Exam 3 lecture 3 EN

Question 1

ROA of EN

Answer 1

bolus
intermittent
continouos
trickle or trophic

Question 2

Describe bolus EN. What dose do we usually give? Max dose? What patients is it usually used in?

Answer 2

Mimics meals
administer >200 mL formula over 5-10 mins
Max volume 300-400

Usually used in patients with PEG tubes

Question 3

advantages/disadvantages of bolus

Answer 3

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

Question 4

describe intermittent EN, how is it administered and how often? Advantages/disadvantages

Answer 4

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)

Question 5

Describe continuous infusion in EN? How is it administered? WHat devices does it require
When is this the preferred method

Answer 5

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

Question 6

advantages/disadvantages of continuos infusion

Answer 6

advantages
- lower risk of gastric distention and aspiration
-better tolerated by pts

disadvantages
- problematic for medication administration
- requires infusion pump

Question 7

describe trickle feed (trophic feeds)

Answer 7

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

Question 8

Initiation and advancement of tube feeding?

Answer 8

Initiate full strength at 25 ml/h
advance 25 ml/h q 4-6 hrs as tolerated up to goal rate

Question 9

EN - ICU initiation points

Answer 9

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

Question 10

When do we use each product on EN

Answer 10

Nepro- renal
Glucerna- Diabetes
Impact 1.5- immune support (usually used in ICU)
jevity- normal

Question 11

What is the EN nutrient composition for protein and fat

Answer 11

1. Protein

Intact protein
- requires complete digestion into smaller peptides

Partially digested (peptide-based)
- elemental; may be beneficial for pts with malabsorption

2. Fat
   - Long chain fatty acids
   - medium chain fatty acids

Question 12

What are some modular supplements we can use for patients that are adjunct with EN

Answer 12

Fiber- nutrisource, fiber, benefiber
Protein- pro-stat
Wound care, HIV, cancer- Juven
Glutamine- glutasolve Burn patients benefit from glutamin supplement)

Question 13

When is glutamine helpful? When not to supplement?

Answer 13

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

Question 14

Complications of EN

Answer 14

Gastrointestinal
Metabolic
Mechanical
Medication-related

Question 15

What are some GI complications of EN

Answer 15

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)

Question 16

What is the cut off when we hold residuals

Answer 16

greater than 500 we hold.

<500 do not hold unless intolerance signs.

Question 17

risk reduction of aspiration seen in EN

Answer 17

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

Question 18

What to do if we see decreased gut motility

Answer 18

Consider prokinetic agents

Metoclopramide (most common) (also used for N/v)
erythromycin
naloxone
Methylnaltrexone

Question 19

If patient has diarrhea, what can we do? WHat meds tend to cause the most diarrhea

Answer 19

Change to soluble fiber containing formulations. Suspect C diff

Evaluate meds
-hyperosmolar meds
-liquid formulations with sorbitol
-Bowel regimen
- broad spectrum antibiotics

Question 20

What meds generally could cause diarrhea

Answer 20

Propofol infusion
polyethylene glycol
Piperacillin/tazobactam
docusate/senna
bisacodyl
acetaminophen

Question 21

metabolic complications with EN? Goal BG in ICU

Answer 21

Hyper or hypoglycemia
- check meds, insulin regimen

Overhydration/dehydration

Electrolyte imbalance (hyponatremia is most common)

<180 is goal

Question 22

mechanical complications of EN

Answer 22

clogging of feeding tube/ malposition
rhinitis (change from NG to OG)
sinusitis

Question 23

Medication related complications of EN (IMPORTANT)

Answer 23

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

Question 24

What meds are on the do not crush list for EN

Answer 24

Enteric coated
buccal/sublingialcarcinogenic, teratogenic, cytotoxic
delayed/ER

Question 25

What meds interact with tube feeds

Answer 25

Antibiotics
fluoroquinolones
itraconazole
tetracyclines
penicillin

Levothyroxine
phenytoin
warfarin

Anti retrovirals (end in vir)

any of these given on the tube switch to IV

Question 26

How long before jevity do you hold before the levo

Answer 26

hold jevity 1 hour before and 2 hour after levo dose

Question 27

What GI things should we monitor on EN

Answer 27

Gastric residuals
emesis/nausea
diarrhea
constipation
aspiration

Question 28

What metabolic things to monitor on EN

Answer 28

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

Question 29

definitely know monitoring weekly/ daily etc for PN

Answer 29

last flash card

Question 30

For patients with AKI what do we consider

Answer 30

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)

Question 31

EN considerations for pulmonary failure patients

Answer 31

Fluid restriction,

calorically dense formulations (1.5-2 kcal/ml)

Monitor phosphate closely

Question 32

What are some EN considerations for acute pancreatitis

Answer 32

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

Question 33

What are some EN considerations with burn patients

Answer 33

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