Enteral Nutrition Flashcards
What is nutrition support?
Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status
Define enteral nutrition
Enteral nutrition (EN): provision of nutrients into GI tract through tube when oral intake is inadequate
(may include formulas as oral supplements or meal replacements)
Define parental nutrition
provision of nutrients intravenously
List some of the impacts of malnutrition
Malnutrition – impacts on:
- Recovery from illness/surgery
- Risk of infection
- Wound healing
- Hospital stay
- Costs
what is the benefit of Early commencement of feeding
reduce mortality and post-op complications (within 24 hours)
What are the benefits of EN vs PN
Better gastrointestinal barrier function
* Preserved gastrointestinal immunity
* Preserved gut-associated lymphoid tissue (GALT)
activity
* Decreased rates of infection presumably unrelated
to GI tract (no central line or PICC)
* Cost
What are some conditions that often require EN?
Impaired nutrient ingestion such as neurologic disorders, HIV/AIDS, facial trauma, oral or esophageal trauma, congenital anomalies,
cystic fibrosis, traumatic brain injury
Inability to consume adequate nutrition orally: for example hyperemesis of pregnancy; hypermetabolic states such as burns and trauma, respiratory illness
Impaired digestion, absorption, metabolism
: from severe gastroparesis, inborn errors of metabolism, Crohn’s disease, short bowel syndrome with minor
resection
Severe wasting or depressed growth * cystic fibrosis, failure to thrive, cancer, sepsis, cerebral palsy
Non-functioning parts of the upper GI tract
Describe the Nasogastric route and the advantages and disadvantages
Gastric = into stomach
Beetter for Short-term: up to 3 or 4 weeks
and requires Normal GI function
ADV:
* Large reservoir
* Maintain gut function
* Bolus, intermittent, or continuous infusions
DIS:
* Increased risk of oesophageal reflux and/or aspiration
* Facial irritation
What are some considerations for EN access?
EN access depends on:
Anticipated length of time of enteral feeding
* Risk for aspiration or tube displacement
* Presence/absence of normal digestion and absorption
* Gastric = into stomach
* Duodenal = into the first part of the small intestine
* Jejunal = into the second part small intestine
Describe the advantages and disadvantages of the Nasoduodenal or nasojejunal route EN?
- Short-term: up to 3 or 4 weeks
- Gastric motility disorders, esophageal reflux, or persistent nausea and vomiting
ADV:
* Can be used for early enteral feeding (4-6 hours after trauma)
* May reduce risk of reflux/aspiration
DIS:
* Intolerance
* Can be more difficult to place
* Risk of displacement/migration
* No gastric acid barrier against bacteria
Describe the advantages and disadvantages of a PEG (percutaneous endoscopic gastrostomy)
- Nonsurgical technique
- Preferred for longer than 3 to 4 weeks
ADV:
* Large reservoir
* Maintain gut function
* Bolus, intermittent, or continuous infusions
DIS:
* Increased risk of oesophageal reflux and/or aspiration
Describe the advantages and disadvantages of a PEJ (percutaneous endoscopic jejunostomy)
Nonsurgical technique
* Preferred for longer than 3 to 4 weeks
ADV:
* Can be used for early enteral feeding
* May reduce risk of reflux/aspiration
DIS:
* Intolerance
* Can be more difficult to place
* Risk of displacement/migration
* No gastric acid barrier against bacteria
The suitability of a feeding EN formula should be evaluated based on:
Functional status of GI tract
* Physical characteristics of formula (osmolarity, powdered/ready-made)
* Energy and nutrient content
* Digestion and absorption capability of the patient
* Clinical considerations, such as fluid and electrolyte status and organ/system function
* Cost-effectiveness
Describe the osmolarity of EN Formula?
Osmolality
o The concentration of a solution expressed as the total number of solute particles per kg
o Iso-osmolar (300-500mOsm/kg) – same as blood
o Facilitates gastric emptying and optimises absorption
o Higher = inhibit gastric emptying
o Be careful when feeding directly into the small bowel
EN Formula selection
Generally, use standard polymeric feed (1kcal/ml) e.g. jevity or nutrision multi fibre, osmolite or nutrision
standard; but may also use standard no fibre e.g. Osmolite
* Might use specialist feed e.g. nepro, novasource renal, Jevity Hi Cal, semi-elemental, elemental
what are some considerations with EN administration?
- Feeds are heat and light sensitive
- Closed feeds – can hang for 24 hours
- Open feeds – can hang for 4 hours max
- Hospitals will usually make up 24 hours of feed at a time and store in bottles (eg. QCH uses 130ml and 240ml bottles, can order any amount of formula in 10ml increments. Adult facilities usually use
ready to hang versions)
how should the bed be positioned for feeds?
Positioning – Head of bed at 30–45-degree angle
what are the three types of EN administration?
Continuous: via gravity/infusion pump (flow rate ranges from 1 to 400ml/hr in 1ml increments)
- Generally, start with 20-40ml/hr for 4-6/24 and increase by 20ml/hr every 4-6/24 as tolerated (adults)
Intermittent/cyclic: as above 4–16-hour break
Bolus: up to 50-500 ml rapid delivery via syringe/gravity 3 or 4 times (or more) daily
- Start small and increase as tolerated
why are water flushes important and how often should they occur
Water flushes
* Minimises blockages and ensures tube patency
* Contributes to fluid requirements
* Continuous feeds: flush 4 to 6 hourly
* Intermittent feed: flush at start and end of feed + q4hrly
* Bolus feeds: flush before and after feeds and meds
* Can do additional flushes to meet fluid requirements
what are some complications of enteral feeding?
- Access problems (eg. tube displacement or obstruction, leakage)
- Administration problems (eg. aspiration, regurgitation, microbial contamination, inadequate delivery)
- Gastrointestinal complications (eg. nausea/vomiting, delayed gastric emptying, high gastric residuals,
constipation, diarrhea, malabsorption, ileus) - Metabolic complications (eg. refeeding syndrome, glucose intolerance, dehydration/overhydration, drugnutrient interactions)
what is refeeding syndrome (RFS)?
“Metabolic and electrolyte alterations occurring as a result of the reintroduction and/or increased provision
of calories after a period of decreased or absent caloric intake” – ASPEN Consensus Recommendations
for Refeeding Syndrome, 2020
What is the diagnosis criteria for RFS (refeeding syndrome)
Specifically, RFS diagnostic criteria are outlined as the following:
* A decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%–20%
(mild RS), 20%–30% (moderate RS), or >30% and/or organ dysfunction resulting from a decrease in
any of these and/or due to thiamin deficiency (severe RS).
* And occurring within 5 days of reinitiating or substantially increasing energy provision
Describe the management of RFS in at risk patients.
Slow increase of feeds or oral intake – main concern is glucose intake
* 42-84kJ/kg for first 24hrs
* Increase by 33% every 1-2 days until goal rate achieved
* If at high risk wait until electrolytes are supplemented before increasing feeds
Monitor electrolytes - K, Mg, PO4
* Before and daily once feeds are commenced
* If any low à Electrolyte repletion – medical team to commence
* Thiamine 100mg before feeds start and daily after
* Supplement with routine MV at least 10 days
What needs to be monitored in patients recieving EN?
Weight (at least 3 times/wk or minimal weekly)
* Signs and symptoms of edema (daily)
* Signs and symptoms of dehydration (daily)
* Fluid intake and output (daily)
* Adequacy of enteral intake (at least 2 times/wk)
* Abdominal distention and discomfort
* Serum electrolytes, blood urea nitrogen, creatinine, (2-3 times/wk)
* Serum glucose, calcium, magnesium, phosphorus, (weekly or as
ordered)
* Stool output and consistency (daily)
how to transition from EN to oral
- Reduce enteral to night only to reestablish hunger/satiety cues (if safe)
- Remove from continuous feeding to a 12- then 8-hour formula administration cycle
- Cease feeds during mealtimes
- May reduce size of bolus feeds
- Need to monitor both EN and oral intake effectively to guide decision making
- Think about fluids
