Exam 3 lecture 3 EN Flashcards
ROA of EN
bolus
intermittent
continouos
trickle or trophic
Describe bolus EN. What dose do we usually give? Max dose? What patients is it usually used in?
Mimics meals
administer >200 mL formula over 5-10 mins
Max volume 300-400
Usually used in patients with PEG tubes
advantages/disadvantages of bolus
Advantage
- More convenient for pts
- requires minimal equipment
- Less medication interaction
disadvantage
- Cannot feed into small bowel
- higher risk for aspiration and intestinal side effects
describe intermittent EN, how is it administered and how often? Advantages/disadvantages
administered >200 mL formula over 20-30 mins
4-8 feedings per day
advantage- helps tolerance
Disadvantage- more equipment required (requires use of reservoir bottle or bag)
Describe continuous infusion in EN? How is it administered? WHat devices does it require
When is this the preferred method
Most common in hospitals
Administered continuously over 12-24 hours/day
Requires use of infusion pump
Preferred method when feeding into jejunum
uses kangaroo pump
advantages/disadvantages of continuos infusion
advantages
- lower risk of gastric distention and aspiration
-better tolerated by pts
disadvantages
- problematic for medication administration
- requires infusion pump
describe trickle feed (trophic feeds)
Slow continuous infusion at 10-30 ml/hr
advantages
- prevent mucosal atrophy and bacterial translocation
- may shorten time on ventilator and decrease mortality
disadvantages
- difficult to achieve sufficient calorie delivery
Initiation and advancement of tube feeding?
Initiate full strength at 25 ml/h
advance 25 ml/h q 4-6 hrs as tolerated up to goal rate
EN - ICU initiation points
Achieve >50-60% goal calories within first week (if not, consider PN)
DO not initiate if hemodynamically unstable
bowel sounds or flatus not needed for initiation
When do we use each product on EN
Nepro- renal
Glucerna- Diabetes
Impact 1.5- immune support (usually used in ICU)
jevity- normal
What is the EN nutrient composition for protein and fat
- Protein
Intact protein
- requires complete digestion into smaller peptides
Partially digested (peptide-based)
- elemental; may be beneficial for pts with malabsorption
- Fat
- Long chain fatty acids
- medium chain fatty acids
What are some modular supplements we can use for patients that are adjunct with EN
Fiber- nutrisource, fiber, benefiber
Protein- pro-stat
Wound care, HIV, cancer- Juven
Glutamine- glutasolve Burn patients benefit from glutamin supplement)
When is glutamine helpful? When not to supplement?
May reduce hospital and ICU length of stay, reduces mortality in burn patients
No systemic effect when given by enteral route
Do not supplement if already receiving glutamine via immune modulating formula
Complications of EN
Gastrointestinal
Metabolic
Mechanical
Medication-related
What are some GI complications of EN
Hugh risk for gastric residuals and aspiration
N/V or decreased motility (consider prokinetic medications, metoclopramide, erythromycin may be given)
Abdominal distention
Diarrhea or constipation (check meds)
What is the cut off when we hold residuals
greater than 500 we hold.
<500 do not hold unless intolerance signs.
risk reduction of aspiration seen in EN
Elevate the head of the bed (30-45 degree of the bed)
Administer continous infusion
Change to post-pyloric delivery
consider pyrokinetic drugs or narcotic antagonists
What to do if we see decreased gut motility
Consider prokinetic agents
Metoclopramide (most common) (also used for N/v)
erythromycin
naloxone
Methylnaltrexone
If patient has diarrhea, what can we do? WHat meds tend to cause the most diarrhea
Change to soluble fiber containing formulations. Suspect C diff
Evaluate meds
-hyperosmolar meds
-liquid formulations with sorbitol
-Bowel regimen
- broad spectrum antibiotics
What meds generally could cause diarrhea
Propofol infusion
polyethylene glycol
Piperacillin/tazobactam
docusate/senna
bisacodyl
acetaminophen
metabolic complications with EN? Goal BG in ICU
Hyper or hypoglycemia
- check meds, insulin regimen
Overhydration/dehydration
Electrolyte imbalance (hyponatremia is most common)
<180 is goal
mechanical complications of EN
clogging of feeding tube/ malposition
rhinitis (change from NG to OG)
sinusitis
Medication related complications of EN (IMPORTANT)
DO NOT CRUSH SUSTAINED RELEASE OR ENTERIC COATED FORMULATIONS.
- Try to use liquid form when giving meds
- if we use oral dosage forms, make sure the tablets are crushable and can be mixed with water
- administer each medication separately
-ensure adequate flushing with water between each med - dilute hypertonic medication in water
Avoid viscous formulations that can clog the tube (syrups, mineral oil, granules)
dilute in 15-30 ml of sterile water
What meds are on the do not crush list for EN
Enteric coated
buccal/sublingialcarcinogenic, teratogenic, cytotoxic
delayed/ER
What meds interact with tube feeds
Antibiotics
fluoroquinolones
itraconazole
tetracyclines
penicillin
Levothyroxine
phenytoin
warfarin
Anti retrovirals (end in vir)
any of these given on the tube switch to IV
How long before jevity do you hold before the levo
hold jevity 1 hour before and 2 hour after levo dose
What GI things should we monitor on EN
Gastric residuals
emesis/nausea
diarrhea
constipation
aspiration
What metabolic things to monitor on EN
Intake/output (I/Os)
check weight 2-3 time per week
daily labs- serum electrolytes, BUN/SCr until stable, then twice weekly, then weekly
weekly- mg, phos, ca, triglycerides, lfts
weekly- albumin, pre albumin/crp, nitrogen balance
definitely know monitoring weekly/ daily etc for PN
last flash card
For patients with AKI what do we consider
Use normal EN unless electrolyte profile dictates
CRRT- Needs higher protein (2.5 g/kg/day)
(normal ICU patient is 1.5-2 g/kg/day)
If they are on Hemodialisis (HD)- 0.8-1.2 g/kg/day protein. Loss of water soluble micronutrients (selenium, zinc, thalamine)
prealbumin accumulates due to being cleared renally (will be falsely high)
EN considerations for pulmonary failure patients
Fluid restriction,
calorically dense formulations (1.5-2 kcal/ml)
Monitor phosphate closely
What are some EN considerations for acute pancreatitis
Patients have increased protein catabolism amd increased energy expenditure so they may need more protein. (1.2-1.5 g/kg/day), add glutamine
Watch blood sugar
Watch triglyceride levels closely
They have increased insulin resistance so they may need more GC monitoring
What are some EN considerations with burn patients
Patients need high protein (2-2.5 g/kg/day)
Early feeding with EN
If TBSA>10%- Ascorbic acid, zinc, vitamin E, selenium
If TBSA>20% oxandrolone/growth hormones
vit D and A
