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Nutrition in Health and Disease > Enteral, parenteral Nutrition & Refeeding Syndrome > Flashcards

Enteral, parenteral Nutrition & Refeeding Syndrome Flashcards

1
Q

Name disciplines from the hospital that make up a multidisciplinary nutrition support team.

A
  • Dietician
  • Nurse
  • Gastroeneterologist
  • Intensivist
  • Internist
  • Surgeon
  • Pharmacist
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2
Q

What is the meaning of enteral nutrition?

A

Enteral nutrition is nutrition delivered using the gut. This can refer to oral, gastric, or postpyloric feeds.
* Example of oral diet: supplements can consists of e.g. protein and energy enriched diets or sip feeding (oral nutritional supplements).
* Example of tube feeding: gastric, duodenal, jejunal.

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3
Q

What is parenteral nutrition?

A

Parenteral nutrition is a way for patients to receive nutrients by bypassing their digestive system.

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4
Q

What are reasons to choose:
* tube feeding
* parenteral nutrition

A
  • tube feeding: if normal diet and supplements are impossible or insufficient.
  • parenteral nutrition: if normal diet and tube feeding are impossible, insufficient or have contra-indications.
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5
Q
  • What is the main goal of enteral nutrition?
  • What general indications exist for enteral nutrition?
A
  • Prevention and/or treatment of malnutrition ot improve outcome.
  • Inadequate oral food intake and/or present or at risk for malnutrition.
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6
Q

What are factors that influence a healthy gut barrier?

A
  • Balanced intestinal bacteria
  • Intact mucose
  • A healthy immune system
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7
Q

What cells are responsible for absorption of nutrients?

A

(Micro)villi

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8
Q

Name the food particles that are broken down by the following digestive juices:
* saliva
* stomach acid
* small intestine digestive juice
* pancreatic juice
* bile acids

A
  • saliva: starch
  • stomach acid: protein
  • small intestine digestive juice: starch, protein, and carbohydrates
  • pancreatic juice: starch, fats, and protein
  • bile acids: fats
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9
Q

Name characteristics of a healthy gut.

A
  • Bowel integrity characterized by maintaining immune, barrier, and absorptive functions.
  • Growth that is stimulated by digestive juices, mechanical factors, and hormones.
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10
Q

What are consequences of fasting, i.e. when a patient cannot digest (certain) food?

A
  • Hypertrophy of the bowel mucosa
  • Permeability of the bowel mucosa (leaky gut)
  • Decreased blood circulation
  • Stase (i.e. paralysis) of the GI tract
  • Bacterial overgrowth
  • Translocation of bacteria (e.g. from bowel to bloodstream)
  • Decreased IgA secretion
  • Impaired immune defense
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11
Q

What are (possible) benefits of enteral nutrition?

A
  • Preservation of mucosal architecture
  • Preservation of gut associated lymphoid tissue (GALT)
  • Preservation of hepatic immune function
  • Preservation of pulmonary immune function
  • Reduction of inflammation
  • Reduction of antigenic (bacterial antiggens) leak from gut
  • Interference with pathogenicity of gut organisms
  • Less hyperglycemia
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12
Q

Tube feeding is chosen when normal diet and supplements are impossible or insufficient. Think of reasons (e.g. diseases) when optimal oral intake is impossible and when optimal oral intake is insufficient.

A

Impossible:
* Obstruction (e.g. esophageal tumor)
* Motility disorder (e.g. gastroparesis)
* ICU (coma, intubation)

Insufficient:
* Decreased appetite (e.g. cancer)
* Reduced intake (e.g. dementia)
* High energy needs (e.g. malabsorption, post-operative).

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13
Q

What are the different options of tube feeding and in what cases are these options used?

A
  • Nasogastric tube: neurological-, oropharyngeal-, oesophageal disorder or chemotherapy.
  • Nasoduodenal tube: gastropareses, reflux, stomach tumor.
  • Percutaneous Endoscopic Gastrostromy: when tube feeding necessary for > 1 month.
  • Jejunostomy: after surgery of the upper GI tract.
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13
Q

Name complications associated with enteral nutrition, i.e. tube feeding regarding:
* gastro-intestinal
* tube
* metabolic

A
  • gastro-intestinal: nausea, gastric retention, vomiting, reflux, aspiration, diarrhoea, constipation.
  • tube: by insertion (perforation of the gut, bleeding), misplacement/dislocation (e.g. lungs), tube irritation nose/throat/skin, tube occlusion, surgical jejunostomies (bowel necrosis and death)
  • metabolic: disruption of fluid and electrolyte balance, hypo- or hyperglycemia, vitamin and/or mineral deficiencies.
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14
Q

What are contra-indications of enteral nutrition?

A
  • Absence of intestinal function (e.g. severe inflammation, failure or peristalsis causing a distended bowel).
  • Complete intestinal obstruction (hernia, torsion, tumor, obstruction ileus).
  • Inability to access the gut (severe trauma)
  • High loss intestinal fistula (entero-cutaneous fistula)
  • Ethical considerations (terminal care)
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15
Q

How is intestinal failure defined?

A

As the reduction of gut function below the miminum necessary for the absorption of macronutrients and/or water and electrolyes, such that intravenous supplementation is required to maintain health and/or growth.

16
Q

Intestinal failure can be classified into 3 different types. What are these types based on?

A

On the basis of onset and metabolic and expected outcome criteria.
* Type I: acute, short-term and usually self limiting condition, resolves within few-days - week.
* Type II: prolonged acute condition, often in metabolically unstable patients, requiring complex multi-disciplinary care and intravenous supplementation over periods of weeks or months.
* Type III: chronic condition, in metabolically stable patients, requiring intravenous supplementation over months or years. May be reversible or irreversible.

17
Q

Name examples of patients that could have type I intestinal failure.

A
  • Hospital patients
  • Patients in peri-operative setting after abdominal surgery
  • Patients with critical illnesses; acute systemic inflammatory or neurological reaction associated with critical illnesses.

Often, these patients have paralytic ileus (paralysis of the intestinal muscles).

18
Q

Name examples of patients that could have type II intestinal failure.

A
  • Short-term home parenteral nutrition
  • After abdominal catastrophe, often occuring in a previously healthy subject
  • Mesenteric ischaemia, volvulus or abdominal trauma
  • Patients with complicating intestinal surgery (anastomotic leak, massive enterectomy, eneterocutaneous fistulae)
19
Q

Name examples of patients that could have type III intestinal failure.

A
  • Long-term home parenteral nutrition
  • Metabolically stable patients
  • As a result of type II intestinal failure
  • After multiple intestinal resections as a result of Crohn’s disease, radiation enteritis, systemic sclerosis
  • Patients with short bowel syndrome, permanent intestinal dysmotility, extensive small bowel mucosal disease
20
Q

What does total parenteral nutrition consist of?

A

Nutrients that are provided intravenously

21
Q

What are indications of when total parenteral nutrition should be applied?

A

When enteral nutrition is impossible, contraindicitive, or inadequate.

Impossible:
* Ileus (paralysis of the intestine or mechanical obstruction)
* Absence enteral route (tube feeding not possible)

Contraindictive:
* Fistula
* High-risk surgical bowel anastomosis

Inadequate:
* Malabsorption (short bowel syndrome, radiation-enteritis)

22
Q

What does parenteral nutrition consist of?

A
  • Glucose
  • Lipids
  • Amino acids
  • Electrolytes
  • Vitamins
  • Trace elements
23
Q

For some diseases, the content of parenteral nutrition is adjusted. Name for the following diseases/disorders how parenteral nutrition is adjusted:
* renal patients
* liver failure
* diabetic patients
* immuno-supporting nutrition

A
  • renal patients: low/no electrolytes
  • liver failure: no fat
  • diabetic patients: additional insuline
  • immuno-supporting nutrition: glutamine, omega-3 fatty acids
24
Q

What are early and late technical complications of total parenteral nutrition?

A

Early:
* Misplacement
* Bleeding
* Lung puncture
* Arterial puncture
* Arrhytmias

Late:
* Blocked catheter
* Ruptured catheter
* Central vein thrombosis
* Blood stream infections (most common)

25
Q

Name metabolic complications associated with total parenteral nutrition.

A
  • Refeeding syndrome
  • Hyperglycaemia
  • Liver steatose
  • Bone disease
  • Gall stones
  • Nutrient deficiencies
  • Intestinal failure associated liver disease (IFALD)
  • Parenteral nutrition associated liver disease
26
Q

Name causes of intestinal failure associated liver disease.

A
  • Intestinal resections
  • Fasting
  • Lack of enteral nutrition
  • Small intestinal bacterial overgrowth
  • Medication
  • Inflammation
  • High calorie, carbohydrate, and/or fat intake (TPN)
  • Soybean oil fat emulsion
  • Continuous TPN
  • Nutrient deficiency
27
Q

How can intestinal failure associated liver disease be prevented?

A
  • Maintain intestinal length
  • Attempt continuity restoring surgery
  • Fistula output return
  • Trophic feeding
  • Treat bacterial overgrowth
  • Protocol for prevention of line sepsis
  • Prevention overfeeding
  • Add omega-3 fatty acids
  • Oral and/or enteral feeding
  • Cyclical TPN feeding
  • Monitoring potential deficiencies
  • Supplementing deficiencies
28
Q

Name reasons why enteral nutrition is superior to partial enteral nutrition (combination of liquid and solid foods)?

A
  • Reduced costs
  • Fewer infectious complications
  • Earlier gut function
  • Reduced length of stay
29
Q

What is refeeding syndrome (RFS)?

A

The severe and potentially fatal shifts in fluids and electrolytes, which may result from the (quick) start of (par)enteral nutrition in (severely) malnourished patients.

30
Q

What are challenges of refeeding syndrome?

A
  • Still much unknown about its incidence, causes, and clinical signs.
  • No strong evidence about the prevention and treatment
  • No uniform performance/definition of refeeding syndrome in individual patients.
31
Q

What happens when a body is malnourished/starved?

A
  • Body goes into catabolic state (low glucose levels, low insuline secretion, increase of gluconegenesis, ketogenesis)
  • Body weight loss
  • Volume and size of cells of liver, heart, brain, and muscles decreases
  • Depleted state of electrolytes
  • Depleted vitamin and mineral storages, thiamine deficiency (storage 1 week)
  • Loss of total body water (dehydration)
32
Q

Describe the process from malnourished/starved patients to refeeding of these patients and how this can lead to refeeding syndrome.

A

When patients are malnourished/starved, there is depletion of proteins, fat, minerals, electrolytes, and vitamins and intolerance of salt and water (catabolic state). When patients are ‘refed’, the catabolic state is switched to anabolic state. Intake of food increases insulin secretion and therefore, molecules like glucose, phosphate, kalium, magnesium are taken up into the cells. This causes a decrease of these molecules in serum (i.e. blood). Therefore, the blood is now ‘deficient’ of these molecules, causing disorders like hypokalaemia, hypomagnesaemia, hypophosphataemia, thiamine deficiency, oedema due to salt and water retention -> refeeding syndrome.

33
Q

It is clear that refeeding syndrome is a metabolic syndrome. These metabolic imbalances in the body could lead to symptoms (e.g. cardiac, respiratory, neurologic, hematologic, metabolic failure, etc.). What determines whether metabolic refeeding syndrome changes into symptomatic refeeding syndrome?

A
  • Degree of malnutrition
  • Underlying disease and medication
  • Form of management employed
34
Q

Who is at risk for refeeding syndrome?

A
  • Low BMI
  • (Severe) weight loss
  • Low caloric intake
  • Low electrolyte levels
  • Comorbidities
35
Q

How can refeeding syndrome be prevented?

A
  • Biochemic controle: daily measurement of electrolytes
  • Vitamine suppletion
  • Nutrition: increase slowly with 5-10 kcal/kg/day in 4-10 days
  • Monitor and anticipate

Nutrition in Health and Disease (9 decks)

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