EN Flashcards
patients initiated on EN MUST have
inadequate oral intake to meet nutritional requirements
sufficient functioning GI tract
safe route for enteral access
potential indications of EN
GI disease, organ dysfunction, hypermetabolic states
examples of GI disease that may be an indication for EN
IBD, short bowel syndrome, pancreatitis, fistulas
examples of organ dysfunction that may be an indication for EN
liver/kidney disease, organ transplant, congenital heart disease
examples of hypermetabolic states that may be an indication for EN
burns, trauma, post-op major surgery, sepsis
other possible indications of EN
neoplastic disease w/wo radiation (head, neck, esophageal cancer), neurological impairment (stroke), failure to thrive, eating disorders, AIDS
advantages of EN versus PN?
EN is
more convenient
less expensive
less invasive
associated with fewer complications
contraindications to EN
distal mechanical intestinal obstruction
bowel ischemia
necrotizing enterocolitis
contraindications to tube placement
active peritonitis
uncorrectable coagulopathy
challenges to EN?
severe diarrhea, protracted vomiting, enteric fistulas, severe GI hemorrhage, hemodynamic instability, intestinal dysmotility
timing of initiation for a previously well-nourished, mildly stressed adult patient
5-7 days
timing of initiation for a critically ill but hemodynamically stable adult patient
24-48 hours
timing of initiation for a critically ill and hemodynamically unstable patient
withhold until the patient is fluid resuscitated and vasopressors are withdrawn or infusing at low, stable doses
short term EN routes?
nasogastric, orogastric, nasojejunal, nasoduodenal
long term EN routes?
gastrostomy, jejunostomy
who gets a nasogastric or orogastric tube?
short term, intact gag reflux, and normal gastric emptying rate
who gets a nasojejunal or nasoduodenal tube?
short term, impaired gastric motility or gastric emptying rate, high risk of aspiration
how is a nasogastric or orogastric tube placed?
manually at bedside
how is a nasojejunal or nasoduodenal tube placed?
manually at bedside, fluoroscopically, endoscopically
advantages of nasogastric and orogastric tubes
easy placement, allows for all methods of administration, and inexpensive
disadvantages of nasogastric and orogastric rubes
potential tube displacement, potential increased aspiration risk
advantages of nasojejunal or nasoduodenal tubes?`
potential reduced aspiration risk, allows for early post-op feeding
disadvantages of nasojejunal or nasoduodenal tubes
manual tube insertion requires greater skill, potential tube displacement or clogging, bolus or intermittent feeding is not tolerated (dumping syndrome)
how long is treatment for short term
4-6 weeks
how is short term most often placed
bedside, metoclopramide can be used to guide placement
pros and cons of large bore?
reduced clog risk, reduced patient comfort
when is a large bore used
nasogastric, orogastric
pros and cons of small bore?
increased clog risk, increased patient comfort
when is a small bore used
nasoduodenal, nasojejunal
which patients get gastrostomy
long term, normal gastric emptying
which patients get jejunostomy
long term, high aspiration risk, impaired gastric motility
tube placement options for gastrostomies and jejunostomies
surgically, endoscopically, radiologically, laparoscopically
advantages of gastrostomy
allows for all methods of administration, low profile buttons are available, less likely to clog (larger bore)
disadvantages of gastrostomy
risks with placement procedure, potential increased aspiration risk, risk of stoma site complications
advantages of jejunostomy
allows for early postop feeding, potential reduced aspiration risk, low profile buttons available
disadvantages of jejunostomy
risks with placement procedure, bolus or intermittent feeding not tolerated, risk of stoma site complications
length of treatment for long term
greater than 4-6 weeks
how come there is an improved quality of life with long term
reduces clog risk (use largest bore possible), increased comfortability, low profile options
associated risks with long term?
surgical procedure, infection/irritation near entrance site
ethical considerations for long term?
inappropriately used in end of life care
methods of administration
continuous, cyclic, intermittent, bolus
define continuous feed
EN via feeding pump for 24h/day
define cyclic feed
EN via feeding pump for <24h/day
define intermittent feed
EN over 20-60 minutes every 4-6 hours with or without a feeding pump
define bolus feed
EN over short time period at specified interval via gravity drip or syringe
considerations for the continuous EN
it is pump-assisted and more common in hospitalized patients
advantages of the continuous EN
improves tolerance, especially with small intestine feeds
disadvantages of the continuous EN
increased nursing time, less convenient, more expensive
special considerations for the cyclic EN?
pump-assisted
advantages of the cyclic EN
pump-free time during the day (nocturnal administration)
disadvantages of the cyclic EN
increased nursing time, less convenient, more expensive
special considerations for the bolus EN?
syringe-administered, common for patients in the home or in the long-term care setting
advantages of the bolus EN
more convenient, mimics normal eating patterns, assists with medication administration (meds that must be administered on an empty stomach)
disadvantages of the bolus EN
not appropriate with duodenal or jejunal access (cramping, nausea, vomiting, aspiration, diarrhea), should be avoided in delayed gastric emptying and risk of aspiration
special considerations for intermittent EN
used in patients with a gastric feeding tube who are unable to tolerate bolus feeds, administered over longer time period, pump or gravity assisted
advantages of intermittent EN
more convenient, mimics normal eating patterns
disadvantages of intermittent EN
not appropriate for duodenal or jejunal access, should be avoided in delayed gastric empty8ing and risk of aspiration
permissive underfeeding is ____% of goal
50-80% of goal
trophic EN is ____
10-20 mL/hr to maintain gut integrity and prevent bacterial translocation
how fast to advance to goal for severe malnutriton
over 24-48 hours and monitor for refeeding syndrome
when to flush feeding tubes
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)
how to flush feeding tubes?
manually with a syringe or via tube feeding pump
what solution to use to flush a tube
safe drinking water (most patients)
purified water (immunocompromised or critically ill)
what does nutrient complexity mean?
the amount of hydrolysis and digestion a substrate requires prior to intestinal absorption
what are polymeric/intact substrates
a similar molecular form to the foods we eat
what are elemental substrates aka hydrolyzed and partially hydrolyzed
macronutrients broken down into components, increase osmolality of EN
____ content of a protein source determines the quality of the protein
essential amino acid content
what are polymeric sources of protein
meat, milks, eggs, caseinates
what are partially hydrolyzed sources of protein
peptides, L-amino acids
_____ are usually the major source of calories
carbohydrates
what are polymeric sources of carbohydrates
starches, glucose polymers
what are hydrolyzed sources of carbohydrates
simple sugars (glucose, galactose)
which sources of carbohydrates are preferred
polymeric sources: they minimize osmotic load and are easily absorbed, but not as sweet
_____ is required to prevent essential fatty acid deficiency
linoleic acid
what are the most common fat sources
vegetable oils (soy, corn), contain polyunsaturated fats
what are the essential fatty acids
omega 3, 6
what forms of fiber are added to EN and why
soluble and insoluble, they stimulate growth of healthy bacteria and maintain bowel function (beneficial with diarrhea or constipation)
when should fiber be avoided
patients at risk for bowel ischemia or severe dysmotility
what is iso-osmolar
300 mOsm/kg
what osmolality are most EN formulations
280-875 mOsm/kg
_______ components have higher osmolality
partially hydrolyzed or elemental
what is higher osmolality linked to
gastric retention, diarrhea, distention, vomiting, and nausea
what does increased renal solute load lead to
increased obligatory water loss via the kidney
what do high-protein formulations lead to
dehydration
which patients are candidates for high protein formulations
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
why do patients on propofol get high protein EN
propofol contains soybean oil and provides 1.1 kcal/mL–> the high protein formulations can prevent overfeeding
high caloric density EN formulations provide _____
1.5-2 kcal/mL and provide less fluid and electrolyte intake
which patients are candidates for high caloric formulations
fluid/electrolyte restriction (heart, kidney, respiratory faiure)
what is in elemental/peptide-based EN formulations
they contain hydrolyzed protein and/or fat
protein is in the form of dipeptide and tripeptides (more readily absorbed)
which patients get elemental/peptide-based EN formulations
impaired digestion/absorption, intolerant to intact nutrition formulations (malabsorption, short bowel syndrome), severe pancreatic insufficiency, abnormalities of the intestinal mucosa, chylothorax/ chylous ascites
what diseases can disease-specific EN formulations target
kidney and liver failure, lung disease, diabetes mellitus, wound healing, metabolic stress
what are modular products
liquid or powder form of a single nutrient- administer separately from EN formulation
can you administer oral rehydration formulations via tube
yes, useful in patients with vomiting or diarrhea
what is a metabolic complication of EN
refeeding syndrome: look out for hypophosphatemia
GI complications of EN
diarrhea
how to prevent aspiration
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)
what is gastric residual volume (GRV)
used to assess volume contents of stomach
if GRV>500, lower tube feed rate/volume
what can be an underlying cause of diarrhea from EN
rapid rate, intolerance to composition, administration of large volumes into the small bowel, formula contamination
measures to prevent or manage diarrhea
fiber, lower fat or higher MCT, excipients can cause diarrhea (sorbitol), use loperamide or diphenoxylate/atropine if infectious etiologies ruled out
mechanical complications of EN
tube occlusion, tube malposition, inadvertent nasopulmonary intubation
what infections can be a complication of EN
sinusitis, exit site-related infections, intraabdominal infections
leaking/bleeding of the exit site cause and management
cause: excessive granulation tissue around site
manage: silver nitrate and corticosteroids
