Exam 1 Flashcards
Nutrition Support
Delivery of formulated enteral or parenteral nutrients to maintain or restore nutritional status.
Enteral nutrition
Provision of nutrients into the GIT through a tube or catheter when oral intake is inadequate. (may include formulas as oral supplements or meal replacements)
Parenteral nutrition
Provision of nutrients intravenously
Enteral Rationale and Criteria
Enteral nutrition: functional GIT, for those who can’t eat or can’t eat enough, and should be first consideration
Parenteral nutrition: Insufficient GIT function
Proposed Benefits of Enteral Versus Parenteral Nutrition
- Better GI barrier function
- Preserved GI immunity
- Attenuate catabolic response
- Better blood glucose control
- Decreased rates of infection
Conditions That Often Require Enteral Nutrition
Impaired nutrient ingestion: Neurologic disorders, facial trauma, oral or esophageal trauma, congenital anomalies, respiratory failure, cystic fibrosis, GI tract surgery (e.g., esophagectomy)
Inability to consume adequate nutrition orally: Hypermetabolic states such as trauma and burns; cancer
Impaired digestion, absorption, metabolism: Severe gastroparesis, inborn errors of metabolism, Crohn disease, ulcerative colitis
Conditions That Often Require Parenteral Nutrition
GI incompetence:
-Short bowel syndrome, severe acute pancreatitis, severe IBD, small bowel ischemia, intestinal atresia, severe liver failure
Critical illness with poor enteral tolerance or accessibility: -Multiorgan system failure, bone marrow transplantation, severe wasting in renal failure with dialysis, small bowel transplantation
Determining EN Access
- Anticipated length of time of enteral feeding
- Risk for aspiration or tube displacement
- Clinical status
- Presence or absence of normal digestion and absorption
- Planned surgical intervention
Nasogastric route
- Short term: Up to 3 or 4 weeks
- Normal GI function
- Bolus, intermittent, or continuous infusions
Nasoduodenal or nasojejunal route
- Short term: Up to 3 or 4 weeks
* Gastric motility disorders, esophageal reflux, or persistent nausea and vomiting
Percutaneous endoscopic gastrostomy or jejunostomy
Percutaneous endoscopic gastrostomy or jejunostomy
Other minimally invasive techniques
Laparoscopic or fluoroscopic techniques
Surgically placed enterostomies
Gastrostomies and jejunostomies
Multiple lumen tubes
Prolonged GI decompression and small bowel feeding
Types of Enteral Formulas
Health care facilities develop a formulary of products to meet the needs of their patients/residents
Modular - isolated nutrient supplement Blenderized - real food blend Specialty - ex. keto diet Elemental - AA based Semi-elemental - pre-digested peptide bond based Standard - body breaks it down
Choosing an Enteral Formula
- Nutrient requirements
- Clinical status and GIT function
- Caloric and protein density
- Form and amount of protein, fat, CHO, and fiber in the formula
- Electrolyte content
- Cost-effectiveness
- Patient compliance
Standard Polymeric Formulas
- Lactose-free
- 1 kcal/mL
- Balanced CHO, fat, and protein
- Meet AMDR
- Concentrated standard formulas: 1.5 to 2 kcal/ml for fluid restriction
Home Blenderized Formulas
ADVANTAGES: Health benefits of using whole foods, Cost effectiveness, Tailor formula to meet individual needs, Social bond with caregiver
DISADVANTAGES: Short hang time, Cannot use with jejunal feedings, Avoid in patients with multiple allergies, immunosuppression, fluid restrictions, Requires large bore feeding tube
Enteral Formula Composition: Protein
- Intact protein, di- and tri-peptides, amino acids and/or crystalline amino acids
- Special amino acids: Branched-chain amino acids, arginine, taurine
- Content varies from 6% to 37% of total kcal
Enteral Formula Composition: Carbohydrate
- Content varies from 30% to 85% of total kcal
- Lactose-free
- Fiber
- FODMAPs
Enteral Formula Composition: Lipid
- Content varies from 1.5% to 55% of total kcal
- 2% to 4% of fat is linoleic acid to prevent essential fatty acid deficiency (EFAD)
- Standard formula provides 15% to 30% kcal from fat
Enteral Formula Composition: Micronutrients
DRIs for 25 vitamins and minerals typically met with varying intake levels
•1000mL for children
•1500mL for over 12 years
Enteral Formula Composition: Fluid
- 1 kcal/ml formulas are about 85% water
- 2 kcal/ml formulas are about 70% water
- Provide 30 to 35 ml/kg of body weight unless fluid restricted
Enteral Administration
Closed vs. open system
Bolus: 500mL, 5-20min, 3-4x
Intermittent/cyclic: 100-150mL, 20-60 min, several x
Continuous
Complications of Enteral Feeding
- Access problems (e.g., tube displacement or obstruction, leakage)
- Administration problems (e.g., aspiration, regurgitation, microbial contamination)
- GI complications (e.g., nausea, vomiting, delayed gastric emptying, high gastric residuals, constipation, diarrhea, malabsorption)
- Metabolic complications (e.g., refeeding syndrome, glucose intolerance, dehydration or overhydration)
Monitoring Enteral Nutrition
- Abdominal distension and discomfort
- Tube placement
- Fluid intake and output
- Gastric residuals if appropriate
- Signs and symptoms of edema or dehydration
- Stool output and consistency
- Weight
- Adequacy of enteral intake
- Serum glucose, calcium, electrolytes, blood urea nitrogen, creatinine
Oral Supplements
- Used to augment intake of solid foods
- Commonly provide 250 to 360 kcal/8 ounces
- Variety of flavors, consistency and nutrients
- Sweeter taste with more simple CHO
- Unpalatable with hydrolyzed protein
- Taste fatigue
- Modular supplements
Central parenteral nutrition (CPN):
catheter tip placed in large, high-blood-flow vein
Peripheral parenteral nutrition (PPN):
catheter tip placed in small vein, typically the arm
Routes of Parenteral nutrition
Peripheral access
•Up to 800 to 900 mOsm/kg
•Principal complication is thrombophlebitis
Short-term central access.
•Direct puncture of subclavian or jugular veins
Long-term central access
•Peripherally inserted central catheter (PICC)
•Tunneled catheter
Parenteral Protein
All essential amino acids; some nonessential
Concentration between 3% and 20% by volume
4 kcal/g
Provides15% to 20% of total kcal
Parenteral CHO
Dextrose monohydrate
Concentration between 5% to 70% by volume
3.4 kcal/g
Maximum rate should not exceed 5 to 6 mg/kg/min
Parenteral Lipid Emulsions
10%, (1.1 kcal/ml) and 20% (2 kcal/ml)
Provide 20% to 30% total kcal as lipid
•Provide about 1 gm/kg
•Do not exceed 2 gm lipid/kg per day
•Stop if triglycerides >400 mg/dl
Soybean oil with egg yolk phospholipid used as emulsifierProvides essential fatty acids
Proinflammatory
Alternative lipid
- Lipid emulsion made of soybean oil, olive oil, fish oil, MCT
- Fish oil emulsion
- Fish oil an MCT reduce inflammation and produce less immunosuppression
Compounding Methods
2-in-1: All nutrients in one bag except fat emulsion, which is infused separately
3-in-1:Total nutrient admixture or three-in-one solution contains lipid, amino acids, and glucose.
Parenteral Administration
Continuous infusion
- Increase incrementally over 2 or 3 days to reach goal rate
- Avoid abrupt cessation to prevent rebound hypoglycemia
Cyclic infusion
- 8 to 12 hours per day, usually at night
- Higher rate or more concentrated solution
- Contraindicated with uncontrolled hyperglycemia and fluid intolerance
Parenteral Complications
- Mechanical
- Infection or sepsis
- Metabolic
- GI
Refeeding Syndrome
Caused by overly aggressive parenteral nutrition, specifically carbohydrate
Potentially lethal
Cardiac and pulmonary complications from fluid overload
Monitor serum magnesium, potassium, and phosphorus
Start with 25% to 50% of goal parenteral nutrition in those at risk
Transitional Feeding
Parenteral to enteral
- Takes 2 to 3 days
- Stop parenteral when enteral reaches 75%
Parenteral to oral
-Stop parenteral when oral consistently provides 75% of needs
Enteral to oral
-Cycle enteral at night to reestablish hunger and satiety cues
