Enteral Nutrition Flashcards
Important consideration when assessing patients current weight
dry weight verses wet weight
* consider that changes in weight that exceed 2 kg in a week is outside the ‘normal’ rate of weight gain.
* Should be worried about fluid weight gain → Does the patient have edema (acute/ chronic)?
* What is their urine output like? (mL/kg/hr 1-2 is not great and <1 is seriously low)
consult tip sheet
Why is it important to review medical history of patient?
Need to consider chronic conditions
* Review history for coinciding diseases or presenting symptoms (e.g fever, GI intolerance, respiratory distress, presence of edema)
Why is it important to review laboratory data and medications?
- laboratory data to consider what factors may be important (e.g glucose in a patient with DM is important but may be limited value. Consider the utility of hemoglobin A1C for longer term glycemic control).
- Medications may influence nutrition absorption (and vica versa), nutrient utilization, GI symptoms etc.
What to consider in terms of nutritional needs/ nutrition support regimen
- NPO? (Yes/No?)
- Route of Administration
- Amounts ordered vs amounts received, taking into consideration anytime they will be off support
- Establish adequacy of current nutrition support regimen by determining nutritional requirements (this will be affected by acute illness)
When is oral supplementation indicated?
Oral supplementation (energy boosting) when decreased appetite due to illness, medical treatment
* Need to assess what food it is replacing
Indications for tube feeding
- When feeding efficiency is dramatically
- or when sole source of nutrition (partial and total enteral nutrition support)
- or when unsafe to consume anything orally (e.g dt swallowing issues leading to a high risk for aspiration of oral contents into lungs).
When is tube feeding considered?
Expected need for nutrition support greater than
* 5-10 days for adults
* for children 24-48 hours
Contraindications to EN
- Expected need for nutrition support less than 5-10 days (for adults); for children 24-48 hours (unless severely malnourished)
- When gut experiences significant dysfunction
- Severe coagulopathy leading to ACTIVE bleeding
- Severe portal hypertension
- Abdominal wall infection
- Massive Ascites
Situations for cautious use of EN
- peritoneal dialysis (EN feed carefully)
- Severe-acute pancreatitis; may feed carefully below Ligament of Trietz (chronic pancreatitis can feed higher up in the small bowel).
- with partial bowel obstructions can feed distal to obstruction very carefully
Examples of significant gut dysfunction
- High-output proximal fistulas; where IV replacement of fistula losses may be difficult, ie. the extent of diarrheal losses and problems with fluid hydration put the patient at risk for dehydration
- Intractable diarrhea or vomiting (especially when chemotherapy places patient at high risk for upper GI bleed)
- Complete bowel obstruction
What are the modes of EN delivery?
- Continous (total nutrition support)
- Cycle or altered duration (partial nutrition support)
- Intermittent/ bolus feeds
Describe continuous EN delivery
- Pump assisted (acute care) or gravity drip (home living)
- 24 hour infusion prescribed as a mL/hr rate
- often used to iniate EN in acute care settings
For whome is continuous EN preferred?
- critically/ acutely ill
- refeeding syndrome
- electrolyte or glucose instability
- demonstrated intolerance to other modes of delivery
Advantages and disadvantages of continuous EN
Description of cycled EN
Advantages and disadvantages of cycled EN
Describe intermittent/ bolus feeds
Advantages/ disadvantages of bolus feeds
What are transitional feeding options?
- cease feeds during meal times
- nocturnal feeds
- intermittent/ bolus feeds
EN feeding routes of delivery
Short term (<8 weeks)
* nasogastric (NG)
* nasojejunal (NJ)
Longer term feeding (endoscopic or radiological placement)
* gastrostomy (G-tubes) (PEG tube - percutaneous endoscopic gastrostomy tube)
* gastro-duodenal
* gastro-jejunal
Describe the Ligament of Trietz
Band of smooth muscle that extends from junction of duodenum and jejunum to the diaphragm which contracts and expands, allowing the movement of intestinal contents
* Located at the junction between duodenum and the jejunum.
Describe an open system versus a closed system
- closed system: formula is already in the bag
- Open system: transfer formula from a bottle/can/tetra into a bag
Advantages versus disadvantages of closed versus open systems
Types of enteral formulas
- polymeric: PRO is intact
- semi-elemental: PRO is partially broke down (and lipids)
- elemental: Amino acids (and lipids as MCT)
Indications for use of semi-elemental or elemental
- short bowel
- severe GI inflammation
- liver disease
Energy density of EN for adults
Energy density varies from 1-2 kcal/mL
* Higher energy density: typically for fluid restricted patients or patients with hypermetabolism
* higher energy formulas often have higher osmolarity and may be harder to tolerate
Protein concentration of EN formula
Protein concentration can vary from 0.04 g/mL – 0.08 g/mL
What are modular formulas?
Adding singular nutrient products to another formula to further increase calories, protein etc.
Adult EN formula decision tree
Clinical symptoms to monitor for EN tolerance
- Abdominal distention
- Abdominal cramping
- Nausea , Emesis
- Bowel movements (frequency, volume, consistency)
- Weight maintenance or weight gain (want to stabilize at minimum and prevent protein catabolism)
- blood work parameters
What is standard bloodwork parameters to monitor with EN?
- electrolytes
- calcium, phosphorous, magnesium
- glucose
- BUN, creatinine
- bilirubin, alkaline phosphatase, AST, ALT
- prealbumin
- hemoglobin
- As required: urine urea/electrolytes/osmolarity, vitamins/minerals, serum osmolarity, CRP, triglycerides
Screening and prioritizing patients for EN feeding by the RD
Consider
* nutritional status
* Duration of NPO status, safety with oral feeding (e.g dysphagia), hydrational status
* Length of time feeds to be needed; short term vs long term
* Permanent condition; this will tell you if you need permanent device or not
* Are EN feeds being used for treatment of underlying condition. Ex. feedings for patients with Crohn’s Disease (particularly small bowel).
* Stage in life cycle.
Who would you see first?
Things to consider when choosing nutrition support
- tube feeding or oral supplementation? why or why not?
- What type of feeding device would you consider?
- Type of Enteral Feed (polymeric vs. specialized formula)?
- Continuous vs. bolus feeds? pros and cons of both types?
- How much Enteral feed? Ensure BMR is being met (+10% and AF)
Feeding rates for continuous feeds for over 14 years of age (general rules)
- Initiation → 0.4-0.5 ml/kg/hr (typically 10-30 mls/hr based on ASPEN guidelines)
- progession → Over 24 hours (0.5-1 mls/kg/hr) max in one day; Most clinicians increase the rate of feeds every 8hrs by: 0.2-0.3 ml/kg/hr q 8 hrs.
Feeding rates for a 50 kg person
- For a 50 kg patient that would mean between 20-25 mls/hr to start feeds (If a patient weights more than 60 kg, then the max rate of EN feeds to start would be 30 mls/hr)
- For a 50 kg patient that would mean increasing feeds between 10-15 mls/hr every 8 hours. This would mean in 24 hours about 30-50 mls/hr total in 24 hours.
When is ideal body weight used?
If body weight <90% of ideal body weight or >120% of ideal body weight, use ideal body weight. Otherwise use actual body weight
What are the components of energy requirements?
- BMR (basal metabolic requirements)
- Activity (requirements for physical activity)
- Metabolic Stress (requirements related to metabolic stress); note many factors may influence this.
Ways to determine energy requirements
- Mifflin St Jeor:: Basal energy requirements (not total) with AF and SF
- Kcal/kg basis (total) (eg. 25-35kcal/kg)
- when weight gain not desired (i.e. >75yrs of age), use 25-30kcal/kg
Activity Factors
Need to consider activity levels: in-patient vs. out-patient. Consider Activity Factor (variable)
* 1.0 Bed-rest
* 1.2 Out of bed; very light activity
* 1.3-1.5 Sedentary
* 1.7 Normal Activity
Stress factors
Can have wide range
* for cancers often 1.1-1.3; but may be higher.
Basal fluid requirements
Review case 2 and case 3
Week 1
