Lecture 5 - Enteral Nutrition Flashcards
Goals of nutrition support
- Provide consistent nutrition support
- Prevent deficiencies
- Provide adequate nutrition to meet metabolic needs
- Avoid complications
- improve patient outcomes
Assessment of Nutritional Status
- Growth Curves
- Intake/output
- Weight
- Anthropometric measurements
- Visceral proteins
- 24hr urine studies
- Immune function tests
Methods to Calc fluid requirements
Method 1:
Young healthy adult = 40mL/kg/day
other adult = 35mL/Kg/day
Elderly = 25mL/kg/day
Method 2:
> 50yrs old, 1500ml + 20ml/kg for each kg > 20
< 50yrs old, 1500ml + 15ml/kg for each kg > 20
Harris Benedict Formula
BMR (men):
66 + 13.7wt(kg) + 5Ht(cm) - 6.8(age)
BMR(women):
655 + 9.6Wt(kg)+1.8(Ht) -4.7(age)
Actual Energy Expenditure
BMR X activity factor X injury (stress) factor
Activity Factors
Bed Rest = 1
Ambulatory = 1.3
Fever = 1.13
Risk Factors
Starvation = 0.7 Surgery = 1.2 Trauma (severe) = 1.35 Head Injury = 1.5 Sepsis = 1.6 Burn < 40% TBSA = 1.5 Burn > 40% TBSA = 2.1
If patient is obese then use….
adjusted bodyweight
If over feeding pt (> 40kcal/kg/day) can lead to..
Fatty liver
Hyperglycemia
Prolonged mechanical ventialtion 2 excess CO2 production
Indirect Calorimetry
Gold standard
Measure O2 consumption + CO2 produced
Done for severe hours
Also determines respiratory quotient
RQ levels
0.85 = goal
> 09 = suggest overfeeding
0.7 = predominate fat utilization
Carb ino
- Limited storage capacity
- Preferred fuel source for CNS,renal medulla
- Enteral carb = 4kcal/g, IV dextrose = 3.4kcal/g
- Recommended 45-60% of total calories
Fat info
- major endogenous fuel source
- 9kcal/g
- contains essential fatty acids, Omega 6/3
- Typically 10-35% of total daily calories
- Deficiency triene:tetraene ratio > 0.2
Protein daily intake
Health adult = 0.8g/kg/day
Severe burn pt = 2g/kg/day
Typical nutritional requirements for healthy adult
Calories: 25-30kcal/kg/day
Protein: 0.8-1g/kg/day
Fluids: 30ml/kg/day
Surgical patients at risk for…
increased risk of malnutrition
- inadequate intake
- surgical stress
- increased metabolic rate
- wound healing = anabolic state
Strongest predictor of surgical outcomes is….
Inverse relationship between pre op albumin lvls and morbidity and mortality
Takes awhile to increase due to 1/2life….~20days
Acute phase response, check with CRP
Prealbumin
shorter 1/2life than albumin, so can asses acute changes in nutritional status
tests more expensive
Check with CRP
Other ways to assess nutritional success?
Nitrogen balance
Protein intake gm/6.25 - (UUN + 4) = balance in g
Positive value = Intake of N2 > losses = good
Negative value = Intake of N2 < losses = bad
Traditional Post OP nutritional Care
- when to restart “house” diet depends on condition of GI tract
- oral feeding delay 24-48hrs post op
- Start clear liquids when bowel function returns…shouldn’t be on this for more than a few days
Enteral Nutrition
- used when oral intake is inadequate or CI
- Utilizes delivery of nutrition via a tube into GI tract
- ** req functional GI tract **
Indications for Enteral nutriton
- prev malnourished patient unable to eat for > 5-7days
- Adequately nourished pt unable to eat > 7-9days
- adaptive phase of short bowel syndrome
CI to Enteral nutrition
- Severe acute pancreatitis
- High output enteric fistula distal to feeding tube
- Severe GI dysfunction
- Inability to obtain access
- Intractable V/D
- expected need < 5 days malnourished or <7-9days normally nourished
Benefits of Enteral nutrition
- Prevents guy atrophy
- preserves guy barrier function
- decreases bacterial translocation
- promotes peristalsis
- Less expensive than parenteral nutrition
Typical EN patients….
Functional GI tract
Inadequate oral intake
Conditions where EN used
- impaired nutrient digestion
- inability to consume adequare oral nutrition
- malabsorption
- impaired metabolism
- severe wasting/growth retardation
NG Tube
- Short Term
- Intact gag reflex
- Normal gastric function
- low aspiration risk
- easy tube placement, no surgery required
- allows for bolus/intermittent feedings
G tubes
- surgically placed directly into stomach
- long term, > 30days
- allows for bolus/intermittent or continuous feedings
PEGs
- placed through endoscope
- Different kinds, G/J tubes
- Allow for gastric decompression and simultaneous JT feedings
- tube in intestine not stomach
Standard formula
Polymeric Normal/minimally impaired digestion Required absorption Intact protein meal replacement May contain fiber
Hydrolyzed formula
for GI compromise
Improved digestion
Protein typically small peptides
Elemental
Limited GI function minimal residue Protein is free amino acid minimal fat or high % MCT oil \$\$$, taste bad tho
Disease specific formulas
signed for specie organ dysfunction or metabolic abnormality
may or may not be nutritionally complete
Methods of EN delivery
Bolus
gravity
pump = if small bowels
G tube feeding
Continuous 1st
Start 30ml/hr, advance in 20ml q8hrs to goal volume
Bolus
start 120ml bolus, inc by 60ml q bolus to goal, freq = q3-8hrs
check for residuals
Small bowel J tube feeding
continuous feeding only
start 20ml/hr, inc 20ml hrs to goal
dont check for residuals
Gastric residuals
Check q 6hrs
If > 150ml, replace residual, old feeds X 4hrs and recheck
If < 150ml, restart
if still more than 150, continue to hold
Monitoring G tube feedings
Gastric residuals
Blood sugar
Complete chem panel q weekly
Check albumin, prealbumin q week
Aspiration precautions
- Keep head of bed > 30deg all time
2. *don’t use blue dye to test for aspiration
Complications of EN
- access
- administration
- GI
- Metabolic
- Psychologic
Mechanical complications of Tubes
- inadvertent tube removal
- tube kinking
- clogging
- inadvertent intubation
- leakage of gastric contents into the abdomen
Infectious complications of tubes
Aspiration pneumonia, Risk = altered mental status, GI dysmotility, prevent b keeping head of bed elevated
Percutaneous tube site infections
Upper respiratory infections
Diarrhea info
Major cause of EN interruption
Maybe due to meds
C.diff prone
Management - switch to peptide-based or semi-elemental formula…add fiber
Medication admin with tube
- Liquid form when available
- Dilute thick meds
- Watch Sorbital content**
- Crush tab, mix with water to form slurry
- Flush tube w/ water before and after giving dose, 1 at time
- Dont Mix meds with feeding
Determining EN prescription
- Estimate calorie, protein,fluid needs
- select most appropriate EN formula
- Determine route
- determine method (continuous vs bolus)
- Determine goal rate/volume
