Enteral Nutrition - Part 1 Flashcards
What is Nutrition Support Therapy?
- The provision of enteral or parenteral nutrients to treat or prevent malnutrition
- A component of medical treatment which can include oral, enteral or parenteral nutrition to maintain or restore optimal nutrition status and health
What are the indications for nutrition support? (IAI-PISS)
- Inadequate oral intake for 7-14 days
- Altered GI function
- Impaired nutrient utilization
- PEM
- Increased nutrient needs that cannot be met orally
- Swallowing/Chewing difficulty
- Significant involuntary weight-loss
Considerations for swallowing/chewing difficulty?
- Consider dysphagia and ability of safe swallows
- If acute dysphagia: often nutrition support, however if chronic we will work towards oral feeds
When may nutrient needs be increased in a way that cannot be met orally?
- Burns, as they are the most metabolically demanding (60% BSA can double to BMR)
- COPD
- Surgery
- Some cancers, such as pancreatic and gastric cancers
Define enteral nutrition
Nutrition provided through the GI tract via a tube, catheter or stoma that delivers nutrients distally to the oral cavity
What is important to consider about EN?
Where the tube ends, and where the nutrients are hitting the GI tract
Give 4 key advantages of using EN over PN
- Avoids infection
- Preserves the GI architecture, especially the mucosal barrier (preserves immune function)
- “First-pass” nutrition, as the liver will be able to metabolize first
- No precipitation issues as with TPN
Discuss why EN is considered a “first-pass” nutrition
It will be metabolzied in the liver first through the portal vein, then distributed to the bloodstream
- -> Appreciate that the liver will be able to turn some nutrients into their metabolically active states
- -> The kidney also doesn’t get hit immediately with nutrients, delaying their excretion
EN tries to do what?
Replicate the normal physiology of oral feedings
What are the indications for EN ?
The patient has a functional GI tract AND:
1) Unable to meet their need orally (<50%) for 7-14 days
2) Expected to not meet their needs orally for at least a 7-14 day period
3) Hemodynamically stable
4) Diagnosis or condition requiring En
Discuss the importance of hemodynamically stability in a patient prior to administering NS
- We need good blood flow and osmolality to be in balance prior to feeding into the GI tract or vein, as we are increasing the solutes.
- EN risks bowel necrosis, as water pulls from tissue to dilute GI tract
- Pn risks tissue burns
- Minimum BP must be obtained
Can bowel necrosis only occur in hemodynamically unstable patients with EN?
No, could occur in healthy persons, such as extremely dehydrated marathon runners.
What are examples of diagnoses/conditions requiring EN?
- GI diseases such as IBD
- GERD
- PEM
- Acute dysphagia (stroke)
- Major surgery, cancer, burns, neurological disorders
- -> Indicated in NRS-2002
What are the 9 key contraindications of EN? (MIS-PISS-HA)
- Mechanical GI obstruction
- Intractable vomiting/diarrhea
- Short bowel syndrome
- Paralytic Ileus
- Inability to gain access to GI tract
- Severe GI bleed or malabsorption
- Short supply period
- High-output GIT fistulas
- Aggressive intervention not warranted/desired (palliative care)
Discuss mechanical GI obstruction
May be OK if we can feed below the obstruction, but may need a surgical placement which will delay nutritional intervention
What doe intractable vomiting/diarrhea increase risk of?
Necrosis of the bowel
What is short bowel syndrome? When may we use TPN?
- <100 cm
- TPN if due to multiple trauma or surgeries
- Sometime EN may be OK
What is a high-output GIT fistula?
- > 500 ml/day
- A confused piece of Gi musculature, and depending where it foes we may not be able to do EN
When may EN be okay with a high-output fistula?
-If we can feed below the fistula
When may we use TPN with a high-output fistula ?
To let it close and put on bowel rest in combination with meds
When may we have inability to gain access to ones GI tract?
- Bowel obstructions
- Ventilation in some cases
- Trauma to abdomen
- Chronic liver disease due to esophageal varices
What is considered a short supply period?
<5-7 days in malnourished
<7-9 days in nourished
–> Not always appropriate if short-term, and not cost-effective, cause patient discomfort and also risk:benefit ratio should be considered (i.e. avoid perforations)
Which of the following is not a contraindication for tube feeding upon admission?
A) Paralytic Ileus
B) Nonresponsive, intractable vomiting and diarrhea
C) Intestinal obstruction distal to tube
D) Severe dysphagia
D
When is tube feeding not warranted?
A) When the person is in shock
B) When aggressive nutritional therapy is not appropriate
C) When the person cannot meet nutritional needs orally
D) When the person has significant weight-loss
E) Both a and b
E
–> When the person is in shock, it is likely that they are not hemodynamically stable
What are the benefits of EN?
- Stimulates release of CCK, causing gallbladder contraction and less risk of gallstones
- Preserves biliary tree and pancreatic secretions
- Reduces length of hospital stay
- Cost effective relatively to TPN
What did the meta–analysis show about length of stay of EN vs PN?
- EN is favoured in CU, and significantly will decrease length of stay
- EN is not significantly favoured for the rest of the hospital
Why will costs always be highest in the ICU?
- Intensive care for one patient
- Often on EN, or TPN which is expensive
- 1 nurse/patient
Short-term tube (<4 wks) and no risk of aspiration?
NG
Short term tube (<4 wks) with risk of aspiration?
NJ
Long-term tube (>4 wks) and no contraindications to esophageal access?
- PEG
- PEG/J
- PRG/J
Long-term tube (>4wk), contraindications to esophageal access/surgical placements?
- Laparoscopic tube (Gastric, Jejunal)
- Open tube (Gastric, Jejunal, GJ)
How is a PEG places?
1) Endoscope is passed through the esophagus
2) A needle i used to puncture the abdominal wall into the stomach
3) A gastrostomy tube is inserted into the stomach through the opening
4) The endoscope ties it, and will then be removed
What are the 5 contraindications for PEG placement?
- Severe ascites
- Severe gatsroparesis
- Coagulopathy
- Gastric varices
- Neoplasia or inflammatory disease of gastric/abdominal wall
Why is severe ascites difficult with PEG?
Too much pressure to insert into the abdominal wall
Why is severe gastroparesis difficult with PEG?
Stomach in not emptying, thus we would not want to feed into it
Wh is neoplasia/inflammatory disease of the gastric/abdominal wall difficult with PEG?
These disease compromise gastric wall architecture, will be difficult to puncture stomach
Your patient has had a portion of his stomach resected. The physician predicts that he will likely be on nutrition support for a long time. He has a functional GI tract. What is the best way to feed this patient?
A) TPN
B) Jejunostomy
C) PEG
D) PPN
B)
Use jejunostomy as we want to bypass the stomach resection, however his GI tract is functional and he is likely to be on nutrition support for a long-time
What are some considerations when selecting formulas?
- Age
- Hospital-specific formulary
- Nutrition req.
- Digestion and absorption
- Medical condition
- Duration of EN
Standard/Polymeric formula?
-Contains intact protein,CHO and LCT
Elemental/semi-elemental formula?
- Completely or partially digested nutrient
- Protein as free amino acids or peptides
- Simple sugars, glucose polymers-
- Fat; MCT and LCT
Disease specific formula?
- Designed to meet needs of certain diseases, such as renal, diabetic etc
- Not appropriate in ICU, maybe LTC
- Not always covered by insurance, not evidence-based and costly
Modular componenets to formula?
Adding protein powders or other nutrients to customize the formula for the patient
Should we add fibres as a modular component?
Best to avoid, as prone to contamination and clogging the tube
What are the 3 main sub-types of standard formulas?
- Fibre containing
- High-protein
- Energy dense
Fibre containing formulas?
- Used in LTC, not in ICU
- Prevents constipation
- Ensure adequate after flushes
High-protein formula?
- > /= 20% energy from protein
- Indicated in malnutrition, trauma, or catabolic state
Energy-dense formula?
- Contains 1.5-2.0 kcal/ml
- Indicated when there is a fluid restriction with high-energy needs.
You have a patient who weight 215 lbs and is on dialysis. This patient often presents with edema. Which one of the following formulas would be best for the patient?
A) Hydrolyzed
B) Polymeric
C) Nutrient dense
D) Hepatic
C)
Edema, thus likely on a fluid restriction. Choose energy dense, which is still polymeric and will not overload with fluid.
Your patient has a PEJ. Which of the following formulas would be best for the patient?
A) High fiber B) Immune enhancing C) Energy dense D) Lactose free E) Semi-elemental
E)
Semi-elemental, as we are bypassing he duodenum and brush-border enzymes, CCK, bile and some pancreatic secretions.
(T/F) Nearly all formulas are lactose free
T
What is an Open System or Ready-to-serve?
- More common in LTC
- Formulation is transferred from can/bottle into a refillable enteral feeding container, may be blenderized
How long can open-system or Ready-to-serve containers be hung for?
- 8-12 hours if using ready-to-serve formula
- 4 hours if using reconstituted formula
Advantage of Open-System and Ready-to-serve? Disadvantages?
- Allows modular to be added
- Increased risk of contamination and mixing formulas
Closed-systems or Ready-to-hang?
- Formulations that are commercially packaged and sealed
- Less chances of contamination and increased compliance to feeding prescription
- Less nursing time
Hand time for close-systems or ready-to-hang?
24 to 28 hour
Disadvantages of close-system or ready-to-hang?
-Increased wastage, misconnections error, no modular can be added and must be pushed through tube manually
In the most critical situations, how will we deliver EN?
By using all the time we have available (usually between 18-24 hours) to intervene nutritionally
Intermittent/Bolus feeding?
- Given over 24 hours with intervals of rest
- Gravity or pump-assisted
- Allows patient more freedome to move
- Closes to mimicking the physiological state
Bolus feeds?
240 ml of formula over 4-10 mins, repeated 3-6x/day
Intermittent feeds?
240-720 ml over 20-60 mins, repeated 4-6x/day
Continuous feeds?
- EN delivered continuously with minimal interruption
- Small, slow amounts means that this delivery method could also feed the jejunum
- Pump assisted
How do we initiate continuous feeds?
- We will work up to the goal feeding rate
- Initiate at 20-50 ml, increase by 10-25 ml/hrq 4-24 hours as tolerated until goal rate is reached.
Initiating continuous feeds in critically ill vs non-critically ill?
- Critically-ill: start slower and lower
- Non-critically ill: start higher and increase at a higher rate
Initiating continuous feeds in re-feeding patient?
-Start as low as 15 ml/hour, and do not advance until electrolytes are corrected
What are cyclic feed?
- Often fed overnights, and given over 8-12 hours with intervals of rest
- Usually later in chronic disease management
- Encourage transition to foods, or acts as a “top-up” when food intake is insufficient to meet needs
When is cyclic feeds ideal?
For those with chronic diseases, such as Crohns or IBD
How do we calculate the EN prescription?
We determine the nutritional needs by using the nutritional assessment
Steps in calculating the EN prescription?
1) Choose feeding route
2) Calculate nutritional needs
3) Choose appropriate formula
4) Determine administration mode
5) Calculate water flushes
6) Verify nutritional goals are met
7) Monitoring
When do we use adjusted body weight?
- To ensure the fluid requirement is accurate
- When IBW >125%
Adj, BW formula?
adjusted wt= {(ABW –IBW) x 0.25} +IBW
John is 55 years with a weight of 95 kg and 180 cm. Estimate his fluid needs assuming otherwise healthy and then if on fluid restriction.
1) Calculate BMI, and then Adj. BW (for fluid restriction)
BMI = 29.3
Adj. BW = (as <27-30 BMI, and we also must adjust as they have a fluid restriction, and we need to avoid fluid overloads)
2) We will use the Adj. BW due to the fluid restriction
Note that if he didn’t need the fluid restriction we would use ABW
Mrs Smith is 45 years old, height = 160 cm and weight = 60 kg. She is on fluid restriction of 1L/day. What are her nutritional needs?
1) Normal BMi of 23.4 kg
2) Rule of thumb (25-35 kcal/kg/day) shows 1500-2100 kcal/day
3) Pro needs (0.8-1.0) = 48-60 g
4) Fluid needs = 1 L
First step in determining the administration rate
Determine the total volume of the formula
i.e. 1800 kcal/ (2kcal/ml) = 900 ml
Second step in determining the administration rate
Calculate goal rate by dividing total volume by feeding hours
i.e. if continuous over 24 hours: 900ml/24 hours = 37.5 ml/hr over 24 hours –> This is the GOAL rate, not the starting rate
First step in calculating free water flushes?
2) Check the free water % of the formula
i. e. water content of 690 ml/1000 ml = 69% free water
Second step in calculating free water flushes?
Multiply free water % by total daily volume of formula
i.e. 900 ml x 0.69 = 621 ml
Third step in calculating free water flushes?
Total H20 required via flushes = Estimated water needs - Free water from formula - Other sources (IV)
–> then establish flush scheudle
i.e. 1000 ml - 620 ml = 380 ml OK for flush
How can we flush schedule?
-Water usually flushed every 4 hours, using 30-60ml syringes
How do we monitor our patient on EN?
- Meeting nutritional needs
- Weight changes
- N/V, diarrhea, constipation
- Abdominal distension
- GRV
- Aspiration
(T/F) Tube feedings are associated with more diarrhea
F, often due to management of tube feed, disease, or medications with alcohols in them
Biochemical monitoring in EN patient?
- Electrolytes, BUN, creat
- Albumin, albumin, liver function
- Lipids
- Bowel function
- Blood glucose
- Fluid status
Define GRV
The fluid remaining in the stomach during EN feeding
If checked, how often should GRV’s be measured?
Every 4 hours during the first 48 hours of gastric feeding, and after that, every 6-8 hours for non-critically ill patients
In critically-ill patients, GRV’s less than ____ should not be stopped unless there are other signs of feeding intolerance
500 ml
GRV’s ranging from ____ should prompt clinicians to implement methods to reduce aspiration risk
200-500 ml
ASPEN recommendations on GRVs?
-Does not recommend in critical care, requires a-lot of nursing time and not as effectiveness as we ting
GRV indicative of aspiration how should it be managed first?
With a prokinetic agents, such as metoclopramide and erythromycin
-May contain alcohol,, causing diarrhea
How do we change the EN formula in the case of GRVs?
- Change to higher density formula
- Switch from gastric to post-pyloric
- Elevate HOB to eat least 30-45 degrees
How to narcotic antagonists, often administered within the context of GRVS impact the GI system?
Will minimize the slowing effect of narcotics on bowel motility to reduce amount of GRVs and reduce risk of aspiration
