabolism/cachexia, fever, and even sepsis. What conditions ( w/ the above abdominal symptoms) could bacterial overgrowth be present?

A

Patient with altered GI anatomy or who have been treated with prolonged antibiotic therapy

50
Q

Using the closed delivery system, what is the recommended hang times?

A

Recommended hang times 24 to 48 hrs.

51
Q

If usual hydration guidelines are contradicted in the treatment of constipation, what options should be considered?

A

A stool softener (colace), laxative or cleaning enema should be consider. Chronic use of stimulant (e.g. senna) often result in tachyphylaxis and is not indicated. Rectal exams and abdominal X-ray may be required in patients with serious complications.

52
Q

Different protocols should be followed for gastrostomy tube as they are positioned in the anterior abdomen and as a result are unlikely to allow full withdrawal of stomach contents during GRV checks. What is the suggested GRV that should indicate evaluation for GI symptoms?

A

A GRV of ≥ 100ml with a gastrostomy tube has been suggested as a prudent trigger for careful evaluation of the patient for GI symptoms. Tube fed patients should be assessed continuously for feeding intolerances, such as abdominal distention, discomfort, or nausea, and measures should be implemented to reduce aspiration risk.

53
Q

Should GRV measurements be used in isolation or be used with several parameters to determine pt’s tolerance to enteral feeding?

A

GRV measurements are one of several parameters that can be used to monitor the pt’s tolerance to EN. It is not meant to be used in isolation and therefore should not result in cessation of EN unless other signs of intolerance were present.

54
Q

What are the recommendations when GRV ≥ 250ml and ≥500ml?

A

If GRV ≥ 250ml, a prokinetic agent can be recommended.
If GRV ≥ 500ml, most clinicians agreed that this volume should warrant holding in EN and consideration of a small bowel feeding or a prokinetic agent, if not already initiated.

55
Q

What other measures should be used in conjunction with GRV assessment to assess EN tolerance?

A

Another measure use to assess EN intolerances is an evaluation for GI symptoms which include abdominal distention, discomfort, nausea and vomiting.

56
Q

What other preventive measures should be done in addition to GRV checks to prevent aspiration and why?

A

a) Other preventive measures includes HOB elevated 30 to 45 degrees if possible, evaluation for GI tolerance, be minimally sedated, and have good glycemic control.
b) GRVs check do not always provide the full amount offload residing in the stomach and pts can still aspirate with low GRVs.

57
Q

Which population is at high risk for referring syndrome?

A

All malnourished patients especially those with large electrolytes losses e.g. those with diarrhea, high-output fistulae, or vomiting.

58
Q

With Pt who are high risk for refeeding syndrome, what is the calorie /day suggested until electrolytes are stable?

A

15 to 20 kcal/kg/day

59
Q

Why using formulas developed to improve glycemic control may be a problem in acutely ill patients with antro-pyloric dysfunction?

A

Formulas developed to improve glycemic control are typically higher in fat and contain fiber, which both delay gastric emptying. This may cause problems in patients with poor gastric emptying/gastroparesis.

60
Q

Why is rate of formula(carbohydrate) delivery important in glycemic control?

A

The rate of carbohydrate delivery affects the rate of absorption of glucose.