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EN Flashcards

1
Q

patients initiated on EN MUST have

A

inadequate oral intake to meet nutritional requirements
sufficient functioning GI tract
safe route for enteral access

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2
Q

potential indications of EN

A

GI disease, organ dysfunction, hypermetabolic states

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3
Q

examples of GI disease that may be an indication for EN

A

IBD, short bowel syndrome, pancreatitis, fistulas

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4
Q

examples of organ dysfunction that may be an indication for EN

A

liver/kidney disease, organ transplant, congenital heart disease

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5
Q

examples of hypermetabolic states that may be an indication for EN

A

burns, trauma, post-op major surgery, sepsis

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6
Q

other possible indications of EN

A

neoplastic disease w/wo radiation (head, neck, esophageal cancer), neurological impairment (stroke), failure to thrive, eating disorders, AIDS

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7
Q

advantages of EN versus PN?

A

EN is
more convenient
less expensive
less invasive
associated with fewer complications

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8
Q

contraindications to EN

A

distal mechanical intestinal obstruction
bowel ischemia
necrotizing enterocolitis

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9
Q

contraindications to tube placement

A

active peritonitis
uncorrectable coagulopathy

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10
Q

challenges to EN?

A

severe diarrhea, protracted vomiting, enteric fistulas, severe GI hemorrhage, hemodynamic instability, intestinal dysmotility

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11
Q

timing of initiation for a previously well-nourished, mildly stressed adult patient

A

5-7 days

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12
Q

timing of initiation for a critically ill but hemodynamically stable adult patient

A

24-48 hours

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13
Q

timing of initiation for a critically ill and hemodynamically unstable patient

A

withhold until the patient is fluid resuscitated and vasopressors are withdrawn or infusing at low, stable doses

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14
Q

short term EN routes?

A

nasogastric, orogastric, nasojejunal, nasoduodenal

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15
Q

long term EN routes?

A

gastrostomy, jejunostomy

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16
Q

who gets a nasogastric or orogastric tube?

A

short term, intact gag reflux, and normal gastric emptying rate

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17
Q

who gets a nasojejunal or nasoduodenal tube?

A

short term, impaired gastric motility or gastric emptying rate, high risk of aspiration

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18
Q

how is a nasogastric or orogastric tube placed?

A

manually at bedside

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19
Q

how is a nasojejunal or nasoduodenal tube placed?

A

manually at bedside, fluoroscopically, endoscopically

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20
Q

advantages of nasogastric and orogastric tubes

A

easy placement, allows for all methods of administration, and inexpensive

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21
Q

disadvantages of nasogastric and orogastric rubes

A

potential tube displacement, potential increased aspiration risk

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22
Q

advantages of nasojejunal or nasoduodenal tubes?`

A

potential reduced aspiration risk, allows for early post-op feeding

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23
Q

disadvantages of nasojejunal or nasoduodenal tubes

A

manual tube insertion requires greater skill, potential tube displacement or clogging, bolus or intermittent feeding is not tolerated (dumping syndrome)

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24
Q

how long is treatment for short term

A

4-6 weeks

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25
Q

how is short term most often placed

A

bedside, metoclopramide can be used to guide placement

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26
Q

pros and cons of large bore?

A

reduced clog risk, reduced patient comfort

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27
Q

when is a large bore used

A

nasogastric, orogastric

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28
Q

pros and cons of small bore?

A

increased clog risk, increased patient comfort

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29
Q

when is a small bore used

A

nasoduodenal, nasojejunal

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30
Q

which patients get gastrostomy

A

long term, normal gastric emptying

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31
Q

which patients get jejunostomy

A

long term, high aspiration risk, impaired gastric motility

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32
Q

tube placement options for gastrostomies and jejunostomies

A

surgically, endoscopically, radiologically, laparoscopically

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33
Q

advantages of gastrostomy

A

allows for all methods of administration, low profile buttons are available, less likely to clog (larger bore)

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34
Q

disadvantages of gastrostomy

A

risks with placement procedure, potential increased aspiration risk, risk of stoma site complications

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35
Q

advantages of jejunostomy

A

allows for early postop feeding, potential reduced aspiration risk, low profile buttons available

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36
Q

disadvantages of jejunostomy

A

risks with placement procedure, bolus or intermittent feeding not tolerated, risk of stoma site complications

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37
Q

length of treatment for long term

A

greater than 4-6 weeks

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38
Q

how come there is an improved quality of life with long term

A

reduces clog risk (use largest bore possible), increased comfortability, low profile options

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39
Q

associated risks with long term?

A

surgical procedure, infection/irritation near entrance site

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40
Q

ethical considerations for long term?

A

inappropriately used in end of life care

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41
Q

methods of administration

A

continuous, cyclic, intermittent, bolus

42
Q

define continuous feed

A

EN via feeding pump for 24h/day

43
Q

define cyclic feed

A

EN via feeding pump for <24h/day

44
Q

define intermittent feed

A

EN over 20-60 minutes every 4-6 hours with or without a feeding pump

45
Q

define bolus feed

A

EN over short time period at specified interval via gravity drip or syringe

46
Q

considerations for the continuous EN

A

it is pump-assisted and more common in hospitalized patients

47
Q

advantages of the continuous EN

A

improves tolerance, especially with small intestine feeds

48
Q

disadvantages of the continuous EN

A

increased nursing time, less convenient, more expensive

49
Q

special considerations for the cyclic EN?

A

pump-assisted

50
Q

advantages of the cyclic EN

A

pump-free time during the day (nocturnal administration)

51
Q

disadvantages of the cyclic EN

A

increased nursing time, less convenient, more expensive

52
Q

special considerations for the bolus EN?

A

syringe-administered, common for patients in the home or in the long-term care setting

53
Q

advantages of the bolus EN

A

more convenient, mimics normal eating patterns, assists with medication administration (meds that must be administered on an empty stomach)

54
Q

disadvantages of the bolus EN

A

not appropriate with duodenal or jejunal access (cramping, nausea, vomiting, aspiration, diarrhea), should be avoided in delayed gastric emptying and risk of aspiration

55
Q

special considerations for intermittent EN

A

used in patients with a gastric feeding tube who are unable to tolerate bolus feeds, administered over longer time period, pump or gravity assisted

56
Q

advantages of intermittent EN

A

more convenient, mimics normal eating patterns

57
Q

disadvantages of intermittent EN

A

not appropriate for duodenal or jejunal access, should be avoided in delayed gastric empty8ing and risk of aspiration

58
Q

permissive underfeeding is ____% of goal

A

50-80% of goal

59
Q

trophic EN is ____

A

10-20 mL/hr to maintain gut integrity and prevent bacterial translocation

60
Q

how fast to advance to goal for severe malnutriton

A

over 24-48 hours and monitor for refeeding syndrome

61
Q

when to flush feeding tubes

A

before and after admin of EN and meds, immediately before and after intermediate and bolus feeds, at standard intervals with continuous feedings (30 mL q4h)

62
Q

how to flush feeding tubes?

A

manually with a syringe or via tube feeding pump

63
Q

what solution to use to flush a tube

A

safe drinking water (most patients)
purified water (immunocompromised or critically ill)

64
Q

what does nutrient complexity mean?

A

the amount of hydrolysis and digestion a substrate requires prior to intestinal absorption

65
Q

what are polymeric/intact substrates

A

a similar molecular form to the foods we eat

66
Q

what are elemental substrates aka hydrolyzed and partially hydrolyzed

A

macronutrients broken down into components, increase osmolality of EN

67
Q

____ content of a protein source determines the quality of the protein

A

essential amino acid content

68
Q

what are polymeric sources of protein

A

meat, milks, eggs, caseinates

69
Q

what are partially hydrolyzed sources of protein

A

peptides, L-amino acids

70
Q

_____ are usually the major source of calories

A

carbohydrates

71
Q

what are polymeric sources of carbohydrates

A

starches, glucose polymers

72
Q

what are hydrolyzed sources of carbohydrates

A

simple sugars (glucose, galactose)

73
Q

which sources of carbohydrates are preferred

A

polymeric sources: they minimize osmotic load and are easily absorbed, but not as sweet

74
Q

_____ is required to prevent essential fatty acid deficiency

A

linoleic acid

75
Q

what are the most common fat sources

A

vegetable oils (soy, corn), contain polyunsaturated fats

76
Q

what are the essential fatty acids

A

omega 3, 6

77
Q

what forms of fiber are added to EN and why

A

soluble and insoluble, they stimulate growth of healthy bacteria and maintain bowel function (beneficial with diarrhea or constipation)

78
Q

when should fiber be avoided

A

patients at risk for bowel ischemia or severe dysmotility

79
Q

what is iso-osmolar

A

300 mOsm/kg

80
Q

what osmolality are most EN formulations

A

280-875 mOsm/kg

81
Q

_______ components have higher osmolality

A

partially hydrolyzed or elemental

82
Q

what is higher osmolality linked to

A

gastric retention, diarrhea, distention, vomiting, and nausea

83
Q

what does increased renal solute load lead to

A

increased obligatory water loss via the kidney

84
Q

what do high-protein formulations lead to

A

dehydration

85
Q

which patients are candidates for high protein formulations

A

critically ill, pressure sores, surgical wounds, high output enterocutanous fistulas
adult patients whose daily protein requirements exceed 1.5 g/kg/day
mechanically ventilated patients who are receiving propofol

86
Q

why do patients on propofol get high protein EN

A

propofol contains soybean oil and provides 1.1 kcal/mL–> the high protein formulations can prevent overfeeding

87
Q

high caloric density EN formulations provide _____

A

1.5-2 kcal/mL and provide less fluid and electrolyte intake

88
Q

which patients are candidates for high caloric formulations

A

fluid/electrolyte restriction (heart, kidney, respiratory faiure)

89
Q

what is in elemental/peptide-based EN formulations

A

they contain hydrolyzed protein and/or fat
protein is in the form of dipeptide and tripeptides (more readily absorbed)

90
Q

which patients get elemental/peptide-based EN formulations

A

impaired digestion/absorption, intolerant to intact nutrition formulations (malabsorption, short bowel syndrome), severe pancreatic insufficiency, abnormalities of the intestinal mucosa, chylothorax/ chylous ascites

91
Q

what diseases can disease-specific EN formulations target

A

kidney and liver failure, lung disease, diabetes mellitus, wound healing, metabolic stress

92
Q

what are modular products

A

liquid or powder form of a single nutrient- administer separately from EN formulation

93
Q

can you administer oral rehydration formulations via tube

A

yes, useful in patients with vomiting or diarrhea

94
Q

what is a metabolic complication of EN

A

refeeding syndrome: look out for hypophosphatemia

95
Q

GI complications of EN

A

diarrhea

96
Q

how to prevent aspiration

A

elevate the head of the bed to a 30-45 degree angle, add a prokinetic agent (metoclopramide, erythromycin) to increase gastric emptying, minimize use of medications that can slow gastric emptying (narcotics, sedatives)

97
Q

what is gastric residual volume (GRV)

A

used to assess volume contents of stomach
if GRV>500, lower tube feed rate/volume

98
Q

what can be an underlying cause of diarrhea from EN

A

rapid rate, intolerance to composition, administration of large volumes into the small bowel, formula contamination

99
Q

measures to prevent or manage diarrhea

A

fiber, lower fat or higher MCT, excipients can cause diarrhea (sorbitol), use loperamide or diphenoxylate/atropine if infectious etiologies ruled out

100
Q

mechanical complications of EN

A

tube occlusion, tube malposition, inadvertent nasopulmonary intubation

101
Q

what infections can be a complication of EN

A

sinusitis, exit site-related infections, intraabdominal infections

102
Q

leaking/bleeding of the exit site cause and management

A

cause: excessive granulation tissue around site
manage: silver nitrate and corticosteroids

GI (15 decks)

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