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ASPEN Adult Nutrition Support Core Curriculum for CNSC Exam > Enteral Nutrition Formulations > Flashcards

Enteral Nutrition Formulations Flashcards

1
Q

EN practice recommendations from ASPEN regarding enteral formula selection

A

The veracity (accuracy, credibility) of adult enteral formula labeling and product claims is dependent on vendors
Nutrition support clinicians and consumers are responsible for determining the veracity of information about adult enteral formulations
Interpret enteral formulation content/labeling and health claims with caution until such time as more specific regulations are in place

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2
Q

Define standard/polymeric enteral nutrition formula?

A

Formula containing macronutrients as nonhydrolyzed protein, fat, carbs

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3
Q

Define elemental and semi-elemental enteral nutrition formulas?

A

Contains partially or completely hydrolyzed nutrients (protein) and altered fats to maximize absorption

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4
Q

Define blenderized enteral nutrition formula?

A

Formulated with a mixture of blenderized whole foods, with or without the addition of standard formula; best suited for patients with a healed feeding site and for those who adhere to safe food practices and tube maintenance

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5
Q

Define disease-specific enteral nutrition formulas?

A

Targeted for organ dysfunction or specific metabolic conditions

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6
Q

Define a modular

A

Used for supplementation to create a formula or enhance nutrient content of a formula or diet

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7
Q

Name carbohydrate sources of polymeric enteral formulas?

A

Main: corn syrup solids
Other: hydrolyzed corn starch, maltodextrin, sucrose, fructose, sugar alcohols

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8
Q

Name carbohydrate sources of elemental formulas?

A

Cornstarch, hydrolyzed cornstarch, maltodextrin, fructose

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9
Q

Name fat sources of polymeric formulas?

A

Borage oil, canola oil, corn oil, fish oil, high-oleic sunflower oil, MCT, menhaden oil, mono- and diglycerides, palm kernel oil, safflower oil, soybean oil, soy lecithin

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10
Q

Name fat sources in elemental formulas?

A

Fatty acid esters, fish oil, MCT, safflower oil, sardine oil, soybean oil, soy lecithin, structured lipids

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11
Q

Why might palm kernel and coconut oil be added to an enteral formula?

A

As a source of MCTs

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12
Q

Describe some advantages of using MCTs in enteral formulations? Disadvantage?

A

Absorbed directly into the portal circulation and do not require chylomicron formation for absorption.
Do not require pancreatic enzymes or bile salts for digestion and absorption.
Cleared from the blood stream rapidly and cross the mitochondrial membrane without the need for carnitine, where they are oxidized to CO2 and water and therefore are not stored.
Disadvantage: MCTs do not provide EFAs, so most enteral formulations contain a mixture of LCTs and MCTs

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13
Q

What are structured lipids?

A

Chemical re-esterification of LCTs and MCTs on the same glycerol backbone. They offer advantages of MCTs while including enough LCTs to meet EFA needs

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14
Q

Describe the health benefits of omega-3 fatty acids?

A

Omega-3 fatty acid end products are metabolized to prostaglandins of the 3 series and leukotrienes of the 5 series, which are associated with anti-inflammatory effects, slowing of platelet aggregation, immune enhancement, and antiarrhythmic properties

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15
Q

What are the most commonly used sources of intact protein in enteral formulations?

A

Casein and soy protein

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16
Q

Elemental or semi-elemental enteral formulas contain protein in what forms?

A

Hydrolyzed protein, small peptides (more than 3 amino acid residues), dipeptides and tripeptides, and free amino acids

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17
Q

What populations are elemental and semi-elemental enteral formulas intended for?

A

GI dysfunction such as short bowel syndrome, malabsorption, or pancreatic exocrine insufficiency

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18
Q

Name common fiber sources in enteral formulas?

A

Guar gum and soy fiber

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19
Q

What is the purpose to soluble fiber in an enteral formula?

A

It is fermented by the gut microbiota in the distal intestine to produce short-chain fatty acids (SCFAs)- which are a source of energy for colonocytes and help increase intestinal mucosal growth and promote water and sodium absorption. May help control diarrhea due to its ability to increase sodium and water absorption. Some formulas supplemented with soluble fiber have been shown to reduce incidence of diarrhea

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20
Q

SCCM guidelines on fiber-containing enteral formulas?

A

Suggest that clinicians consider their use if patients have persistent diarrhea, and suggest both insoluble and soluble fiber be avoided if patients are at a high risk for bowel ischemia and have severe dysmotility

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21
Q

Describe the relationship of fiber-containing formulas with the frequency of bowel movements according to a systematic review

A

Fiber-containing formulas reduced bowel frequency when baseline bowel frequency was high and increased bowel frequency when baseline bowel frequency was low.

22
Q

Benefits of fiber in an enteral formula?

A

May speed up transit time, increase fecal bulk, reduce constipation, and improve gut barrier function through the stimulation of colonic bacteria

23
Q

True or false: Research suggests nitrogen absorption is greater with enteral formulations containing only free amino acids

A

False. Suggests absorption may be greater with peptide-based formulations

24
Q

Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in volumes of ___ to ___ mL/day

A

1000-1500 mL/day

25
Q

Define the osmolality of an enteral formula and typical ranges

A

The concentration of free particles, molecules, or ions in a given solution, expressed as milliosmoles per kilogram of water (mOsm/kg).
Ranges from 280-875 mOsm/kg

26
Q

Does the osmolality increase or decrease as the content of free particles, ions, or molecules increases?

A

Increases

27
Q

Describe some contents of formulas that would have a higher osmolality than others

A

Formulas with sucrose rather than cornstarch or maltodextrin have higher osmolality
Formulas with single amino acids or high amounts of di- and tripeptides rather than intact protein have higher osmolality

28
Q

When is a formula considered hypertonic?

A

When the osmolality is >320 mOsm/kg

29
Q

Under what circumstance would it be reasonable to relate a patient’s diarrhea to the osmolality of the enteral formula used?

A

When hyperosmolar formulas containing sucrose are delivered directly into the small intestine, dumping syndrome can occur. But this problem is unlikely to occur when peptide or single amino acids are provided in a similar manner

30
Q

Describe considerations when evaluating research or specialized enteral formulas

A

In vitro (animal) versus in vivo (human) study
Quality of study design (prospective randomized controlled trial, retrospective review, case reports)
Similarity of patient population studied to patients being cared for (demographic factors, clinical status, clinical environment, etc)
Generalizability of results

31
Q

Describe the general macronutrient distribution of diabetes-specific formulas and the reasoning?

A

Lower in carbs (33-40% of total energy)
Higher in monounsaturated fat and total fat (42-54% of total energy)
Provide more fiber (14-16 gm/L) than standard polymeric formulas
Rationale is that this mixture of low carb, high fat and fiber will slow gastric emptying and lead to better glycemia control

32
Q

ADA macronutrient distribution recommendation for patients with diabetes?

A

There is not an ideal percentage of calories from carbs, protein, and fat for all patients with diabetes. Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. The ideal quantity of carb intake as well as insulin therapy should be individualized for each patient.

33
Q

What is the best approach to enteral nutrition management in a post-op patient with T2DM?
Scenario: 56 y/o M PMH of T2DM and HTN admit to STICU s/p aortic valve replacement. Intubated and sedated post-op day 1 getting IV fluids @ 100 ml/hr using 5% dextrose with half-normal saline. 5’10” and 80 kg (5kg less than 2 months prior). All lab values insignificant except BG which were consistently >180 mg/dL. Treated with subcutaneous insulin q 4 hr following standard glucose monitoring schedule. Energy requirements estimated 2000 kcal/day, protein 96-120 gm/day (1.2-1.5 g/kg/day). EN started ICU day 1 using diabetes-specific formula at 30 ml/hr and insulin management unchanged. After initiation of EN, BG levels continued to be higher than 180 mg/dL

A

Diabetes- specific formula is not necessary in ICU patients with diabetes and hyperglycemia. Pt was experiencing hyperglycemia prior to initiation of EN due to T2DM, postsurgical stress, and IV fluids (were providing 400kcal from dextrose). Intervention: change to standard 1.0 kcal/ml polymeric formula, decrease IV fluids and change to 1/2 NS, start continuous IV insulin infusion

34
Q

Name some prebiotics

A

Fructooligosaccharides (FOS) and inulin

35
Q

ASPEN recommendation regarding routine use of elemental formulas in critical illness?

A

Recommend that routine use of elemental and disease-specific formulas be avoided in critically ill patients because no clear benefit has been shown in the literature.

36
Q

Why have the branched chain amino acids (BCAAs) leucine, valine, and isoleucine been promoted for use in hepatic encephalopathy?

A

Because they clear ammonia in the skeletal muscles, decreasing cerebral ammonia levels and reducing the uptake of aromatic amino acids (AAAs) across the blood-brain barrier

37
Q

Is protein restriction recommended in liver failure?

A

No; leads to a further decline in nutrition status and lean body mass and may result in higher ammonia levels

38
Q

Define immune-modulating formulations (IMFs)

A

Enteral formulas that contain arginine, glutamine, omega-3 polyunsaturated fatty acids, nucleotides, and antioxidants. These specific nutrients are thought to have the potential to modulate the metabolic response to surgery or stress

39
Q

SCCM/ASPEN guidelines regarding the use of IMFs in critical illness?

A

Guidelines do not recommend the routine use to IMFs with severe sepsis; IMF use should be reserved for the post-op patient in the surgical ICU

40
Q

What is the respiratory quotient (RQ) for each macronutrient?

A

RQ is a value that describes CO2 production in relation to oxygen consumption
Carb: 1.0
Protein: 0.8
Lipid: 0.7

41
Q

Describe the role of HMB (beta-hydroxy beta-methylbutyrate) in wasting conditions?

A

HMB is a metabolite of leucine. Promotes anabolism by increasing protein synthesis and inhibiting the ubiquitin-proteasome pathway controlling protein degradation, thereby conserving and even promoting accretion of LBM. Helps preserve LBM in patients with sarcopenia, cancer cachexia, and AIDS

42
Q

Name nutrients beyond energy and protein that are linked with improving patient outcomes in regard to wounds

A

Glutamine, arginine, omega-3 fatty acids, zinc, selenium, and vitamins A, C, and E

43
Q

SCCM/ASPEN guidelines regarding nutrient provision in critically ill obese population?

A

The critically ill obese patient should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores

44
Q

How might weight loss positively influence outcomes in the critically ill obese patient?

A

Weight loss may increase insulin sensitivity, facilitate nursing care, and reduce the risk of comorbidities

45
Q

Enteral formulas that provide 1 kcal/ml have a higher or lower NPC:N (nonprotein calorie-to-nitrogen) ratio?

A

Lower

46
Q

What makes 1 kcal/ml enteral formulas a good choice for critically ill obese patients?

A

Lower NPC:N ration, less need for protein modular, additional fluid

47
Q

What factors should be considered when developing an enteral formulary?

A

Patient acuity
Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
Formulation components that may be contraindicated
Need for fluid restriction
Need for added formulation components

48
Q

How often should administration sets for open system enteral feedings be changed?

A

At least every 24 hours

49
Q

Recommended hang time for powdered, reconstituted formula and EN formula with additives?

A

4 hours

50
Q

Recommended hang time for closed-system EN formulas?

A

24-48 hours

51
Q

Recommended hang time for sterile, decanted formula?

A

8 hours

ASPEN Adult Nutrition Support Core Curriculum for CNSC Exam (19 decks)

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