Enteral and Parenteral Nutrition Flashcards
What are some of the consequences of malnutrition?
Weakness and loss of muscle mass Apathy and depression Reduced immune response Poor wound healing Increased morbidity and mortality
Who needs artificial nutrition?
Patients who fail to maintain their nutritional status, this is simply patients who can’t meet their requirements by eating and drinking ‘normally’
What are the usual normal feeding aims?
Energy 25-35kcal/kg/day
Protein 0.8-1.5g/kg/day
Fluid 30-35ml/kg/day
Adequate electrolytes, minerals, micronutrients and fibre
How does refeeding affect the normal feeding aims?
Should use no more than 50% of targets
What is the nutrition team?
A multidisciplinary team including consultants, junior doctors, pharmacists, dieticians, nurses, biochemists
How can we feed patients?
Normal diet Softened diet Enteral nutrition IV fluids Parenteral nutrition (TPN)
What is enteral nutrition (EN)?
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)
What are some of the benefits of enteral nutrition?
More physiological Less risk of infection Maintain GIT Costs less Easier for patients Calorie control
Who needs EN?
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)
What is a risk when using EN?
Refeeding syndrome
What are the routes of administration of EN?
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
What are some of the problems associated with EN?
Diarrhoea (10-25% of patients) Regurgitation Abdominal distension Blocked feeding tubing Problems with the pump Taste and patient acceptability Dislocation of tubes, especially NG
How are sip feeds obtained?
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
What are some examples of sip feeds?
Milk based products e.g. Fortisip, Complan Fruit juice based e.g. Fortijuice Semi-solid (stroke patients) High protein (burns) Energy supplements (renal patients)
What are some of the considerations needed when administering a drug down an enteral feeding tube?
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?
When administering drugs via EN, you should?
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
What are the 2 ways in which drugs can interact with enteral feeds?
Directly with the feed e.g. Ciprofloxacin
Physiological interactions e.g. disturb anticoagulation (warfarin) by decreasing vitamin K
What NPSA patient safety alert was put out on oral syringes?
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
When should total parenteral nutrition (TPN) be given?
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
In what scenarios is TPN given short term?
Awaiting feeding tube Bowel obstruction Following major excisional surgery ICU patients with MOSF IBD patients Severe pancreatitis Pre-term neonates Acute intestinal failure
In what scenarios is TPN given long term?
Radiation enteritis Crohns disease following multiple resections Motility disorders Bowel infarction Cancer surgery Chronic intestinal failure
How can we give TPN short term?
Peripheral TPN via venflon - enters at the forearm
How can we give TPN long term?
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
How is TPN given/done initially?
Tend to underfeed and build up calories slowly
What needs to be considered when designing a TPN regimen?
Length of intended treatment
Route of administration (venflon, PICC, central line)
Osmolality (peripheral <900mosmol/L, 1800kcals, PICC <1200mosmol/L, 2000kcals, central <1700mosmol/L, >2000kcals)
What PN bags are available in the UK?
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
Where are PN bags made?
In aseptic suites in a sterile environment with careful stability checks
All units are monitored by the government
What are the basic contents of a TPN bag?
Macronutrients (nitrogen, glucose, fats, fluids)
Micronutrients (electrolytes, vitamins, trace elements)
Drugs (compatibility needs to be checked, very important since these are direct access lines)
What are the biochemical monitoring requirements for patients on TPN?
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
What are the patient monitoring requirements for TPN?
Weight Height Temperature Line site GI function (N&V, bowels, distention) Nutrient intake
What are some of the complications of TPN?
Air embolism or insertion problems Catheter blockage Line infections Metabolic problems (e.g. hypo/hyperglycaemia, impaired liver function) Bone disease Refeeding syndrome
What is refeeding syndrome?
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
What patients are at risk of refeeding syndrome?
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
How can we manage the risk of refeeding syndrome?
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
What nutrient levels should be maintained in refeeding?
Potassium 2-4mmol/kg/day
Phopshate 0.3-0.6mmol/kg/day
Magnesium 0.2mmol/kg/day