Initiating Enteral Nutrition Overview Flashcards
What is the maximum hang time for closed-system enteral formulas
48 hours (or based on manufacturer’s guidelines)
A 74 year old male with history of Alzheimer’s dementia and dysphagia requires enteral nutrition as his sole source of nutrition. He presents to the hospital with a fever, hypotension, poor skin turgor an dry mucous membranes. He is 5 feet 9 inches tall and 67 kg. He is currently getting 1200mL of free water daily from the EN + 400 mL from free water flushes. His estimated calorie needs are 1800 kcals/day. How should his fluid needs be estimated?
30mL per kg of body weight as using mL /kcal is NOT appropriate and can lead to overhydration
what are three methods for estimating fluid needs in enterally fed patients
1mL per kcal of enteral feeding (<65 years old)
Weight based (25-35kcal/kg) for adults > 65 years old
Holliday-Segar Method (1500mL for the first 20 kg and 15mL/kg for each kg remaining over 20kg)
how is the Holliday-Segar Method calculated in adults
1500mL of fluid for the first 20 kg
add an additional 15ml/kg over 20 kg
weight based fluid calculations are not recommended for
patients with cardiac/kidney failure issues as can lead to fluid overload
A 56 year old female with dysphagia who is afebrile weighs 60kg, is on a standard 1kcal/mL enteral formula at 180mL/hr for 10 hours nightly. What volume of water flushes would best meet her daily estimated fluid requirements
1mL/kcal = 1800 mL of total water needed (same as 30mL x 60 kg of water = 1800mL)
Tube Feed Volume + 180mL/hr x 10 hours = 1800 mL, a 1mL/kcal formula contains 84% water, so 1800 x0.840 is approx 1500mL so 1800mL - 1500 mL from tube feed leaves over 300 mL of water for free water flushes
Adult, afebrile patients who are enterally fed can have their fluid needs calculated by
1mL or 30-40mL/kg
Standard enteral formulas that are 1mL/kcal contain ____% water
84%
what are the benefits of starting early, appropriate enteral feedings
decreased bacterial translocation in the gut
preserves gut mucosal lining to decrease infection risk
decreases atrophy of the intestinal villi
lack of feeding via the gut during critical illness may lead to ____ of the intestinal villi, predisposing a patient to _____, increased gut ___ and potentially increased ____ risk
atrophy
bacterial translocation of the gut
increased gut permeability
increased infection risk
A patient is receiving EN during her 2nd trimester of pregnancy. Nutrition assessment data reflects an average maternal weight gain of 0.42 pounds a week, normal fetal growth, an albumin of 0.2 g/dL and a nitrogen balance of +2 grams a day. based on the data provided, which parameters are useful in assessing efficacy of enteral nutrition in pregnancy. Which ones are not?
Good indicators: maternal weight gain, fetal growth
Poor indicators: albumin, protein
what are the most important factors in assessing adequacy and efficacy of enteral nutrition in pregnancy?
fetal growth & maternal weight gain
there is a strong correlation between infant birth weight and ______ weight
maternal
a positive nitrogen balance indicates adequate
protien provision
A diabetic patient with early satiety, bloating, occasional vomiting & extensive weight loss. After a thorough GI workup, the patient is diagnosed with gastroparesis. What type of EN formula is most efficacious?
concentrated (if sensitive to volume)
standard/polymeric (esp. if given jejunum)
low in fat and fiber to avoid delayed gastric emptying
elemental formulas are reserved for patients with
malabsorption and pancreatic insufficiency
high protein enteral formulas are reserved for patients with
wound healing and critical care nutrition
Lactose is a common ingredient in which type of EN formula?
standard infant formula as it mimics the carbohydrate content found in human milk
Most adult medical nutrition products are _____ free because many adults are lactose intolerant, and lactase efficacy is decreased during illness
lactose
Patients with chyle leaks will have trouble tolerating polymeric EN formulas becuase
they cannot absorb long chain fatty acids well
Elemental EN formulas contain individual _____ and 2-3% of calories from these types of fats ______
amino acids
long chain fatty acids
Patients with chyle leaks need to decrease the quantity and duration of chyle loss using ___ formulas and a ______ diet
elemental
low fat
patients with Chron’s or Celiac Disease usually do well with intact macronutrients true or false
true
patients with gastroparesis can usually tolerate polymeric enteral formulas especially wehn
they are provided in the jejunum
In patients with pancreatitis, which parameters are important in predicting tolerance of enteral feedings?
APACHE II Score
Duration of NPO
Abdominal pain
What is the most influential factor to determine tolerance of enteral nutrition in pancreatitis
disease severity as measured by APACHE II Score
A duration of NPO > _____ days has indicated poor tolerance to EN in studies for pancreatitis
6 days
Increased ______ is a clinical indication of enteral feeding intolerance in patients with pancreatitis
abdominal pain
what is the rationale for starting EN
it may be started in patients who cannot or will not eat adequately
Prior to starting EN, what should be considered
ethics patient & family wishes quality of life risks & benefits clinical status prognosis
EN should be started when patients are expected to or have not had adequate oral intake for ______ days
7-14 days
EN should not be initiated if the expected duration is less than ____ days in the malnourished patient or less than ____ days in an adequately nourished pateint
5-7 days (malnourished)
7-10 days (adequately nourished)
EN should only be started when the patient is
fully resuscitated or stable
What is the preferred method of nutrition for open abdomen
enteral
when should PN be started in open abdomen when
EN isn’t tolerated for greater than 7 days
PN is indicated in high output mid-jejunal fistula, intractable obstipation & vomiting and short bowel syndrome with < _______ cm and without a ______
<50 cm w/ out a colon
what are common indications to place a gastro-jejunostomy tube?
diabetic gastroparesis as it bypasses the stomach to prevent nausea, vomiting during feeding
Skin level or low profile enteral access devices have what desire features?
more comfortable
more cosmetically pleasing
can be capped when not in use
what are cons of low profile enteral access devices
they require an access connector to provide meds or feedings & requires manual dexterity
what is the gold standard for determining proper position of a feeding tube placed at the bedside?
radiographic confirmation
do auscultation, pH testing, aspiration still require cxr
yes
placement of a jejunostomy feeding tube would NOT be beneficial in _____ as it would increase stool output , decreased absorption
short bowel syndrome
what are uses for jejunostomy
gastroparesis, pancreaticduodenectomy (whipple), chronic pancreatitis
for patients with short bowel syndrome what type of enteral feeding is recommended
slow, continuous infusion in the stomach to maximize absorption and intestinal transit time
compared to gastric feeding, small bowel feeding is associated with which of the following outcomes in critically ill patients
increased nutrient delivery, reduced GRV and reflux, shorter time to get to target goal
what intervention may assist with the appropriate placement of a nasogastric feeding tube in an alert patient?
elevated the HOB
have the patient in a sitting position
take small sips of water
what is most likely to facilitate transpyloric placement of a nasoenteric feeding tube
fluoroscopy & endoscopy or bedside electromagnetic imaging system
what are contraindications for the placement of a PEG in a patient with liver disease
ascites (it may prevent the gastric and abdominal wall from being in close proximity so the trocar won’t be able to pass through the stomach wall with a poor seal possibly leading to peritonitis
what are POSSIBLE contraindications to PEG tube placement when risk vs. benefit should be evaluated
esophageal & gastric varices coagulopathy hepatic encephalopathy fulminant hepatic failure portal HTN
What is an advantage of a gastrostomy feeding tube compared to an NG tube
gastrostomy tubes can be used in long term needs
When EN is needed for over 4 weeks what type of feeding tube is preferred
gastrostomy
do gastrostomy tubes decrease the risk of aspiration
no, but the due have an increased risk of gastric perforation
Ascites is considered a relative contraindication to PEG tube as it increases the risk of
peritonitis
A patient with a traumatic brain injury will require enteral nutrition for three weeks. What is the preferred method of feeding tube placement
naso-enteric
what are the risks of an open feeding tube, laparoscopic feeding tube and endoscopic feeding tube placement
bleeding, anesthesia, bowel perforation , infection
What is the primary advantage of a direct percutaneous endoscopic transgastric placed jejunal (PEG-J) tube vs a a PEJ
the PEG-J has a decreased risk of migration into the stomach
placement of a percutaneous endoscopic _____ tube increases the risk of developing a gastric outlet obstruction
PEJ tube
What characteristic of EN formulas is MOST likely to increase splanchnic blood flow in a critically ill patient?
high fat enteral formulas
high fat enteral nutrition helps promote what in a critically ill patient
blood flow to the bowel is maxamized
what type of enteral nutrition formula is ideal for patients at high risk for intestinal ischemia, as adequate bowel perfusion is needed for tolerance of high fiber, high osmolarity
isotonic, fiber free
Hospital prepared enteral nutrition formulas should be stored at approximately what temperature
4 degrees C to 39 degrees F
what is considered the danger zone for food contamination
5-57 decrees C
A 60 year old female is admitted with a stroke and fails a swallowing evaluation. An NG tube is placed and the MD requests an isotonic formula. What calorie density of EN formulas is isotonic
1 kcal/mL which is about 300 mOsm/kg
what is the range of osmolarity for 1kcal/mL EN formulas
300-350 mOsm/kg
what is the range of osmolarity for 1.2 kcal/mL EN formulas
400-450 mOsm/kg
what is the range of osmolarity for 1.5 kcal/mL EN formulas
500-650 mOsm/kg
what is the range of osmolarity for 2 kcal/mL EN formulas
700-800 mOsm/kg
what is the best initial enteral feeding regimen for a critically ill adult
full strength started at a low rate and slowly advance to goal
why is it not encouraged to dilute enteral formulas
it can cause microbial growth and inadequate nutrition provision
What is the most important intervention to decrease the risk of pulmonary aspiration during gastric tube feedings
elevated the HOB 30-45 degrees
drugs that cause diarrhea are due to their
hypertonicity, laxative action from sorbitol or magnesium containing products
what are drugs/medications that are known to cause diarrhea
medications containing sorbitol, magnesium citrate, antibiotics that cause enteritis, high TF osmolarity/bolus (sometimes)
tube feeding is often held 2 hours before and after enteral administration of these types of meds
warfarin ciprofloxacin phenytoin carbamazepine fluoroquinolones
what strategies can be employed to reduce the risk of feeding tube occlusion
flush with water before and after each medication
drugs that are microencapsulated with beads or pellets are most effectively administrated through large bore feeding tubes when mixed with _______ due to the acidity to reduce the beads/pellets from sticking to the tube. The tube should also be flushed with water before and after the OJ and separately from the EN formula. Don’t use warm water.
orange juice
what type of enteral formulas are least likely to be contaminated with microorganisms
ready to hang
what is the hang time of formula made from reconstituted powder
4 hours
what is the hang time of home made blenderized enteral formulas
2 hours
what is the hang time of commercially made blenderiezed enteral formulas
4-8 hours
A 45 year old male is admitted with stage 4 pressure wounds, sepsis and acute respiratory failure who requires mechanical ventilation. BUN is stable, no additional excessive GI losses are noted. A polymeric high protein EN formula was started on day 1 of admit. On day 7, the primary care team requested an eval of the protein dose provided by EN. The EN formula gives 136 grams of protein (1.5g/kg/day). What is the best method to assess protein adequacy
nitrogen balance study
_____ is the gold standard for assessing the adequacy of protein intake in the acute hospital setting
nitrogen balance
Nitrogen balance is the difference of
nitrogen intake -nitrogen output
nitrogen output as part of a nitrogen balance study is measured from
urine urea nitrogen from a 24 hour urine collection
nitrogen intake as part of a nitrogen balance study is measured from
EN or PN intake
what are limitations to using a nitrogen balance study
renal dysfunction, errors estimating output and intake
Use of a semi-elemental or elemental formula in place of a polymeric formula should be considered with
intolerance to polymeric formula
Use of immune modulating formula may be beneficial in
elective surgery, TBI, abdominal and torso injury from a MVA crash
immune modulating formulas contain
arginine, glutamine, nucleotides, omega 3 fatty acids
the use of immune modulating formulas is not recommended for routine use
use is controversial, there are inconsistent outcomes and contraindicated in septic patients 2/2 adverse effects with arginine
what would be the most appropriate TF formula for a patient with extensive second degree burns
high protein
high protein EN formulas are needed in severe burns because
burns cause a breakdown of lean muscle for energy and loss from wounds
What are types of modular products for EN
MCT Oil
Glucose
Fiber
Protein
what are EN modulars used for
to fortify EN regimens or meals
EN modulars should not be added directly to
enteral formula
Early initiation of EN has been a suggested benefit LICU patients by reduction infectious complications, length of stay and possibly decreased mortality. Which group of patient’s might be at significant risk from early EN.
patients with increased vasopressor support which may increase the risk of intestinal ischemia from decreased blood perfusion
a patient with ARDS getting EN will benefit most from
avoidance of overfeeding
this disease is associated with inflammation causing alveolar damage and lung capillary endothelial injury
ARDS
Formulas with omega 3’s are thought to be used for ARDS because
the omega 3 fatty acids, arginine, and glutamine may down regulate the inflammatory response induced by ARDS
immune modulating formulas with omega 3 fatty acids are not recommended for routine use in ARDS because
research remains inconclusive
The use of EN formulas enriched with branched-chain amino acids may benefit with
refractory encephalopathy
Theory: liver failure is thought to increase the ratio of aromatic amino acids (AAA) to branched chain amino acids (BCAAs). BCAAs also decrease from muscle breakdown. Increased AAAs develop “fake neurotransmitters” causing encephalopathy. Only use formulas with increased BCAAs if a patient is still encephalopathic despite medicine
encephalopathy
unresponsive to standard medical therapy
EN may be contraindicated in early post transplant period with hematopoietic cell transplants because of
potential mucosal toxicities r/t conditioning regimen that causes to GI toxicities that cause, nausea, vomiting, delayed gastric emptying, diarrhea within the first 2-3 weeks of post stem cell transplant may provide EN
in patients with early post transplant period with hematopoietic cell transplants what form of artificial nutrition is recommended
there is insufficient data to establish the benefits of enteral nutrition over parenteral nutrition for hematopoietic cell transplants
which medication would be appropriate to crush and deliver via enteral nutrition tube
immediate release
____ medications should not be crushed to be put through a feeding tube as can cause medication toxicity
slow release typical abbreviations (XL, XR,SR,CD)
which describes an optimal method of preparing and administering meds via enteral tube
flush the tube with water before and after each medication
in patients with severe acute pancreatitis, EN has been documented to provide the following benefits over parenteral nutrition
EN will decrease infection rate, decrease length of stay and decrease mortality
In a pt with fat malabsorption of an enteral products containing which of the following concentrated source of energy
MCT’s; they are absorbed directly into the blood stream into the portal circulation by passing need for pancreatic enzymes, bile carnitine dependent transport into the mitochondria
