Enteral and Parenteral Nutrition

Question 1

When is it acceptable to use parenteral nutriton?

Answer 1

• Enteral nutrition is better than parenteral nutrition
• in pts with no nutritional deficiencies, no nutrition is better than enteral

Question 2

How many kcal in 1 gram of protien?

Answer 2

4 kcal

Question 3

How many kcal in 1 gram of dextrose?

Answer 3

3.4 kcal

Question 4

How many kcal in 1 gram of fat?

Answer 4

9 kcal

Question 5

What are indications for enteral nutrition?

Answer 5

• hemodynamically stable pt at risk of malnutrition
• oral feedings will be inadequate for several days

Question 6

What are contraindication for enteral nutrition? (6)

Answer 6

• complete intestinal obstruction
• GI fistula
• extreme short bowel
• severe diarrhea or vomiting
• hemodynamic instability or intestinal ischemia (not enough blood to the intestine)
• paralytic ileus (inablility to move food through GI because of paralytic activity)

Question 7

What are the advantages of enteral over parenteral?

Answer 7

• maintain gut integrity
• prevent stress ulceration
• improves outcomes
• more physiologic
• less costly
• less risk of infection

Question 8

What are the six types of feeding tubes?

Answer 8

• orogastric- mouth to stomach
• nasogastric- nose to stomach
• nasoduodenal- from the nose to the duodenum
• nasojejunal- through the nose and into the jejunum
• gastrostomy- opening in the stomach
• jejunostomy- surgical opening in the jejunum

Question 9

When would you use a nasogastric (NG) tube?

Answer 9

• short term
• prolong use can cause sinusitis or nasal mucosal ulceration
• cannot use in pt with gastric ileus

Question 10

What are the pros and cons of nasoduodenal/nasojejunal?

Answer 10

• smaller and more flexible than NG tubes
• easier to clog, required continuous infusion feeds

Question 11

What is a PEG tube?

Answer 11

Percutaneous endoscopic gastrostomy

Question 12

When would you perform a gastrostomy?

Answer 12

• Long term use
• PEG requires continuous infusion of feeds

Question 13

When would you perform a jejunostomy?

Answer 13

• long term use
• facilitate immediate postoperative or post injury feeding

Question 14

Why would would opt for an enteral feeding pump in a hospital?

Answer 14

• reduced risk of aspiration compared with bolus feedings
• cyclic feeding are administered for 10-12 hours overnight to allow for mobility during the daytime

Question 15

What is usually in an enteral formula?

Answer 15

• contains carbohydrates, fat, protien, electrolytes, water, vitamin, and trace elements
• ex: ploymeric, monomeric (elemental), disease specific, modular

Question 16

What are the specifics of polymeric (intact) enteral formulas?

Answer 16

• formulas are used in patients with normal digestive process
• contain 1-1.2 kcal/mL
• generally inexpensive
• some formulas are concentrared for patients requiring fluid restriction and contain 2 kcal/ML

Question 17

What are the specifcs of monomeric (elemental) enteral formulas?

Answer 17

• easily digested for pts with impaired digestive capacity or malabsorption
• more expensive than polymeric EN

Question 18

What are the disease specific EN formulas?

Answer 18

• renal formulas (magnacal renal)
• pulmonary formulas (pulmocare)
• diabete formulas (glucerna)
• hepatic formulas (NutriHep)

Question 19

What does an EN renal formula consist of?

Answer 19

• concentrated (2 kcal/mL)
• low protein formula for non-dialysis pts
• high protein formula for dialysis pts

Question 20

What does an EN pulmonary formula consist of?

Answer 20

• more calories from fat to reduce CO2 production
• facilitate vent weaning
• controversial and expensive

Question 21

What does an EN diabetic formula consist of?

Answer 21

Low sugar, extra fiber

Question 22

What does an EN hepatic formula contain (ingredient)?

Answer 22

more branched chain AA less aromatic AA
may improve encephalopathy

Question 23

What is in the modular enteral nutrition formula?

Answer 23

• Carbohydrate (Polycose)
• Protein powder (ProSource)
• Fat (corn oil, MCT Oil)

Question 24

What are the complications to enteral feeding?

Answer 24

• Improper tube placement
• clogged feeding tubes (flush feeding tube with warm water, soda, pancreatic enzymes, or bicarb)
• aspiration pneumonia (keep head elevated, gastric residual monitoring possibly effective, start at a slow rate)
• diarrhea
• constipation can be prevented by adding fiber or metoclopramide
• dehydration
• hypernatremia occurs when pts are given insufficient water (1mL of water per calorie)

Question 25

How does one develop an enteral feeding regimen?

Answer 25

1. Determine caloric requirements 2. Choose forumla and asses the calories per milliliter 3. Determine infusion rate 4. Make sure patient will receive enough protein 5. Make sure patient will receive about 1 mL of water each calorie

Question 26

How do you determine carloric requirements?

Answer 26

25-30 kcal/kg/day or use Harris Benedict equation

Question 27

What are the options for EN formula concentration?

Answer 27

1, 1.2, 1.5, or 2 kcal/mL

Question 28

How do you determine the infusion rate?

Answer 28

(volume of EN) / 24 hours

Question 29

How do you administer drugs through an ET tube?

Answer 29

* use liquids diluted with 2-3 times the medication volume * diarrhea can happen with drugs that have high osmolality * flush with 20mL of water * do not crush SR or enteric coated pills * discontinue tube feedings before and after drug admin temp * consider feeding tube locatio and subsequent drug absorption

Question 30

When would you opt for parenteral nutrition?

Answer 30

IV nutrition indicated in pts with nonfunctioning or inaccesible GI tract if pt cannot be fed enteraly for 7 days

Question 31

What is TPN?

Answer 31

* Total parenteral nutrition * administered through central line * IV catheter where the tip is in the vena cava or adjacent to the right atrium * ex: PICC-- peripherally inserted central catheter

Question 32

Whar is PPN?

Answer 32

* peripheral parenteral nutrition * administered through peripheral line * won't give everything the person requires but better than nothing

Question 33

What are the types of PN?

Answer 33

* 2-in-1 -- amino acids and dextrose in one bag- liquids infused separately (increased risk of bacterial growth in lipids) * 3-in-1-- dextrose + amino acids + lipids

Question 34

What are the benefits and disadvantages of 3-in-1 PN formulation?

Answer 34

* nutrients all mixed in the same bag * stability dependent on final concentration of amino acid * acidic enviornment limits bacterial growth * shorter stability * cannot inspect for precipitates

Question 35

When components must be considered when developing a regimen?

Answer 35

* dextrose 70% is commonly used as a carb source (70% = 70 grams in 100mL-- 1 gram =3.4 kcal) * fat emulsion 10%, 20%, 30% * 20% is most commonly used-- available as 250mL that provide 2kcal/mL * should be 20-30% of total calories * amino acid 15% is commonly used -- 1g amino acid = 4 kcal * electrolytes added to maintain physiologic serum concentrations * multivitamins and trace elements supplemented

Question 36

How do you develop a parenteral feeding regimen?

Answer 36

1. determine caloric requirements 2. determine fluid requirements (1500mL for first 20kg with 15-20mL/kg additional) 3. determine protien requirements (0.8 to 2.5g/kg/day-- use ideal body weight) 4. subtract calories from protein (20-30% total calories from lipid emulsion and remainder from dextrose) * max dextrose infusion rate of 4-6 mg/kg/min * max lipid infusion rate of 0.1g/kg/hr

Question 37

What can be used for daily maintenance amount of electrolytes, vitamins and trace elements?

Answer 37

* sodium and potassium can be given as chloride or acetate * chloride can cause acidosis, useful in pts with alkalosis * acetate converted into bicarb-- useful in metabolic acidosis * parenteral multivitamin should be added daily (additional thiamine supplemented in pts with alcohol use)

Question 38

What is in tralement?

Answer 38

* selenium * copper * manganese * zinc

Question 39

When would you need to use tralement?

Answer 39

* pt with high-output fistulas, diarrhea, burns, or open wounds may need **zinc** supplementation * pt with chronic diarrhea, malabsorption and short-gut syndrome may require additional **selenium** supplementation * pt with severe cholestasis should have **copper** and **manganese** restricted to prevent accumulation and toxicity because both undergo biliary elimination

Question 40

What are possible complications of PN?

Answer 40

* calcium and phosphate precipitation (use calcium gluconate; more acidic increases solubility) * many meds are incompatible with TPN * risk of catheter related infection * acid-base abnormalities (mitigated through changing from acetate to chloride salts) * hyperglycemia (treated with insulin outside of TPN) * overfeeding * gut atrophy * aluminum toxicty (long term PN use in pt with renal dysfunction-- brittle bones and encephalopathy * refeeding syndrome * hypertriglyceridemia

Question 41

What are conclusions that can be made about parenteral and enteral feeding?

Answer 41

* enteral is preferred if it can be safely done * PPN can't deliver adequate calories and nutrients * process for constructing a TPN regimen that meets the nutritional need of the pt