EN and PEN Flashcards
List types of short-term EN
NG, nasoenteric (ND, NG), OG, OD, OJ
List types of long-term EN
PEG, gastostomy, jejunostomy
What is a PEG tube?
PEG=percutaneous endoscopic gastrostomy tube
These are direct access from outside source to GI tract. Can handle well as long as keep site on skin clean.
More invasive. Allow for larger bolus feeds for food and medication compared to short-term.
What are the adv/disadv of a jejunostomy?
Jejunostomy adv: decreases risk of aspiration. don’t have to worry about reflux from stomach into esophagus. More difficult to place.
Also need infusion pump for feeds.
List types of peripheral PN
peripheral vein
midline catheter access
List types of central parenteral nutrition
central venous catheter (subclavian=SC, internal jugular=IJ, femoral)
List yptes of central PEN
central venous catheter (SC, IJ, femoral)
peripherally inserted center cathter=PICC.
More concentrated PN must be administered through
central veins
PICC is a ___ line
central
What is combination feeding?
administration of both EN and PN
bridge therapy for pts who are unable to meet caloric/protein req with EN
preserves enterohepatic circ and barrier function of the GI tract
risk factors for malnutrition
- unintentional weight change (>10% w/in 6 mo or >5% w/in 1 mo)
- body weight 20% under IBW
- NPO >7-10 d
- incr metabolic needs
- inadequate nutrient intake (alcoholic/substance abuse, chronic disease states, deficiencies)
describe acute malnutrition
status of protein-depleted pt w adequate fat reserve
desribe chronic malnutrition
depletion of pro and fat stores, w class emaciated-appearence
SGA for normal noursihment
no wt loss (<0.5-1 kg)
no abnormal dietary ntake
no hx of <2d of anorexia, N/V, diarrhea
SGA for moderate malnourishment
wt loss of 5-10% of usual wt in 6 mo
abnormal dietary intake for 1 mo
hx of anorexia, N/V or diarrhea for short time
SGA for severe malnourishment
wt loss of >10% in <6 mo
inadequate intake for >1 mo
hx of anorexia, n/V, or diarrhea for >1 mo
**=====> visual somatic protein wasting; BMI<18.5 `
Define Kwashiokor
protein malnutrition:
caused by dietary deficiency of protein for several wks/mos
Features of Kwashiokor
hypoalbuminemia anemia edema muscle atrophy delayed wound healing imp'd immunocompetence
Define Marasmus
protein-calorie malnutrition
devos over mo-yrs
Features of Marasmus
wt loss reduced BMR depletion of SQ fat decr tissue turgor bradycardia hypothermia
What is an appropriate visceral protein to monitor for acute nutritional status?
pre-albumin
t1/2=2-3 d
What visceral proteins are used to assess nutritional status?
albumin
pre-albumin
transferring
retinol-binding
Measuring ___ can be used to individual daily protein reqs
24 hr urine collection (UUN)
Define nitrogen balance
measurement of urinary excretion of nitrogen as urea
=N(in) minus N(out)
During times of stress urinary nitrogen excreteion incr or decr?
increases as stress causes proteins to be broken down.
List non-urinary sources of nitrogen loss.
sweat feces respiration GI fistula wound drainage burns
How to calculate daily nitrogen intake.
24 hr protein intake (g)/6.25
How to calculate nitrogen output
24 hour UUN (g) + 4
UUN=urinary urea nitrogen
4 is a correction factor that accounts for non-urinary nitrogen losses
What is the goal nitrogen balance?
zero for maintenance
*** +4 g for repletion
How many kcal/g of protein?
4 kcal/g
How many kcal/g of carbs?
3.4 kcal/g
How many kcal/g of IV lipids?
10 kcal/g
What to monitor for refeeding syndrome?
Mg, Phos, K levels
What is the metabolic response to stress such as illness or injury?
hypermetabolism and hypercatabolism
increased sympathetic NS stimulation
What occurs during incr’d SNS stimulation as a metabolic response to stress?
incr counterregulatory hormones (catecholamines, cortisol, glucagon, GH)
incr cytokines (TNF-alpha, interleukins 1&6)
incr immunomodulators–thromboxanes and prostaglandins
What is the end results of metabolic responses to stress?
accelerated proteolysis, glcogenolysis, lipolysis, gluconeogenesis, & insulin resistance
What does proteolysis during acute stress result in?
negative nitrogen balance and weight loss
What does a reduced tolerance to carbs during acute stress result in?
hyperglycemia
What does reduced fat utilization during acute stress result in?
hypertriglyceridemia
What is BEE?
Basal energy expenditure = BMR
metabolic activity req’d to maintain life
What is RRE?
resting energy expenditure or resting metabolic rate
of calories eq’d during 24 hrs in a non-active states
~10% higher than BEE (accounts for thermal effect of food, awake state)
What is TEE?
total energy expenditure
calories req’d to maintain current body wt
TEE=BEE x activity or stress factor
activity factor for bed rest/sedentary
1.2
activity factor for ambulatory
1.3
activity factor for anabolic
1.5
stress factor for non-malnourished adult s/p minor surgery
1.2
stress factor for adult w/ongoing sepsis, severe thermal injury, or hx severe malnutrition
1.4-1.5
If actual BW <130% IBW use
actual BW
if actual body >130% IBW use
nutritional BW
obese pts (>150% IBW) use
IBW
**goal daily calories fi non-stressed, non-depleted
20-25 kcal/kg/d
**goal calories if trauma/stress/surgery/critically ill
25-30 kcal/kg/d
**goal calories if major burn
35-40 kcal/kg/day
**goal calories for obesity
22-5 kcal/kg/day
use IBW
**goal protein for maintenance
0.8-1 g/kg/d
**goal protein for mild-moderate condition (repletion/med floor)
1-1.5 g/kg/d
**goal protein for mod-severe condition (trauma, surgery, ICU)
1.5-2 g/kg/d
**goal protein for burn
2-2.5 g/kg/d
**goal protein for obesity (>150% IBW)
2 g/kg/d
use IBW
standard distribution of non-protein calories
70% dextrose
30% fat
concurrent disease states for adjusting distribution of non-protein calories
DM, renal, hepatic dx
blood sguar
TG
concurrent infx of sepsis (consider omitting fat)
How to measure energy expenditure
indirection calorimetry
R!=VCO2/VO2
Goal R1=0.85-0.95
If RQ>1 = overfeeding and lipogenesis
RQ values for oxidized substrates
0.7 for fat
0.8 for proteins
1 for carbs
Phsyiologic adv of EN over PN
maintain gut integrity, prevent villi atrophy
immunologic adv of EN over PN
fewer infectious complication than PN, prevent bacterial translocation
safety adv of EN over PN
avoid catheter sepsis, embolus, arterial laceration, pneumothorax
cost adv of EN over PN
less expensive than PN, less equipment/personnel
less waste
indications for NE
inability to consume o abs adequate nutrients due to inability to consume orally (burn/trauma) or where oral consumption is contraindicated
contraindications for oral consumption
CVA; dysphagia dementia head and neck surgery esophageal obstruction trauma/burn
contraindications for EN
expected need <5-10d severe acute pancreatitis high-output proximal fistuals inability to gain access intractable vomiting and diarrhea GI ischemia ileus
describe continuous EN admin
pump, lower risk for abdominal distention d/t smaller volume, better tolerated
describe intermittent EN admin
several feeds, gravity admin; >200 ml over 20-30 min
describe bolus EN admin
> 200 mL over 5-10 min in gastostomy; higher aspiration risk
but adv is fewer feedings
describe cyclic EN admin
over 8-20 h/d, depending on volume tolerance
also uses a pump, spread out over more time
What is the usual calorie density of EN formulation?
1-2 kcal/mL
What is the usual calorie density of EN formulations for fluid restriction?
2 kcal/mL
What is the carb content of EN formulations?
glucose polymers for TFs, simple glucose for PO supplements
what is the protein content for EN formulations?
intact or partially digested peptides (malabs or diarrhea)
what is the fat content of EN formulations?
long, medium-chained FAs
What are non-macronutrients included in EN formulations?
fiber water electrolytes MVI trace elements
What are immune-modulating ingredients in EN formulation?
omega-3 FAs
gluatmine
arginine
What are appropriate EN formulations for pts w kidney disease?
calorically dense
var. protein
low elytes
What are appropriate EN formulation for pts w liver disease
higher BCAA/AAA ratio, high calories
What are appropriate EN formulations for pts w lung disease?
high fat
low carb
What are appropriate EN formulation mods for pts w DM?
high fat
low carb
What are appropriate EN formulation mods for pts that need immune modulation?
glutamine
arginine
omega-3 FAs
EN supplements for protein
1 gel tube Prostat = 15 g protein
1 packet Beneprotein = 6 g protein
En supplements for carbs
polycose, cuocal, benecalorie
EN supplements for fiber
benefiber
Mechanical EN complications
feeding tube misplacement, clogging, aspiration
airway/GI injury leading to resp compromise or abdominal abscess/infx
GI complications of EN
gastroparesis
GERD
diarrhea
constipation
metabolic complications of EN
hyperglycemia
elyte, vit, mineral def
refeeding syndrome
dehydration
Initial monitoring parameters for EN
I/O
wt
feeding tube position and site
gastric residual volume
daily monitoring parameters for EN
I/O
wt
number and consistency of stools
abdominal distention
prn monitoring parameters for EN
chemsticks
feeding tube position and site
gstric residual volume
Oral med admin w/EN
common
many meds can be crushed, admin’d in feding tube, then flushed w sterile water
do NOT crush meds w special delivery systems
avoid mixing liquid meds w EN formulation d/t phys incompatabilities
How to unclog feeding tubes
pancreatic enzyme tablet
NaHCO3 tab
10 mL warm water
How to prevent drug-nutrient interactions w continuous feed EN
interrupt to give meds
how to prevent drug-nutrient interactions w bolus feed EN
space meds btw TFs
Example of drug-nutrient interactions in EN
phenytoin fluoroquinolones tetracyclines warfarin PPIs (omeprazole, lansoprazole)
Describe TNA PN formulation
Total Nutrient Admixture or 3-in-1
carbs, fat, and AA in same IV admixture
milky appearance
Describe 2-in-1 PN formulation
carbs, AA in same admixture
several commercially prepared pre-mixed formulations
fat infused separately
Central PN
delivered by a large diameter vein
Central line (SC, IJ, femoral) or PICC
PPN
periphal parenteral nutrition
by peripheral vein of hand or forearm
limitations of PPN
dextrose 12.5%
Ca and Phos content
Osmolarity (max 900-1100 mOsm/L)
PPN not recc’d for
severe stress
malnutrition
considerable caloric/elyte reqs
PN >5 d
indications for PPN
nonfunctioning/inaccessible GI tract: bowel ischemia intractable vomiting/diarrhea hyperemesis gravidum GI bowel obstruction/ileus severe IBD short bowel syndrome
prolonged NPO course >7d
contraindications for PN
functioning GI tract treatment <7d in pts w/o severe malnutrition inability to obtain venous access prognosis does not warrant PN when risks exceed benefits
max carb utilization rate
4-5 mg/kg/min
proprofol 10% provides
1.1 kcal/mL
PN for egg allergy pts?
cannot use fat emulsion bc egg yolk phospholipid is used
max intake of fat emulsion in PN
2.5 g/kg/d lipid
not to exceed 60^ of daily caloric intake
EFAD
essential fatty acid deficiency
must include lineoleic and linolenic acid
can result from several day sof therapy w/o fat supplementation
Na in PN
1-2 mEq/kg/d
added as Cl, acetate, or phosphate; largely dep on fluid balance of pt
K in PN
1-2 mEq/kg/d
added as Cl, acetate, or phosphate
Phosphorus in PN
20-40 mM/d
1 mM phosphate supplies 1.33 mEq Na or 1.47 mEq K *****
Ca in PN
10-15 mEq/d
added as gluconate; watch Ca-Phos to avoid precip
Mg in PN
8-20 mEq/d
high demands in catabolic/malnourished pts
vitamins in PN
RDA
include ADEK, ascorbic acid, B complex
trace elements in PN
RDA
include Zn, Cu, Mn, Chromium, selenium
increased Cl ratio (vs acetate) for micronutrient PN rec’d in:
metabolic alkalosis d/t K def
loss of gastric contents from vomiting
gastric decompression
When is an increased acetate ratio (vs Cl) rec’d for micronutrients in PN?
RF metabolic acidosis due to excessive bicarb loss in RTA massive diarrhea small bowel pancreatic fistulas
Acetate is converted in the body to ___ in a ___ ratio
bicarbonate
1:1
PN solutions are intially formulated to provide ___ of cation salts as __ and __ as ___
2/3 as chloride
1/3 as acetate
Possible additives in PN
H2-antagonists
Regular Insulin
Heparis is mostly EXCLUDED
Albumin should NOT be added to PN
Regular insulin in PN
hyperglycemia cases:
0.1 U/2.4 kcal dextrose
high insulin req should be maintains via separate drip
[don’t include <10 U b/c binds to plastic; really only for long term insulin needs]
What are examples of mechanical complications in PN?
infusion pump failure
catheter-related: pneumothorax, migration to wrong vein, improper position w/in cardiac chambers, arterial puncture, bleeding
What are examples of infectious complications in PN?
central venous catheter (CVC) infx
infx 2/2 soln contamination (rare)
What are examples of metabolic complications of PN?
liver disease hypertriglyceridemia hyperglycemia refeeding syndrome essential FA def metabolic bone disease
When to monitor Chem 6 for PN?
initially, daily (unstable), 1-2 x /wk (stable)
same for BUN, SCr, and glucose!
When to monitor albumin for PN?
initially
1-2 x/wk 9stable)
when to monitor prealbumin in PN?
prn
Monitoring PT/INR prn n PN is useful bc
bleeding risk
assess certain micronutrients: vit K, Calcium
Describe Refeeding Syndrome
fluid and elyte abnorm ass’d w metabolic complications that devo during nutrition repletion in malnourished pts
for example, new glc load –> insulin –> ATP –> need phos –> hypohpos (symp)
insulin –> decr K –> hypokal –> hypomag
Important clinical manifestations of hypophosphatemia
Sz
coma
death
Important clinical manifestations of hypokalemia
cardiac arrhythmia
atrial tachycardia
sudden death
Important clinical manifestations of hypomagnesemia
Sz
coma
death
Important clinical manifestations of vitamin/thiamine deficiency
lactic acidosis
death
Important clinical manifestations of sodium retention
fluid overload
pulmonary edema
cardiac decompensation
How to prevent refeeding syndrome
identify pt at risk
correct elyte abnormal before nutrition
start low and go slow: ~25% of goal on day 1, incr over 3-5 d
___ affects the stability of IV lipids
pH: coagulates in acidic environment
this leads to problems when try to acidify bags to avoid CaPhos precip
TPN Destabilization to look out for
aggregation and cracking of lipid
Precipitation of CaPhos
how to reduce destabilization of lipds
keep AA conc at 2.5% or more
pH >5.0
dextorse conc >3.3%
avoid trivalent cations (iron dextran)
avoid mixing dextrose and lipid directly
add lipid last
how to calculate protein calories
g protein x 4 kcal/g
how to calculate non-protein claories
total kcal - protein kcal
How much space in the TPN should be used for electolytes/additives?
~150 mL
Always start a TPN at no more than ___ of goal.
50%
25% if at risk for refeeding is good start
Some appropriate monitoring factors for TPN
Accucheck BUN Cr elytes (chem-6, Mg, Phos, Ca) LFTs alb/pre-alb CRP PT/INR TG
what is the appopriate filter size for 2-in-1 TPN?
0.22 micron
What is the appropriate filter size for 3-in-1 TPNs?
1.2 micron
How to d/c TPN?
taper progressively and be sure to d/c insulin
Max admin of TPN in cycling TPN
200 mL/hr
Nutrition in short bowel syndrome
recs based on presence/absence of a colon:
w/ colon: high car-low fat (80/20)
consider vit B12 supp
Nutrition in DM pts
maintain glc btw 110-220 mg/dL
**140-180 mg/dL in critically ill pts
Give 30% of total kcal as fat
Gastric atony and delayed emptying is typical in type 1 DM
nutrition in cardiac disease pts
avoid overfeeding
fluid restriction
Nutrition in renal disease
fluid restriction : 2kcal/mL EN formula
pre-dialysis: low protein
w/ renal insuff (<30 mL/min): 0.5-0.8 g/kg
w/o renal insuff: 0.5-01 g/kg
dialysis: standard protein
Intermittent HD: 1-1.3 g/kg
continuous renal replacement therapy (CRT): 1.5-2 g/kg
Nutrition in pulmonary failure
Calories: 20-30 kcal/kg
give 30-50% of total kcal as far;
protein: 1-2 kg/kg
limit carbs: avoid overfeeding
Nutrition in hepatic disease
high caloric intake: 35 kcal/kg/day
no encephalopathy, standard protein: 1-1.2 g/kg/d
encephalopathy: protein restriciton 0.6 g/kg/d
Na restriction if ascites or edema
Other special pops in Nutrition
acute pancreatitis surgical subsets: trauma, TBI, open abdomen, burns sepsis SICU chronically critically ill obese critically ill
*Nutrition in GERD
make sure H2 antag or PPI is ordered, place in TPN if able (famotidine)
*Nutrition in NG suctioning
may cause hypnatremia, hypokalemia, and/or hypochloremia
*Nutrition in N/V
may lead to hypovolemia, Na+ imbalance, hypokalemia
*Nutrition in dialysis
removes 10-20% AAs
*Nutrition in wound healing
consider adding zinc, vitamin C
*Nutrition w loop diuretics
May cause hypokalemia Na+ balances
*Nutrition w steroids
may incr blood sugars, may need to add insulin
Use NBW if BMI
> 30
