Lecture 6 Flashcards
Enteral Nutrition
Related
Complications
GI Metabolic, pulmonary fluid status mechanical
Gastrointestinal EN-Related Complications
Nausea and vomiting – Occurs in 7-26% of patients on EN • Increased risk of aspiration – Possible etiologies • Delayed gastric emptying / gastroparesis • Hypotension, hemodynamic instability • Stress, sepsis • Anesthesia / surgery • Medications (i.e. narcotics, sedation) • Very cold enteral formula
Gastrointestinal EN-Related Complications
Interventions
Interventions ü Change EN formula • Low-fibre, low-fat ü Temporarily reduce the formula infusion rate ü If applicable, change feeding modality (i.e. from bolus to intermittent or continuous ü Use room temp feeds ü Liase with team re meds: • Reassess narcotics • Prokinetic agent?
Prokinetic Agents
• “Prokinetic” = promote movement • Drugs that enhance GI motility – Various mechanisms of action • Stimulate gut motility, esophageal peristalsis, strengthen lower esophageal sphincter pressure to promote gastric emptying • Common prokinetic agents in Canada – Metclopromide (Maxeran®) – Domperidone – Erythromycin (antibiotic)
Gastrointestinal EN-Related Complications
Abdominal distension – GI ileus – Bowel obstruction – Constipation / obstipation – Ascites – Initial use of high fibre feed
Gastrointestinal EN-Related Complications Abdominal distension
Interventions
ü Testing to r/o (rule out)obstruction or ileus • Imaging • Abdominal x-ray • CT ü Hold feeds if necessary • Not necessary if intestinal appearance/function are normal and patient not experiencing pain
Gastrointestinal EN-Related Complications
Malabsorption
– Signs and symptoms (s/s) • Weight loss • Steatorrhea • Diarrhea – Disease related • IBD (Crohn’s, Colitis) • Radiation enteritis • Enteric fistulas • Pancreatic insufficiency • Short bowel syndrome
Gastrointestinal EN-Related Complications
Malabsorption
Interventions
Interventions
ü Trial (semi) elemental formula
ü (Supplemental) PN if
unresponsive to EN
Gastrointestinal EN-Related Complications
Diarrhea
Incomplete absorption of fluid and electrolytes from lumen of GIT – No true definition • Abnormal volume & consistency • >500 mL/24h • 3 loose stools/d x 2d – Etiologies • Drugs • Disease, infection • Feeding formulas – Hyperosmolar – Lactose containing
Types of Diarrhea
5
Secretory • Caused by abnormal ion transport in intestinal epithelial cells resulting in decreased electrolyte absorption
Osmotic • Excess amounts of poorly absorbed substances remain in GIT which obligate water retention 2o to osm
Malabsorption • Conditions resulting in malabsorption of nutrients
Inflammatory • Inflammatory bowel diseases • Infectious etiologies (i.e. C.diff)
Disordered Motility • Diabetic neuropathy • Irritable bowel syndrome • Postvagotomy etc.
Conditions Associated with Secretory Diarrhea
• Clostridium difficile infection • Intestinal resection • Inflammatory bowel disease • Bile acid malabsorption • Chronic infections • Celiac sprue • Small intestinal lymphoma • Villous adenoma of the rectum • Zollinger-Ellison syndrome • Collagen vascular diseases • Congenital defects • Malignant carcinoid syndrome
Enteral Formula
Hyperosmolar formulas – What types of formulas tend to be hyperosmotic? • Components of formulas or modulars – Lactose – Read the ingredients! – Clinical observation
Managing Diarrhea: Other Nutrition Strategies
• Change formula type – Intact protein à peptides • Add soluble or insoluble fibre – Change EN formula – Fibre modular (i.e. Benefibre®) – Metamucil, pectin • Consider PN if warranted
Gastrointestinal EN-Related Complications
Constipation – Also difficult to define • Physical s/s • Imaging (Abdo XR) – Common causes • Dehydration • Inadequate/excessive fibre • Medications • Immobilization
Gastrointestinal EN-Related Complications
Constipation
Interventions
Interventions ü Ensure adequate hydration ü Switch to formula with fibre ü Ensure patient is on a “bowel routine” (i.e. medications prn) ü Mobilize patient • “Mobility = motility”
Pulmonary EN-Related Complications Pulmonary
• Pulmonary aspiration
– Definition: Inhalation of material into the airway • EN-related concern – Inhalation of gastric contents/feed into airway – Aspiration pneumonia
• Pulmonary aspiration
Management Strategies
Tube placement confirmed radiologically • Chest x-ray (CXR) NG tubes • Abdo x-ray G/J-tubes ü HOB > 30-45 degrees while feeding ü Manage nausea and vomiting ü Gastric residual volumes (GRV’s) • Controversial!
Hydration Fluid Considerations with EN
• Avoid dehydration – Patient’s on EN at high risk – EN feed alone won’t provide sufficient fluid/free water • Water flushes • “Ins and outs” – Ins: IV’s, EN, free water, medications – Outs: • Urine, stool, “insensible losses” • Disease: ostomy, fistula, drains, paracentesis etc.
Hydration Fluid Considerations with EN
Management Strategies
Management Strategies ü Physical assessment to detect ü Laboratory findings to detect ü Assess “ins and outs” ü Include fluids/water in your EN calculations
Mechanical Complications Associated with EN
Tube blockage
– Inadequate flushing
– Large amounts of crushed meds, modulars going into tube
Tube blockage
Management Strategies
ü Routine water flushes (minimum 25-30 cc q4h)
ü Tube unclogging protocol: pancrealipase / NaHCO3 mixture
• DO NOT USE: coke, cranberry juice etc.
ü Tube change may be required
Mechanical Complications Associated with EN
Irritation from Feeding Tube
– Sinusitis from NGT/OGT – Nose bleeds – ? Swallowing dysfunction with NGT in situ – Leakage or wound infection (PEG/PEJ)
Irritation from Feeding Tube
Management Strategies
ü Proper tube/wound care
ü Tube changes as needed
Specific Drug-Enteral Nutrition Interactions
Indications that drug bioavailability is reduced when administered
with EN formula for the following:
– Phenytoin (Dilantin®) (anti-seizure medication)
– Fluoroquinolone antibiotics
• Ciprofloxacin, Levoflaxcin, Ofloxacin
– Levothyroxine (Synthroid®) (for hypothyroidism)
• Very controversial
• Management
– Hold enteral feed 2h pre/post drug administration
– Change to IV
