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BCPS Exam > FEN: Enteral Nutrition I > Flashcards

FEN: Enteral Nutrition I Flashcards

1
Q

When is enteral nutrition indicated?

A

EN is used in patients who are at risk of malnutrition and in whom it is anticipated that oral feedings will be inadequate for 5-7 days

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2
Q

What are risks of malnutrition in critically ill patients?

A
  1. poor wound healing

2. increased risk of infection

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3
Q

ASPEN guidelines for indication and timing of EN in non critically ill patients

A
  1. According to the American Society for Parenteral and Enteral Nutrition,
  2. Well-nourished adults without excessive metabolic stress
  3. Can tolerate little to no nutrition for up to 7 days.
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4
Q

2016 ASPEN and SCCM guidelines for indication and timing of EN in critically ill patients

A
  1. 2016 ASPEN and Society of Critical Care Medicine (SCCM) guidelines
  2. For critically ill patients recommend starting enteral feedings
  3. Within the first 24-48 hours after intensive care unit admission.
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5
Q

List six contraindications for enteral nutrition

A
  1. Complete intestinal obstruction
  2. GI fistula (specific cases)
  3. Extremely short bowel
  4. Severe diarrhea or vomiting
  5. Hemodynamic instability or intestinal ischemia
  6. Paralytic ileus
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6
Q

Are positive bowel sounds required for EN initiation?

A

Absence of bowel sounds is not a contraindication for the provision of enteral nutrition

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7
Q

Specifically, what situations of GI fistula result in a contraindicated enteral nutrition?

A
  1. Feeding tube cannot be placed distal to the fistula OR

2. High-output fistula (greater than 500 mL of output per day)

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8
Q

Despite paralytic ileus, many patients can still be fed through the _____?

A

Small bowel

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9
Q

List three routes of enteral nutrition (tube feeding) administration

A
  1. Large-bore orogastric and nasogastric tubes
  2. Small-bore feeding tubes
  3. Percutaneous endoscopic tubes, e.g. long-term tubes
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10
Q

Both large and small-bore feeding tubes are commonly placed in the ____, but can be placed in the ______ in patients with _______

A
  1. Nose
  2. orally
  3. nasal or facial trauma or sinusitis
  4. Orogastric tubes are uncomfortable for alert patients.
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11
Q

What is a complication of prolonged use of large-bore feeding tube?

A

Prolonged use can cause sinusitis or nasal mucosal ulceration

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12
Q

Large-bore feeding tubes can also be used for _____ in addition to enteral feeding

A

Stomach decompression

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13
Q

Why are small-bore feeding tubes preferred in patients with a gastric ileus?

A
  1. Patients with a gastric ileus will not tolerate gastric feedings, and there is an increased risk of aspiration
  2. Small-bore feeding tubes can be placed past the pyloric sphincter to improve tolerance and prevent aspiration.
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14
Q

Compare the administration of medications in NG tubes, NDT, and NJ tubes

A
  1. Nasogastric tubes better than nasoduodenal tubes better than nasojejunal tubes.
  2. The smaller the diameter and the longer the tube, the more likely to clog.
  3. Lack of evidence of drug absorption from jejunum.
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15
Q

List three types of long-term feeding tubes (percutaneous)

A
  1. Gastrostomy tube (G-tube)
  2. Gastro-jejunostomy tube (GJ-tube, or PEG-J tube)
  3. Jejunostomy tube (J-tube)
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16
Q

Describe three situations when a percuanteous tube would be inserted directly into the jejunum (e.g. J-tube)

A
  1. Usually to facilitate immediate postoperative or postinjury feeding,
  2. Or when the stomach has been removed,
  3. or when the esophagus has been removed and the stomach has been relocated into the chest.
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17
Q

To what does gravity control refer to with enteral feeding?

A

Gravity control refers to delivery with tubing that is fitted with a roller clamp to allow infusion into the stomach as desired

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18
Q

Under what criteria are bolus feedings not permitted?

A

Duodenal or jejunal feedings, high risk of aspiration (i.e. bolus feedings can only be used for feeding tubes ending in the stomach in stable patients)

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19
Q

What type of EN delivery is most common in hospitals and why?

A

Continuous infusions by an enteral feeding is usually used in hospitals because of the lower risk of aspiration compared with bolus feedings

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20
Q

Describe cyclic feedings and their purpose

A

Cyclic feedings are administered continuously for 10-12 hours (overnight) to facilitate patient mobility during the daytime

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21
Q

Describe how to give intermittent bolus feedings (e.g. indication, quantity, duration of infusion, frequency)

A
  1. Only for feeding tubes ending in the stomach in stable patients,
  2. 100-300 mL for 30-60 minutes every 4-6 hours
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22
Q

List two benefits of enteral nutrition over peripheral nutrition

A
  1. EN is preferred in patients wtih a functional GI tract because it is associated with a lower risk of infection than PN
  2. Early administration of EN is associated with lower rates of infection and shorter lengths of stay
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23
Q

Describe mechanism of how higher rates of infection can occur without enteral nutrition or oral nutrition

A

GI mucosal atrophy occurs with an absence of enteral or oral nutrition. This can increase risk of bacterial translocation because of gut bacteria crossing the weakened intestinal barrier.

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24
Q

What 7 components are typical in most EN formulations

A
  1. Carbohydrate
  2. Fat
  3. Protein
  4. Electrolytes
  5. Water
  6. Vitamins
  7. Trace elements
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25
Q

What type of formula is used in patients with impaired digestive capacity? This is different than _____, which is used in patients with normal digestive processes

A
  1. Elemental or semi-elemental formulas

2. Intact or polymeric formulas

26
Q

What is typical caloric content of intact or polymeric formulas?

A

1-1.2 kcal/mL

27
Q

What is caloric content of concentrated intact/polymeric formulas used for patients with fluid restriction?

A

2 kcal/mL

28
Q

Compare cost between elemental or semi-elemental formulas and polymeric formulas

A

Polymeric formulas are less expensive

29
Q

Some polymeric formulas are used for ____ administration and are used to _________

A
  1. Oral administration

2. Supplement the patients diet

30
Q

List two types of conditions that would result in patients using elemental or semi-elemental formulas

A
  1. Impaired digestive capacity

2. Malabsorption (short bowel, pancreatic insufficiency)

31
Q

What type of EN formulation is used for patients with constipation? Two examples?

A
  1. Some EN contains fiber for patients with constipation,

2. Replete with Fiber and Jevity.

32
Q

List five disease-specific enteral nutrition formulas

A
  1. Renal
  2. Respiratory failure
  3. Diabetes
  4. Hepatic disease
  5. Highly stressed patients
33
Q

List two qualities of EN formulations for renal failure

A
  1. EN formulations for patients with renal failure are typically concentrated (i.e. 2 kcal/mL to adhere to fluid restrictions)
  2. Contain differing amounts of protein and electrolytes
34
Q

Describe two qualities of EN formulations for respiratory failure and the purpose for that design

A
  1. Some EN products designed for patients with respiratory failure have more calories from fat (40-55% of total calories)
  2. And fewer from carbohydrates
  3. To reduce production of CO2 and facilitate ventilator weaning.
35
Q

Describe the benefit/cost of respiratory failure-designed EN formulations

A
  1. Excessive CO2 production is primarily caused by overfeeding with total calories rather than total amount of carbs,
  2. Therefore these expensive formulations may be unnecessary as long as the patient is not being overfed.
36
Q

List three qualities of EN formulations for EN designed for diabetes

A
  1. EN formulations for patients with diabetes have more calories from fat,
  2. Fewer calories from carbohydrates,
  3. Added fiber to improve glycemici control.
37
Q

List two qualities of EN formulations designed for hepatic failure and hepatic encephalopathy and their purpose

A
  1. EN formulations for patients with hepatic failure and hepatic encephalopathy contain more branched-chain AAs
  2. And fewer aromatic AAs,
  3. which may improve encephalopathy.
38
Q

Describe the evidence/ use of EN formulations designed for hepatic failure

A
  1. More branched-chain AAs and fewer aromatic AAs improving encephalopathy is controversial,
  2. And these formulations are not commonly used.
39
Q

List four types of highly stressed patients for which the immune-modulating EN formulations are used

A
  1. Trauma
  2. Burn injury
  3. Acute respiratory distress syndrome
  4. Sepsis
40
Q

List six types of ingredients which may be added to highly stressed/ immune modulating EN formulas?

A
  1. Protein
  2. Arginine
  3. Glutamine
  4. Omega-3 fatty acids
  5. Nucleotides
  6. Beta carotene
41
Q

What are the recommendations for using immune-modulating EN formulas?

A
  1. Recommended for surgical ICU patients in the postoperative setting,
  2. Not recommended for the medical ICU population.
42
Q

What do the ASPEN guidelines say about disease-specific EN formulations in critical care patients?

A
  1. Specialty formulas are not recommended for routine use in a general ICU setting (lack of benefit).
  2. Most patients can be started on polymeric formula.
43
Q

List four complications of enteral nutrition related to the tube itself

A
  1. Improper tube placement or displacement
  2. Clogged feeding tubes
  3. Nasopharyngeal erosions, epistaxis, tracheoesophageal fistula
  4. Sinusitis
44
Q

List two ways to prevent clogged feeding tubes from medication administration

A
  1. Flush feeding tube before, between and after administration of each drug.
  2. Use of liquid formulations of medications if available is also recommended.
45
Q

List the 2 preferred ways to unclog feeding tubes, and which 2 ways should be avoided.

A
  1. Unclog feeding tubes with warm water or a pancreatic enzyme solution mixed with sodium bicarbonate
  2. Avoid using cola or juice (acidity can worsen clog depending on EN formula)
46
Q

List six medical complications of enteral nutrition

A
  1. Aspiration
  2. Diarrhea
  3. Constipation
  4. Dehydration
  5. Hypernatremia
  6. Electrolyte abnormalities
47
Q

List four ways to prevent aspiration from enteral nutrition

A
  1. Elevate head of bed at 30-45 degrees.
  2. Prevent delays in gastric emptying
  3. Post-pyloric tube
  4. Initiate EN at a slow rate
48
Q

How to prevent delays in gastric emptying by choosing correct EN formula?

A

Using an EN formula with less fat will prevent delays of gastric emptying

49
Q

What two agents can be given to improve gastric motility to improve tolerance of EN feedings?

A
  1. Metoclopramide

2. Erythromycin

50
Q

How to dose metoclopramide for improving tolerance to EN feedings?

A

metoclopramide 5-10 mg IV every 6 hours

51
Q

How to dose erythromycin for improving tolerance to EN feedings?

A

erythromycin 250 mg IV every 6-8 hours

52
Q

How to use metoclopramide and erythromycin to improve tolerance to EN feedings?

A
  1. Administer medications until tolerating for at least 24 hours
  2. Can be used in combination
  3. Monitor for diarrhea and tachyphylaxis.
53
Q

Why should you avoid prolonged use of promotility agents in setting of EN intolerance?

A

Increased risk of adverse drug effects

54
Q

How to prevent aspiration by controlling EN infusion rate?

A
  1. Start at a slow rate (e.g. 20 mL/hour)

2. Advance every 4-6 hours as tolerated to goal rate.

55
Q

What property of EN formulations increase the risk of it causing diarrhea?

A

More common with products with a higher osmolarity

56
Q

List five other causes of diarrhea common in patients receiving enteral nutrition

A
  1. Antibiotic use
  2. infection
  3. Lactose intolerance
  4. Magnesium
  5. Sorbitol in liquid medications
57
Q

Two ways to prevent constipation in patients receiving enteral nutrition?

A
  1. Adding fiber

2. Bowel stimulation

58
Q

When does hypernatremia occur when patients are receiving enteral nutrition?

A

Given insufficient water while receiving enteral nutrition

59
Q

How much water do patients require when receiving enteral nutrition?

A

30 ml per kg per day

60
Q

What type of patients are at an increased risk of hypernatremia when receiving enteral nutrition?

A

Altered mental status who may be unable to communicate thirst

61
Q

What type of EN formula requires additional attention to avoid hypernatremia?

A
  1. Calorie dense (i.e. 1.5 or 2 kcal/mL) EN formulas have less water than products containing 1 kcal/mL
  2. Therefore, additional water is needed to prevent hypernatremia.
62
Q

In what situations are electrolyte abnormalities most likely to develop in patients receiving enteral nutrition?

A

Patients who develop refeeding syndrome

BCPS Exam (34 decks)

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