Enteral and Parenteral Nutrition

Question 1

What are some of the consequences of malnutrition?

Answer 1

Weakness and loss of muscle mass
Apathy and depression 
Reduced immune response 
Poor wound healing 
Increased morbidity and mortality

Question 2

Who needs artificial nutrition?

Answer 2

Patients who fail to maintain their nutritional status, this is simply patients who can’t meet their requirements by eating and drinking ‘normally’

Question 3

What are the usual normal feeding aims?

Answer 3

Energy 25-35kcal/kg/day
Protein 0.8-1.5g/kg/day
Fluid 30-35ml/kg/day
Adequate electrolytes, minerals, micronutrients and fibre

Question 4

How does refeeding affect the normal feeding aims?

Answer 4

Should use no more than 50% of targets

Question 5

What is the nutrition team?

Answer 5

A multidisciplinary team including consultants, junior doctors, pharmacists, dieticians, nurses, biochemists

Question 6

How can we feed patients?

Answer 6

Normal diet 
Softened diet 
Enteral nutrition 
IV fluids 
Parenteral nutrition (TPN)

Question 7

What is enteral nutrition (EN)?

Answer 7

Nutrition administered via the GIT
More used by patients in their own homes
Most feeds are prescribable by the NHS
Nutritionally complete (including vitamins, minerals and trace elements)

Question 8

What are some of the benefits of enteral nutrition?

Answer 8

More physiological
Less risk of infection 
Maintain GIT
Costs less
Easier for patients 
Calorie control

Question 9

Who needs EN?

Answer 9

Eating and swallowing difficulties (facial injury, surgery, stroke, MS)
Severe intestinal malabsorption (Crohns, major GI surgery)
Those with increased nutritional requirements (severe burns)
Eating disorders (anorexia nervosa)
Self neglect (intentional or not)

Question 10

What is a risk when using EN?

Answer 10

Refeeding syndrome

Question 11

What are the routes of administration of EN?

Answer 11

Orally (as a sip feed/softened foods)
Naso-gastric tube (NG)
Percutanoeus endoscopic gastronomy (PEG) - tube passed into stomach through abdominal wall, long term feeding e.g. oesophageal problems
Percutaneous endoscopic jejunostomy (PEJ) - into jejunum

Question 12

What are some of the problems associated with EN?

Answer 12

Diarrhoea (10-25% of patients)
Regurgitation 
Abdominal distension 
Blocked feeding tubing 
Problems with the pump 
Taste and patient acceptability 
Dislocation of tubes, especially NG

Question 13

How are sip feeds obtained?

Answer 13

Can be given on FP10 for specific conditions as borderline substances
Otherwise can be purchased from pharmacy or supermarket, although should be taken under medical supervision
For many people, just short term

Question 14

What are some examples of sip feeds?

Answer 14

Milk based products e.g. Fortisip, Complan 
Fruit juice based e.g. Fortijuice 
Semi-solid (stroke patients)
High protein (burns)
Energy supplements (renal patients)

Question 15

What are some of the considerations needed when administering a drug down an enteral feeding tube?

Answer 15

Compatibility and formulation (is it an MR product?)
Are all drugs necessary?
Is there an alternative ROA?
Could another drug in the same class be used instead?

Question 16

When administering drugs via EN, you should?

Answer 16

Use liquid preparation where available 
Give each drug separately
Flush with >20ml of water before and after each drug 
Remember crushed tablets may block tube 
Not to be used for MR, e/c, or cytotoxic

Question 17

What are the 2 ways in which drugs can interact with enteral feeds?

Answer 17

Directly with the feed e.g. Ciprofloxacin

Physiological interactions e.g. disturb anticoagulation (warfarin) by decreasing vitamin K

Question 18

What NPSA patient safety alert was put out on oral syringes?

Answer 18

To only use oral syringes not compatible with IV lines to give oral medicines
Syringes should be different colours and marked oral/enteral
Three way taps should not be used to give oral medicines

Question 19

When should total parenteral nutrition (TPN) be given?

Answer 19

Only when EN is not an option
When patient cannot take anything by mouth or via GI tract e.g. dysphagic post stroke, trauma, surgery, ‘gut failure’ (inability to digest and absorb food)
Can be used short or long term

Question 20

In what scenarios is TPN given short term?

Answer 20

Awaiting feeding tube 
Bowel obstruction 
Following major excisional surgery 
ICU patients with MOSF
IBD patients 
Severe pancreatitis 
Pre-term neonates 
Acute intestinal failure

Question 21

In what scenarios is TPN given long term?

Answer 21

Radiation enteritis 
Crohns disease following multiple resections 
Motility disorders
Bowel infarction
Cancer surgery 
Chronic intestinal failure

Question 22

How can we give TPN short term?

Answer 22

Peripheral TPN via venflon - enters at the forearm

Question 23

How can we give TPN long term?

Answer 23

Peripherally inserted central catheter (PICC) (Hickman line) - enters at the arm into the heart
A central line (intrajugular, subclavian, femoral) - enters at the chest into the heart

Question 24

How is TPN given/done initially?

Answer 24

Tend to underfeed and build up calories slowly

Question 25

What needs to be considered when designing a TPN regimen?

Answer 25

Length of intended treatment
Route of administration (venflon, PICC, central line)
Osmolality (peripheral <900mosmol/L, 1800kcals, PICC <1200mosmol/L, 2000kcals, central <1700mosmol/L, >2000kcals)

Question 26

What PN bags are available in the UK?

Answer 26

Usually nutritionally complete (composition may vary from day to day e.g. vitamins)
Can get all in one mixtures off the shelf e.g. Kabiven, can add things to these bags
Can get tailor made bags (scratch regimens), made up from individual ingredients in aseptic pharmacy departments, they are patient specific/bespoke

Question 27

Where are PN bags made?

Answer 27

In aseptic suites in a sterile environment with careful stability checks
All units are monitored by the government

Question 28

What are the basic contents of a TPN bag?

Answer 28

Macronutrients (nitrogen, glucose, fats, fluids)
Micronutrients (electrolytes, vitamins, trace elements)
Drugs (compatibility needs to be checked, very important since these are direct access lines)

Question 29

What are the biochemical monitoring requirements for patients on TPN?

Answer 29

U&E's (Na, K, Ur, Cr)
Glucose
LFT's (including albumin baseline)
FBC (including folate and B12)
Trace elements (Mg, PO4, Ca)
Vitamins (selenium and zinc)
Fluid balance

Question 30

What are the patient monitoring requirements for TPN?

Answer 30

Weight
Height 
Temperature 
Line site 
GI function (N&V, bowels, distention)
Nutrient intake

Question 31

What are some of the complications of TPN?

Answer 31

Air embolism or insertion problems 
Catheter blockage 
Line infections 
Metabolic problems (e.g. hypo/hyperglycaemia, impaired liver function)
Bone disease
Refeeding syndrome

Question 32

What is refeeding syndrome?

Answer 32

Refeeding syndrome is a metabolic disturbance that occurs as a result of reinstitution of nutrition to people who are starved, severely malnourished or metabolically stressed due to severe illness
Characterised by abnormalities in fluid balance, glucose metabolism, vitamin deficiency, hypophosphatemia, hypomagnesaemia and hypokalaemia

Question 33

What patients are at risk of refeeding syndrome?

Answer 33

Patients who have had little or no nutritional intake for 5-10 days prior
BMI <18.5 kg/m2
Unintentional weight loss in preceding 3-6 months
High nutrient losses (K, Mg, PO4) prior to feeding

Question 34

How can we manage the risk of refeeding syndrome?

Answer 34

Introduce feeding at no more than 50% of normal requirements
Maximum 10kcal/kg/day increasing slowly to meet full needs by 4-7 days
Restore circulatory volume and monitor fluid balance
Provide oral thiamine, vitamins B, multivitamin
Treatment for around 10 days or until stable

Question 35

What nutrient levels should be maintained in refeeding?

Answer 35

Potassium 2-4mmol/kg/day
Phopshate 0.3-0.6mmol/kg/day
Magnesium 0.2mmol/kg/day