Enteral Nutrition

Question 1

EN is the _______ route of nutritional support

Answer 1

preferred

Question 2

EN benefits

Answer 2

maintains intestinal integrity and immune function
dec risk infectious and metabolic complications compared to PN
stimulates biliary function and dec potential for cholestasis and cholelithiasis

Question 3

EN routes

Answer 3

nasal
PEG, Gastrostomy
Jejunostomy

Question 4

gut defenses

Answer 4

HCl kills bacteria
mucosal layer prevents bacterial adherence
peristalsis
environment favors good anaerobic bacteria

Question 5

bedside/short term routes

Answer 5

nasogastric (NG), orogastric (OG), esophagostomy

Question 6

surgical/long term routes

Answer 6

gastrostomy, PEG, PEJ

Question 7

jejunostomy j-tube indication (PEJ)

advantages
disadvantages

Answer 7

long term
impaired GE aspiration
(+) : earlier feeding, comfort, reduced aspiration
(-) : procedure risk, smaller tube, NO BOLUS FEEDS, site complications

Question 8

Gastrostomy G tube (PEG) indication

advantages
disadvantages

Answer 8

long term
normal GE

(+) : all feeding methods, comfort, larger tube
(-) : procedure risk, aspiration, site complications

Question 9

NG, OG indication

advantages
disadvantages

Answer 9

short term
intact gag
normal GE
  (+) : ease of placement, inexpensive, all feeding methods
  (-) : tube placement, aspiration

Question 10

ND (nasoduodenal), NJ (nasojejunal) indication

advantages
disadvantages

Answer 10

short term
aspiration
impaired GE aspiration

(+) : potential reduced aspiration risk, earlier feeding
(-) : skill for placement, smaller tube, NO BOLUS FEEDS

Question 11

what access options for EN can we not do bolus feeds through

Answer 11

ND (nasoduodenal), NJ (nasojejunal) and jejunostomy J-tube

Question 12

what access option for EN does not allow for crushed meds

Answer 12

jejunostomy J-tube

Question 13

continuous method of admin

Answer 13

gastric, small bowel

method of choice in the ICU and other hospitalized patients

Question 14

cyclic method of admin

Answer 14

gastric, small bowel
usually at night
provides supplemental nutrition

Question 15

bolus method of admin

Answer 15

gastric
quick, convenient, physiologic
avoid if high aspiration risk (ND, NJ, J-tube)
avoid in poor gastric emptying

Question 16

intermittent method of admin

Answer 16

slower

for those who do not tolerate bolus feeds

Question 17

+ and - of early EN

Answer 17

early EN is within 48h of admin
+ : attenuates stress response, dec inflammatory cytokines and dec impact on gut permeability, may reduce disease severity and infectious complications
-: delay early EN if pt is hemodynamically unstable. initiate when fluid resuscitated and vasopressors are w/drawn

Question 18

EN is not warranted for _________

Answer 18

well-nourished, mild-mod stressed adult patients who are not critically ill

Question 19

how long can we delay EN for

Answer 19

up to 5-7d

Question 20

standard polymetric formulas for EN

formula is like “baby formula” not a math formula

Answer 20

recommended for most patients
usually 1-2kcal/mL
fiber content
selection based on meeting protein needs
isosource HN, replete fiber, isosource 1.5 cal

Question 21

which standard formula has highest CHO

Answer 21

Isosource 1.5 cal

Question 22

which standard formula has the highest fat %

Answer 22

Isosource 1.5 cal

Question 23

which standard formula has the highest fiber content

Answer 23

REPLETE FIBER

Question 24

isosource HN

Answer 24

house-formula
fiber free
isotonic
pre-ESRD

Question 25

replete fiber

Answer 25

high protein with fiber wound healing

Question 26

Isosource 1.5 cal

Answer 26

``` high protein lower CHO (still higher than others though) ```

Question 27

what specialty enteral formula is for renal dysfunction

Answer 27

NOVASOURCE RENAL

Question 28

what specialty enteral formula is for hepatic dysfunction

Answer 28

NUTRIHEP

Question 29

If GIT is functioning, patient requires enteral support, and theres no organ dysfunction, which formula do we use?

Answer 29

standard (isosource HN, replete fiber, isosource 1.5 cal)

Question 30

If GIT is functioning, patient requires enteral support, and theres no organ dysfunction, standard formula is used but not tolerated well, which formula do we use?

Answer 30

specialty

Question 31

EN monitoring: Gastric Intolerance

Answer 31

contributes to aspiration requires holding feeds GVR (gastric volume residuals) = vol in stomach after given intervals SHOULD BE <50mL sx of tolerance: flatus and stools, neg abdominal xray, abdominal exam, no bloating, distention, abd pain

Question 32

Are sx of intolerance or GVR a better measure of overall tolerance

Answer 32

sx of intolerance

Question 33

ways to prevent GI intolerance with EN

Answer 33

keep HOB 30-45 deg. minimize opioids correct fluid and electrolyte abnormalities continuous feeding>bolus prokinetic agents: Metoclopramide (10mg q6h, dec dose 50% if CrCl<40) Erythromycin 3-7mg/kg/day

Question 34

EN complications: diarrhea definition contributing factors antidiarrheals when?

Answer 34

>3 liquid stools on 2 consecutive days rate of feeding, formula composition, lack of fiber, contamination, broad spec ABX (C diff) meds antidiarrheals only ok if infectious causes are ruled out

Question 35

EN complications: bowel ischemia RFs prevention

Answer 35

RF: neonates, critically ill, imm suppressed, jejunal feeding, hyperosmolar feeds, discolored peristalsis prevention: delay feeding until fo=ully volume resuscitated, initiate w iso-osmolar, fiber free formula, monitor for s/sx

Question 36

metabolic complications

Answer 36

glucose, fluid, electrolytes, macronutrient and micronutrients pertubations

Question 37

mechanical complications

Answer 37

feeding tube occlusion, malposition, nasopulmonary intubation

Question 38

infectious complications

Answer 38

aspiration, sinusitis, gastric tube

Question 39

monitoring of hospital patei\\ients

Answer 39

``` fluids, weights qd glucose q1-6h elec daily-TIW LFT, visceral proteins, CBC, PT/PTT 1-2x/week protein turnover weekly GI tolerance daily up to q4h ```